Competency Areas: Area 2: Communication

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Competency Areas H. Musculoskeletal System

Inflammatory Disorders: Arthritis
Area 2: Communication Inflammatory Disorders: Osteoporosis
2.1.f Speak in language appropriate to the listener. I. Endocrine System
2.3.c Establish trust and rapport with patients and colleagues. Diabetes mellitus
2.3.d Recognize and react appropriately to non-verbal Electrolyte imbalances
behaviours. Thyroid disease
2.4.g Exhibit diplomacy, tact, and discretion. J. Multisystem Diseases and Injuries
Toxicologic Illness: Prescription medication
Toxicologic Illness: Non-prescription medication
Area 5:Therapeutics Toxicologic Illness: Alcohols
5.1.a Use manual maneuvers and positioning to maintain airway Environmental Disorders: Hyperthermal injuries
patency. Environmental Disorders: Hypothermal injuries
5.7.a Immobilize suspected fractures involving appendicular Trauma: Falls
skeleton. K. Psychiatric Disorders
5.7.b Immobilize suspected fractures involving axial skeleton. Affective Disorders: Depressive disorders
Affective Disorders: Suicidal ideation
Area 6: Integration Psychosocial Disorders: Antisocial disorder
6.2.c Provide care for geriatric patient.
6.3.a Conduct ongoing assessments based on patient Appendix 5: Medications
presentation and interpret findings. A. Medications affecting the central nervous system.
6.3.b Re-direct priorities based on assessment findings. A.5 Anxiolytics, hypnotics, and antagonists
A.8 Opioid analgesics
Appendix 4: Pathophysiology B. Medications affecting the autonomic nervous system.
B.4 Cholinergic antagonists
A. Cardiovascular System
B.5 Antihistamines
Cardiac Conduction Disorder: Benign arrhythmias
D. Medications affecting the cardiovascular system.
Cardiac Conduction Disorder: Lethal arrhythmias
D.2 Cardiac Glycosides
Cardiac Conduction Disorder: Life-threatening arrhythmias
D.5 Class 2 Antidysrhythmics
B. Neurologic System
E. Medications affecting blood clotting mechanisms.
Altered Mental Status: Metabolic
E.1 Anticoagulants
Altered Mental Status: Structural
H. Medications used to treat electrolyte and substrate
Chronic Neurologic Disorders: Alzheimer’s
imbalances.
Chronic Neurologic Disorders: Parkinson’s disease
H.2 Antihypoglycemic agents
C. Respiratory System
I. Medications used to treat/prevent inflammatory
Medical Illness: Chronic obstructive pulmonary disorder
responses and infections.
Medical Illness: Pneumonia/bronchitis
I.1 Corticosteroids
Medical Illness: Pulmonary embolism
I.2 NSAID
E. Gastrointestinal System
I.3 Antibiotics
Esophagus/Stomach: Obstruction
J. Medications used to treat poisoning and overdose.
Esophagus/Stomach: Peptic ulcer disease
J.1 Antidotes or neutralizing agents
Esophagus/Stomach: Upper gastrointestinal bleed
K. Psychiatric Disorders
Small/Large Bowel: Lower gastrointestinal bleed
Cognitive Disorders: Delirium
G. Integumentary System
L. Ears, Eyes, Nose, and Throat
Infectious and Inflammatory Illness: Infections
Eyes—Medical Illness: Cataracts
Eyes—Medical Illness: Glaucoma
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Chapter 42 Geriatrics 42.3
owing to the larger number of older persons in Canada, a

Introduction countertrend is for elderly people to maintain independent
lives. Many older adults continue to live at home with support
Geriatrics is the assessment and treatment of disease in some-
from a spouse or family member and a visiting nurse; others
one 65 years or older. In 2003, elderly Canadians accounted
live in a more dependent care environment such as a senior
for 13% of the population; this percentage is expected to grow
centre facility. Still others may seek an assisted-living facility or
to 22%, largely driven by aging of the “baby boomers” (born in
a total care nursing home.
the period 1946–1964). Furthermore, the elderly population is
Determining how and where older adults will spend their
itself growing older. The most rapidly growing segment of the
retirement years is a difficult and complex process involving
Canadian population is people 85 years and older.
numerous social and economic issues such as the person’s mar-
Elderly people constitute an ever-increasing proportion of
ital status, financial resources, religious beliefs, ethnicity, sex,
patients in the health care system, particularly the emergency
and general health. Because such decisions may place a burden
care sector. Individuals 65 years of age and older account for
on family members, their wishes must be considered by health
one third of all hospitalizations, and more than one half of all
care providers. When making these decisions, older adults and
hospital stays. People are receiving more of their care out of
their families can seek advice from medical social workers, pro-
hospital, and with insurance issues, this trend will continue in
fessional care managers, discharge planners at health care facil-
the future. This population also has more contacts with doctors
ities, and a large number of private and public resources. The
than those under 65 years of age.
range of services available includes delivered meals, personal
The old-age dependency ratio depicts the dependency
care, housekeeping, adult day care, transportation, caregiver
individuals place upon society as they age. It is defined as the
support, respite care, and emergency response systems, includ-
number of older people for every 100 adults (potential care-
ing EMS services and lifelines Figure 42-1 .
givers) between the ages of 18 and 64. In 1990, there were 20
Psychosocial factors may influence successful aging. For
older people for every 100 “caregivers.” By 2025, it is projected
example, at retirement, a person may no longer feel useful or
that there will be 32 older people for every 100 “caregivers.”
productive in society and may experience diminished self-
The supply of caregivers is not keeping pace with the growth of
esteem. Age also brings bereavement—sadness over the loss of
the older population. The need for caregivers is going to
friends and loved ones. Notably, the likelihood of death
increase, and society is going to have difficulty keeping up with
increases during the year following the death of one’s spouse.
the demand for services as the population continues to age. As
As friends and family die, elderly persons tend to experience
the older population grows, paramedics will be required to
increasing loneliness and isolation—factors shown to have neg-
offer services that are cost effective and efficient. Insurance reg-
ative effects on health.
ulations, costs associated with providing care, and facility
Finally, the health problems of older people are quantita-
issues will make cost a continuing concern.
tively and qualitatively different from the problems of younger
Most of your geriatric patients will not reside in nursing
people. One cannot simply transfer the principles of caring for
homes. Although nursing home admissions are increasing
You are the Paramedic Part 1

You have been assigned to orient a newly hired paramedic, Mike, who graduated paramedic school 7 months ago. Your focus for the
day has been on geriatric emergencies because your territory provides service to six nursing homes and assisted-living facilities. As
luck would have it, your unit is dispatched to one of the smaller community nursing homes for a sick person.
Upon arrival you are escorted to the day room where the residents spend most of their time. A nurse sitting next to a patient seated in
a wheelchair by the window waves you over. She introduces you to Mrs. Howard, a frail-appearing 86-year-old widow. The nurse
explains that Mrs. Howard has been running a low-grade fever since last evening and is “not acting like her normal self.” The physician
has requested that she be transferred to the hospital to be evaluated. When asked how she is feeling, Mrs. Howard slowly turns her
head away from the window toward you and replies “not well.”
Initial Assessment Recording Time: 0 Minutes

Appearance Frail, weak, elderly woman
Level of consciousness A (Alert to person, place, and day)
Airway Open and clear
Breathing Adequate chest rise and volume
Circulation Strong, rapid radial pulse, slightly irregular
1. Why is it important to review common medical problems of elderly people?

2. Which organ systems are greatly affected by age-related changes?
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42.4 Section 6 Special Considerations
Muscular wall
Lumen
Lining
Cholesterol
Blood clot
Lumen
Figure 42-1 EMS professionals should be familiar with available Calcium

resources.
Figure 42-3 Atherosclerosis, the buildup of fatty plaque on
arterial walls.
the younger population without modification. The special
problems of older people require special approaches.
who is unaware of the normal changes of aging may mistake

the changes for signs of illness and be tempted to give treat-
Anatomy and Physiology ment when none is necessary. At the other end of the spec-
Human growth and development peaks in the late 20s and early trum, there is a widespread—and unfortunate—tendency to
30s, at which point the aging process sets in. Aging is a linear attribute genuine disease symptoms to “just getting old” and to
process; that is, the rate at which we lose functions does not neglect their treatment.
increase with age. A 35-year-old is aging just as fast as an
85-year-old, but the older person exhibits the cumulative results Changes in the Cardiovascular System
of a longer process. Of course, the aging process can vary dramat- A variety of changes occur in the cardiovascular system as a per-
ically from one person to another. Most of us can report having son grows older, with their net effect being to decrease the effi-
seen 60-year-olds who look frail and elderly and 80-year-olds ciency of this system. Specifically, the heart hypertrophies
who run marathons (enlarges) with age, probably in response to the chronically
Figure 42-2 . increased afterload imposed by stiffened blood vessels. Bigger is
The aging process is not better, however. Over time, cardiac output declines, mostly
inevitably accompanied as a result of a decreasing stroke volume. Arteriosclerosis—the
by changes in physio- stiffening of vessel walls—contributes to systolic hypertension
logic function, such as a in many older patients, which places an extra burden on the
decline in the function heart. This phenomenon may be a consequence of disease states
of the liver and kidneys. such as diabetes, atherosclerosis Figure 42-3 , and renal
All tissues in the body compromise, and it is associated with an increased risk of car-
undergo aging, albeit not diovascular disease, dementia, and death. Compliance of vascu-
at the same rate. The lar walls depends on the production of collagen and elastin,
decrease in the func- proteins that are the primary components of muscle and con-
tional capacity of various nective tissue. An increase in pressure (normal hypertension
organ systems is normal seen in aging) leads to overproduction of abnormal collagen
but can affect the way and decreased quantities of elastin, both of which contribute to
in which a patient vascular stiffening. The result is a widening pulse pressure,
responds to illness. decreased coronary artery perfusion, and changes in cardiac
It can also affect the ejection efficiency.
Figure 42-2 Many older people, way health professionals At the same time, the electric conduction system of the
especially those who have hobbies respond to a patient’s heart deteriorates over time. For example, the number of pace-
and activities, are healthy and
vital. illness. For example, a maker cells in the sinoatrial node decreases dramatically as
health care provider a person ages. In many cases, the changes in the conduction
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system lead to bradycardia, which can in turn contribute to the decreased central nervous system (CNS) response to such
decline in cardiac output. changes. As a consequence, elderly people have a slower reac-
Some changes in cardiovascular performance are probably tion to hypoxemia and hypercarbia.
not a direct consequence of aging, but rather reflect the decon- Musculoskeletal changes, such as kyphosis (outward cur-
ditioning effect of a sedentary lifestyle. Whether because of vature of the thoracic spine; also called hunchback), may also
other disabilities (such as arthritis) or for psychological rea- affect pulmonary function by limiting lung volume and maxi-
sons, many people tend to limit physical activity as they grow mal inspiratory pressure. In addition, the lung’s defence
older. The bodybuilder’s slogan, “Use it or lose it,” applies just mechanisms become less effective as a natural consequence of
as much to the cardiac muscle as to the biceps. aging. The cough and gag reflexes decrease with age, increas-
ing the risk of aspiration. Furthermore, the ciliary mecha-
Changes in the Respiratory System nisms that normally help remove bronchial secretions are
A person’s respiratory capacity also undergoes significant markedly slowed.
reductions with age, largely due to decreases in the elasticity of
the lungs and in the size and strength of the respiratory mus- Changes in the Renal System
cles. In addition, calcification of costochondral cartilage tends Age brings changes in the kidneys as well. The kidneys are
to make the chest wall stiffer. As a result of these changes, the responsible for maintaining the body’s fluid and electrolyte
vital capacity (the amount of air that can be exhaled following balance and have important roles in maintaining the body’s
a maximal inhalation) decreases, and the residual volume (the long-term acid-base balance and eliminating drugs from the
amount of air left in the lungs at the end of a maximal exhala- body. In a young adult, the kidneys weigh 250 to 270 g; in a
tion) increases. Thus, although the total amount of air in the healthy 70-year-old, they weigh 180 to 200 g. This decline in
lungs does not change with age, the proportion of that air use- weight results from a loss of functioning nephron units, which
fully used in gas exchange progressively declines. Air flow, translates into a smaller effective filtering surface. At the same
which depends largely on airway size and resistance, also dete- time, renal blood flow decreases by as much as 50% as a per-
riorates somewhat with age. son ages.
Meanwhile, changes in the distribution of blood flow Although the kidneys of an elderly person may be capable
within the lungs result in declining PaO2. At age 30, the PaO2 of dealing with day-to-day demands, they may not be able to
of a healthy person breathing ambient air is usually around meet unusual challenges, such as those imposed by illness. For
90 mm Hg; at 80 years, the PaO2 under the same conditions is that reason, acute illness in elderly patients is often accompa-
around 75 mm Hg (PaO2 = 100 – age/3). Furthermore, the res- nied by derangements in fluid and electrolyte balance. Aging
piratory drive becomes dulled as a person ages because of kidneys, for example, respond sluggishly to sodium deficiency.
decreased sensitivity to changes in arterial blood gases or An elderly patient may lose a great deal of sodium before the

Recognizing an opportunity to complement your earlier review of elderly emergencies with hands-on experience, you ask Mike to begin
a physical examination while your partner obtains a set of vital signs. The nurse caring for your patient is new to the facility and is not
very familiar with her. She is able to tell you that your patient has a history of atrial fibrillation, congestive heart failure, diabetes, and
hypertension. She is currently prescribed digoxin, pioglitazone (Actos), enalapril (Vasotec), and simvastatin (Zocor).
While you are speaking with the nurse, another patient approaches you and sets her hand on your patient’s shoulder. She introduces
herself as Mrs. Jessup, a good friend of Mrs. Howard. She tells you that it is normal for them to go for a walk every night after dinner;
however, they have not walked for the past couple of evenings because Mrs. Howard has been feeling weak. She also volunteers that
Mrs. Howard has not been eating much the past few days. Mrs. Howard brushes off her friend’s concerns. You are able to ascertain
from Mrs. Howard that the last meal she had was a bowl of soup yesterday at lunch.
Vital Signs Recording Time: 5 Minutes

Level of consciousness Alert
Pulse 110 beats/min, strong and irregular
Blood pressure 168/94 mm Hg
Respirations 22 breaths/min, regular
Skin Hot, pink, and dry
SpO2 93% on room air
3. Why might obtaining an accurate medical history and history of the present illness be challenging when interviewing an elderly
patient?
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The opposite of incontinence is urinary retention or diffi-

culty urinating. Patients may have difficulty voiding or absence
of voiding as a result of many medical causes. In men, enlarge-
ment of the prostate can place pressure on the urethra, making
voiding difficult. Bladder and urinary tract infections can also
cause inflammation. In severe cases of urinary retention,
patients may have acute or chronic renal failure.
Changes in the Digestive System

The process of digestion begins in the mouth, which is also
where aging-related changes in the digestive system may first
be noted. A decrease in the number of taste buds and changes
in olfactory receptors may diminish an older person’s senses of
taste and smell, which may in turn interfere with the enjoy-
ment of food. The consequent decrease in appetite may lead to
malnutrition. Other changes in the mouth include a reduction
in the volume of saliva, with a resulting dryness of the mouth.
Dental loss is not a normal result of the aging process, but
rather the result of disease of the teeth and gums; nevertheless,
Figure 42-4 dental loss is widespread in the elderly population and con-
tributes to nutritional and digestive problems.
Like oral secretions, gastric secretions are reduced as a per-
kidneys halt urinary sodium excretion, a problem that is exac- son ages—although enough acid is still present to produce
erbated by the markedly decreased thirst mechanism in elderly ulcers under certain conditions. Changes in gastric motility
people. The net result may be a rapid development of severe also occur, which may lead to slower gastric emptying—a fac-
dehydration. tor of some importance when assessing the risk of aspiration.
Conversely, elderly patients are at considerable risk of Function of the small and large bowel changes little as a
overhydration if they are exposed to large sodium loads (such consequence of aging, although the incidence of certain dis-
as from intravenous [IV] saline solutions or heavily salted eases involving the bowel (such as diverticulosis) increases as a
foods) Figure 42-4 . Because of its lower glomerular filtra- person grows older.
tion rate, the aging kidney is less able than its younger counter- In the liver, there are changes in hepatic enzyme systems,
part to excrete a large sodium load, making the patient with some systems declining in activity and others increasing.
vulnerable to acute volume overload. Notably, the activity of the enzyme systems concerned with the
The same factors that reduce an older person’s ability to detoxification of drugs declines as a person ages.
handle sodium also affect the body’s ability to handle potas-
sium. Thus, elderly patients are prone to hyperkalemia, which Changes in the Musculoskeletal System
can reach serious—even lethal—levels if the patient becomes Aging brings a widespread decrease in bone mass in men and
acidotic or if the potassium load is increased from any source. women, but especially among postmenopausal women. Bones
Bowel and bladder continence require anatomically correct become more brittle and tend to break more easily. Narrowing
gastrointestinal (GI) and genitourinary tracts, functioning and of the intervertebral disks and compression fractures of the
intact sphincters, and properly working cognitive and physical vertebrae contribute to a decrease in height as a person ages,
functions. Urinary incontinence (involuntary loss of urine) can along with changes in posture. Joints lose their flexibility and
have significant social and emotional impact, but relatively few may be further immobilized by arthritic changes. In fact, more
people admit to the problem and even fewer seek treatment. than half of all elderly people have some form of arthritis. Mus-
Incontinence is not a normal part of aging and can lead to skin cle mass decreases throughout the body, with an accompanying
irritation, skin breakdown, and urinary tract infections. As decrease in muscle strength. From your perspective, the
people age, the capacity of the bladder decreases. As a conse-
quence, an older person may find it difficult to postpone void-
ing or may have involuntary bladder contractions. Two major
types of incontinence are distinguished: stress and urge. Stress At the Scene
incontinence occurs during activities such as coughing, laugh- Growing old does not naturally or normally
ing, sneezing, lifting, and exercise. Urge incontinence is trig- include confusion, dementia, delirium, depression,
gered by hot or cold fluids, running water, and even thinking falls, weakness, syncope, and other conditions
about going to the bathroom. Treatment of incontinence con- related to disease processes.
sists of medications, physical therapy, and, possibly, surgery.
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changes in the musculoskeletal system most often translate into

fractures incurred as the result of falls. Special Considerations
With patients who have some degree of hear-
ing loss, don’t yell! Lean closer and speak into the patient’s
Changes in the Nervous System ear using a somewhat low pitch. Remember that patients
Aging produces changes in the nervous system that are with limited vision are not necessarily hard of hearing.
reflected in the neurologic examination. Changes in thinking
(cognitive) speed, memory, and postural stability are the most
common normal findings in older people. Studies have docu- middle age, with symptoms presenting in cycles that last sev-
mented age-associated declines in mental function, especially eral months at a time. The typical symptoms include vertigo
slower central processing of sensory stimuli and language, and (a sudden loss of normal balance or equilibrium), hearing
longer retrieval times for short- and long-term memory. Collec- loss, tinnitus, and pressure in the ear.
tively, these changes affect performance on the mental status For many older people, physiologic changes make it diffi-
portion of the neurologic examination, with common findings cult to produce speech that is loud enough, clear, and well
including slow responses to questioning or requests to repeat a spaced. Weakness, paralysis, poor hearing, or brain damage can
question. damage the delicate functions that make these abilities possible.
The brain decreases in terms of weight (5% to 10%) and Sense of body position (proprioception) also becomes
volume as a person ages. The functional significance of these impaired with age. Proprioception enables us to maintain pos-
changes is not clear, however. The human brain has an enor- tural stability by using a variety of receptors in the joints and
mous reserve capacity, and having a smaller and lighter brain information provided by the eyes. As these mechanisms fail
does not interfere with the mental capabilities of productive with age, people become less steady on their feet, and the ten-
elderly people. dency to fall increases markedly.
Undeniably, though, the performance of most of the sense
organs suffers with increasing age. The senses of taste and
Changes in the Integumentary System
smell become diminished as a person ages.
Visual changes may begin as early as 40 years, such that as Wrinkling and loss of resiliency of the skin are the most visible
many as 50% of patients older than 65 years have vision prob- signs of aging. Wrinkling occurs because the skin becomes
lems. Causes of visual impairment in elderly people may include thinner, drier, less elastic, and more fragile. Subcutaneous fat
diabetic retinopathy and age-related macular degeneration. becomes thinner, making for a loosened outer cover for the
The two most common causes of visual disturbances in body. Elastin (the substance that makes the skin pliable) and
elderly people, however, are cataracts and glaucoma. Cataracts are collagen (the substance that makes the skin strong) decrease
a result of hardening of the lenses over time. The lenses eventu- with age. Thinner skin tears much more easily, and the loss of
ally become opaque, which prevents light and images from elasticity allows for more bleeding before tamponade occurs.
being transmitted to the rear of the eye. Patients with cataracts As a person ages, the sebaceous glands produce less oil,
may complain of blurred vision, double vision, spots, and/or making dryer skin. Sweat gland activity also decreases, hinder-
ghost images. Surgical repair may be required to gain vision. By ing the ability to sweat and to regulate heat. Hair follicles pro-
contrast, glaucoma is caused by an increase in intraocular pres- duce thinner hair or may stop producing hair. Follicles
sure severe enough to damage the optic nerve, potentially result- produce less melanin (the pigment that gives hair colour),
ing in permanent loss of peripheral and central vision. Treatment making the hair colour revert to grey or white.
of glaucoma consists of oral medications and eye drops. The blood vessels that supply the skin also are affected by
Decreases in visual acuity are common in older people, atherosclerosis and provide less oxygenated blood at the cellular
even without disease processes such as cataracts. Night vision level. As a consequence of the skin’s lower metabolism, epider-
becomes impaired, as does the ability to adjust to rapid mal cells develop more slowly and do not replace outgoing cells
changes in lighting conditions, depth perception, and percep- as quickly as with younger skin. Elderly patients, therefore, are
tion of colour. Changes in a patient’s vision can affect inde- at higher risk for secondary infection after the skin breaks, for
pendence, ability to read, and ability to drive a vehicle. skin tumours, and for fungal or viral infections of the skin.
The possibility of hearing loss increases with age. A com-
mon cause of hearing impairment in geriatric patients is presby- Homeostatic and Other Changes
cusis, a progressive hearing loss, particularly in the high Homeostasis is the process by which the body maintains a
frequencies, along with lessened ability to discriminate between constant internal environment. Many homeostatic mecha-
a particular sound and background noise. Patients who lose the nisms work on a feedback principle, much like the thermostat
ability to interpret most speech experience a decreased ability to in a house—that is, a change in the internal environment
communicate, which may lead to isolation and depression. feeds back to the control system to induce a corrective
Another hearing-related impairment noted in the elderly response. For example, when the body temperature starts to
population is Meniere disease (prevalence, 2 people per rise, temperature sensors are activated, which in turn activate
1,000 population). Onset of symptoms usually occurs in early compensatory responses: Cutaneous blood vessels dilate, and
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excess heat is transferred from the body to the environment.

Similarly, when the concentration of glucose in the blood
rises, the pancreas is stimulated to secrete insulin, which leads
to uptake of glucose by cells and reduction of the blood glu-
cose level back toward normal.
Across the board, aging is accompanied by a progressive
loss of these homeostatic capabilities. For that reason, a specific
illness or injury in elderly people is more likely to result in
generalized deterioration. For example, the thirst mechanism,
which ordinarily protects a person from dehydration, becomes
depressed in elderly patients. Likewise, temperature-regulating
mechanisms tend to become disordered, which makes elderly
patients much more vulnerable to environmental stresses such
as heat exhaustion and accidental hypothermia after relatively
minor exposures. A defect in temperature regulation also may
account for the absence of a febrile response to illness in many
elderly people. Infections that would ordinarily produce high
fever, such as pneu-
mococcal pneumo-
Notes from Nancy nia, may produce
only a low-grade or
Figure 42-5
A specific illness or injury in the no fever in elderly

elderly is more likely to result in people.
generalized deterioration. The regulatory ics), exercise, weight control, and control of hypertension. A
system that manages physician may also order aspirin to help reduce the risk of
the blood glucose heart attack.
level similarly becomes impaired with increasing age, such that People 65 years and older are a high-risk group for heart
an elevated blood glucose level occurs quite commonly in failure. In fact, this problem is the most common reason for
older patients. Ordinarily, moderate hyperglycemia does no hospitalization in the geriatric population. Heart failure is on
harm, but overly aggressive treatment of this problem may pro- the rise in this cohort for two paradoxical reasons: better care of
duce damaging hypoglycemia. the diseases that might otherwise result in failure (such as CAD
and hypertension), which enables patients to live long enough
to develop heart failure, and more effective management of
heart failure once it develops. Risk factors include sex, ethnicity,
Pathophysiology family history and genetics, long-term alcohol maltreatment,
and multiple medical conditions—CAD, emphysema, hyperthy-
Cardiovascular System roidism, thiamine (vitamin B) deficiency, and human immunod-
Diseases of the heart remain the leading cause of death among eficiency virus infection, among others. As with MI, prevention
older adults in Canada, and coronary artery disease (CAD) is is aimed at lifestyle changes: cessation of tobacco use, eating a
the number one culprit. Heart attack is the major cause of mor- healthy diet, good control of blood glucose (in diabetics), exer-
bidity and mortality in people older than 65 years, and its cise, weight control, and control of hypertension.
potential for mortality increases significantly after a person Rhythm disturbances (arrhythmias) of the heart occur
reaches 70 years Figure 42-5 . when the electrical system controlling the heartbeat experi-
Myocardial infarction (MI) is the death of part of the heart ences an interruption or malfunction. These irregularities cause
muscle due to the blockage of one of the coronary arteries. heartbeats that are too fast, too slow, irregular, or absent. Many
Although chest pain is a common presentation for acute people experience an occasional or harmless arrhythmia, which
myocardial infarction in older patients, it may be decreased in they may describe as a skipping, fluttering, or fast heartbeat.
intensity or atypical. In fact, it may even be absent, with the Arrhythmias in older people are generally a result of age-
patient complaining primarily of dyspnea or fatigue. Major risk related changes in the heart, existing cardiac disease, adverse
factors for MI include tobacco use, hypertension, diabetes, drug effects, or a combination of these factors.
obesity, psychosocial factors, physical activity, and alcohol con- Cardiac arrhythmias are classified by the part of the heart
sumption. Preventive strategies include measures to prevent from which they originate. Unlike tachyarrhythmias or brady-
the first MI, avoidance of recurring MIs, and lifestyle interven- arrhythmias, which speed up or slow down the heart, prema-
tions. Lifestyle changes include the cessation of tobacco use, ture beats signify no change in speed but rather alter the
eating a healthy diet, good control of blood glucose (in diabet- regularity of the heartbeat. In contrast, atrial fibrillation (coming
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from the atria), which is the most common arrhythmia among caused by atherosclerosis, are responsible for 14,000 deaths
elderly people, increases the risk of stroke and heart failure. The (7%) anually in Canada, making stroke the third leading cause
fibrillating atria allow stasis of the blood, thereby encouraging of death. The risk of stroke doubles each decade after 35 years,
clot formation and increasing the chances that a clot fragment mirroring the increase in risk factors such as hypertension and
might travel to the brain and cause a stroke. Most of the blood atrial fibrillation. Hypertension is the primary risk for stroke,
in the atria enters the ventricles when the valves open, with but age, family history, smoking, diabetes, high cholesterol,
about 20% being kicked in by contraction of the atria. The and heart disease also contribute. Prevention is aimed at reduc-
aging heart may function adequately when preload provided by tion of risk factors, improving diet and exercise, and lowering
the atria ends up in the ventricles; however, when that 20% cholesterol.
remains in the atria, new signs or symptoms of heart failure may Transient ischemic attacks (also called TIAs and mini-
develop or stable heart failure may decompensate. strokes) entail a temporary disturbance of blood supply to the
Bradycardias are also more common in elderly people. The brain that results in a sudden, temporary decrease in brain
aging conduction system may produce sinus abnormalities function. The symptoms are the same as those for a stroke but
such as sick sinus syndrome. CAD may produce high-degree last less than 24 hours, and most will last less than 60 minutes.
blocks, whereas medications such as beta blockers or calcium They are warning signs of a future stroke.
channel blockers can slow the heart too much.
The human heart beats 2.5 billion times and moves Respiratory System
200 million litres of blood in an average lifetime. Not surpris- Although tobacco maltreatment seems to be decreasing among
ingly, this workload affects the cardiovascular system through- elderly people, chronic lower respiratory disease, influenza,
out the entire body over the lifespan. For example, the and pneumonia remain in the top five causes of geriatric
incidence of aneurysm increases with age. An aneurysm is a deaths. In fact, one of the most common causes of death in
weakness in any artery that produces a balloon defect, weaken- older patients is infection with Pneumococcus bacteria.
ing the arterial wall. This weakness may be congenital (present Pneumonia involves an inflammation of the lung, secondary
at birth) or acquired. In the latter case, hypertension, athero- to infection by bacteria, viruses, or other organisms. Although it
sclerotic disease, and obesity are contributing factors to devel- can affect people at any age, this disease has its biggest impact
opment of such a defect. For example, blood pressure greater on very young and elderly people, typically during the colder
than 160/95 mm Hg doubles the mortality risk in men and can seasons (winter and early spring). People considered at risk
lead to kidney loss and blindness by damaging the blood ves- include elderly people; people with underlying health problems
sels that supply the kidney and eyes. Life-threatening such as chronic obstructive pulmonary disease (COPD), diabetes
aneurysms can develop in the brain, chest, or abdomen. A new mellitus, and vascular diseases; and any person with a depressed
headache or a change in chronic headache patterns, for exam- immune system because of acquired immunodeficiency syn-
ple, may signal early cerebral bleeding from an aneurysm; all drome, cancer therapy, or organ transplantation. Treatment is
too often, the first manifestation is a sudden and devastating primarily supportive, consisting of bed rest, fluids, oxygen ther-
stroke. Preventive measures—proper diet, exercise, smoking apy via nasal cannula or mask to relieve dyspnea, analgesics to
cessation, and cholesterol control—aim to control the risk fac- reduce fever, and antibiotics. Preventive measures include a vac-
tors associated with hypertension and atherosclerotic diseases. cine given once and boosters after 3 to 5 years.
Aortic dissection occurs when the inside wall of the artery COPD includes chronic asthma, chronic bronchitis, and
becomes torn and allows blood to collect between the arterial emphysema, all of which are characterized by the presence of
wall layers. It may occur with trauma or sustained hyperten- bronchial obstruction and airway inflammation. Distinguishing
sion. Dissection weakens the arterial wall, making it prone to these diseases can be difficult, so the problem may not be diag-
rupture. A thoracic dissection, for example, can produce chest nosed or treated correctly. COPD affects approximately 10% of
pain that is difficult to differentiate from cardiac ischemia. the older population, mostly owing to tobacco use. Its effects
Therefore, it is helpful to take blood pressure readings in both reflect the age-related loss of elastic tissue in the lungs (senile
arms in all patients with chest pain. A systolic blood pressure emphysema) and a decreased ability to defend against infection.
difference of 15 mm Hg or higher suggests a thoracic dissection. These factors may increase the baseline disability of COPD and
More than half of all older persons are hypertensive. The set up older patients for an increased risk of acute exacerba-
majority have isolated systolic hypertension resulting from a tion, often caused by infection.
loss of arterial elasticity. Controlling systolic and/or diastolic Preventive measures for COPD-related complications
hypertension in elderly people helps prevent strokes and MIs. include immunization for influenza and pneumococcal pneumo-
Geriatric hypertensive emergencies require a controlled decline nia. Long-term oxygen therapy has proven helpful in hypoxemic
in blood pressure that often cannot be achieved in the prehos- patients. In addition, pulmonary rehabilitation may improve
pital environment. functional status and the quality of life for some patients.
Stroke is a significant cause of death and disability in Approximately 1 in 20 elderly people has a history of
elderly people. More than 80% of all stroke deaths occur in asthma or is affected by it. Onset can occur in old age with
persons older than 65 years, and stroke is the leading cause of presenting symptoms of shortness of breath (especially with
long-term disability at any age. Strokes, which are mainly effort), chronic or nocturnal cough, and wheezing.
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A pulmonary embolus arises when a blood vessel supply- Table 42-1 Signs of Dehydration in Elderly People
ing the lung becomes blocked by a clot. Any obstruction in
blood flow to the lung can result in irreversible damage or I Dry tongue
infarction. An embolus is often released from a vein in a lower I Longitudinal furrows in the tongue
extremity, the pelvis, or the abdomen but could also result I Dry mucous membranes
I Weak upper body musculature
from a damaged heart. The risk of pulmonary embolus
I Confusion
increases with age because of increasing immobility. Older I Difficulty in speech
patients may also be bedridden after recent surgery (such as I Sunken eyes
abdominal procedures). Finally, elderly patients have an
increased incidence of diseases associated with a higher risk of
pulmonary embolus, such as cancer, heart attack, cardiac
arrhythmias, and clotting disorders. hypothyroidism, for example, the signs and symptoms may
Prevention of thromboembolism is based on the patient’s match those seen with normal aging: cold intolerance, constipa-
risk level—high, moderate, or low. Surgical patients are in the tion, dry skin, weakness, and so on. For acute-onset hyperthy-
highest-risk category for potential emboli, and prophylaxis is roidism (thyrotoxicosis), the presentation can be blunted;
recommended, including warfarin (Coumadin) and/or heparin although tachycardia is generally present, older patients may
and compression stockings. experience less tremor, anxiety, or hyperactive reflexes than
their younger counterparts. Atrial fibrillation is more likely to
Endocrine System be induced by an overactive thyroid gland in a geriatric patient.
Diabetes arises when the body cannot oxidize complex carbo- A smaller percentage of elderly hyperthyroid patients present
hydrates (sugars) due to impaired pancreatic activity—namely, with symptoms opposite those expected: weakness, lethargy,
production of insulin. Insulin moves carbohydrates out of the and depression. Care in the prehospital setting is supportive.
bloodstream, through the cellular walls, and into the cells to be
metabolized. With diabetes, more glucose is present in the Gastrointestinal System
blood than the body can handle. Geriatric patients with dia- Constipation is a frequent and significant problem in elderly
betes are at increased risk for hypoglycemia for several reasons: people. Although it can cause acute abdominal pain, it should
medications, inadequate or irregular dietary intake, inability to not be the initial suspect when a patient experiences such dis-
recognize the warning signs due to cognitive problems, and/or comfort. Instead, causes with high mortality, such as bleeding
blunted warning signs. Delirium may be the only indication of from an acute abdominal aneurysm or dead bowel from
hypoglycemia in an elderly patient. mesenteric ischemia, should be investigated first. Many elderly
Over 2.25 million Canadians are estimated to have dia- people have diverticulosis (small outward pouches in the colon
betes, 10% of these are over 65 years of age, primarily type 2 wall) and are at risk for diverticulitis and/or perforation.
diabetes (adult-onset, or non–insulin-dependent diabetes). The Appendicitis can be difficult to diagnose in older people, which
most common risk factor for this disease is having more than probably accounts for the high perforation rate (50%) seen
one chronic disease, and many elderly people with diabetes with this condition. The incidence of peptic ulcer disease is
also have hypertension, heart disease, and stroke. Other risk also increased among the older population, likely because of
factors for diabetes include a family history of diabetes, genet- their relatively high use of nonsteroidal anti-inflammatory
ics, age, diet, obesity, and a sedentary lifestyle. Symptoms of an drugs (NSAIDs) for pain management.
elevated blood glucose level (that is, hyperglycemia) include Large bowel obstructions in elderly people are likely to be
fatigue, poor wound healing, blurred vision, and frequent caused by cancer, impacted stool, or sigmoid volvulus. In addi-
infections. Other symptoms of diabetes include the three Ps: tion, small bowel obstruction secondary to gallstones increases
Polyuria, Polydipsia, and Polyphagia. Prevention of type 2 dia- significantly with age. One third to one half of all elderly peo-
betes is aimed at changes in lifestyle that include dietary ple have cholelithiasis (gallstones), although most remain
restrictions, exercise, and controlling obesity. asymptomatic for life. With one or more episodes of cholecysti-
Older diabetics whose blood glucose levels tend to be high tis (inflammation of the gallbladder), the gallbladder adheres to
are more prone to hyperosmolar hyperglycemic nonketotic the small bowel and, over time, creates an opening or fistula.
(HHNK) coma than diabetic ketoacidosis. The most frequent The stone(s) drop into the bowel and produce the obstruction.
cause for HHNK coma is infection. Presentation is likely to be Such a gallstone ileus may account for as many as 25% of geri-
acute confusion with dehydration, although signs of dehydra- atric small bowel obstructions. The large and small intestines
tion may be altered in elderly patients Table 42-1 . Pre- are at risk for obstruction from adhesions due to previous sur-
hospital treatment remains the same as for younger patients, gery or infection or when a segment of bowel is forced into a
albeit with a cautious approach to fluid resuscitation. fascial defect (hernia) in the abdominal wall.
Thyroid abnormalities also increase with aging. Many older Older patients are more likely than younger ones to have
patients remain asymptomatic, and the disease is diagnosed stomach or duodenal ulcers (peptic ulcer disease). The main
only when a routine blood test reveals a thyroid problem. With risk factors for peptic ulcers are regular use of NSAIDs and
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infection with Helicobacter pylori (an ulcer-associated bacteria specific disease states), and (2) the onset and progression of
of the stomach), both of which are more common in older these findings are “in time” with the person’s aging process
patients. Other medications have also been implicated in ulcer (that is, the findings are not sudden or extreme, and they do
formation. The main symptom of peptic ulcer disease is dys- not extend to other abnormalities).
pepsia (gnawing, burning pain in the upper abdomen), which Delirium (also known as acute brain syndrome or acute
usually improves immediately after eating but returns several confusional state) is a symptom, not a disease. A reflection of
hours later. Other causes of dyspepsia include acid reflux, gas- an underlying disturbance to a person’s well-being (usually a
tritis, and gastric cancer. treatable physical or mental illness), this temporary, usually
reversible condition results in rapid changes in brain function.
Musculoskeletal System In elderly people, delirium often replaces or confounds the
Changes in physical abilities can affect older adults’ confidence typical presentation caused by a medical problem, an adverse
in their mobility. The muscle system atrophies and weakens with medication effect, or drug withdrawal. Disorders that cause
age. Muscle fibres become smaller and fewer, motor neurons delirium may also include poisons, electrolyte imbalances,
decline in number, and strength declines. The ligaments and car- nutritional deficiencies, and infections such as urinary tract
tilage of the joints lose their elasticity. Cartilage also goes through infections and pneumonia. Onset of confusion or disorienta-
degenerative changes with aging, contributing to arthritis. tion is abrupt (occurring during hours to days) but generally
The stooped posture of older people comes from atrophy resolves with treatment of the underlying problem. The confu-
of the supporting structures of the body. Two of every three sion and disorientation fluctuate with time, and hallucinations
older patients will show some degree of kyphosis (also called may occur. The patient experiences a rapid alteration between
humpback, hunchback, and Pott curvature). Lost height in mental states, such as lethargy and agitation, serious attention
older adults generally results from compression in the spinal disruption, disorganized thinking, and changes in perception
column, first in the disks and then from the process of osteo- and sensation.
porosis in the vertebral bodies. Unlike delirium, dementia is a disease that produces irre-
Osteoporosis, a condition that affects men and women, is versible brain failure. Disorders that cause dementia include
characterized by a decrease in bone mass leading to reduction conditions that impair vascular and neurologic structures
in bone strength and greater susceptibility to fracture. The within the brain, such as infections, strokes, head injuries,
extent of bone loss that a person undergoes is influenced by poor nutrition, and medications. The two most common
numerous factors, including genetics, smoking, level of activity, degenerative types of dementia in older people are Alzheimer’s
diet, alcohol consumption, hormonal factors, and body weight. disease and multi-infarct or vascular dementia, both of which
The most rapid loss of bone occurs in women during the years cause structural damage to the brain. An estimated 6% to 10%
following menopause, and many postmenopausal women use of elderly people will eventually have dementia, although this
hormone replacement therapy as a means to reduce the loss of percentage increases with advancing age. Dementia may be
bone. Calcium and vitamin D supplementation is another diagnosed when two or more brain functions are impaired.
treatment for the condition, and many other medications are These cognitive and psychomotor functions consist of lan-
available to improve bone strength. Older people should guage, memory, visual perception, emotional behaviour and/or
remain active and perform low-impact exercises to maintain personality, and cognitive skills. Other risk factors that may
bone and muscle strength. predispose a patient to dementia include lower level of educa-
Osteoarthritis is a progressive disease of the joints that tion, female sex, and African ethnicity. Although most cases of
destroys cartilage, promotes the formation of bone spurs in dementia cannot be prevented, some experts suggest that low-
joints, and leads to joint stiffness. This type of arthritis is fat diets and exercise may help ward off vascular dementia.
thought to result from “wear and tear” and, in some cases, from Experts have not identified a single cause for Alzheimer’s
repetitive trauma to the joints. It affects 35% to 45% of the disease, but most believe it is not a normal part of the aging
population older than 65 years. Typically, osteoarthritis affects process. Although age is a significant risk factor for this disease
several joints of the body, most commonly those in the hands, (Alzheimer’s disease typically affects patients older than 60
knees, hips, and spine. Patients complain of pain and stiffness years), but age alone is not the cause. This progressive disease
that gets worse with exertion. The end result is often substan- cannot be cured or reversed by any known treatment or inter-
tial disability and disfigurement. Patients are typically treated vention. Symptoms are subtle at onset. Over time, patients lose
with anti-inflammatory medications and physical therapy to their ability to think, reason clearly, solve problems, and con-
improve the range of motion. centrate; they may present with altered behaviour that includes
paranoia, delusions, and social inappropriateness. In the later
Nervous System stages of Alzheimer’s disease, patients cannot take care of them-
Normal age-related cognitive changes have two major features: selves and may lose the ability to speak. People with severe
(1) They are relatively isolated (that is, they are not associated Alzheimer’s disease become completely debilitated and totally
with multiple abnormal neurologic findings that suggest dependent on others.
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Patients with Parkinson’s disease—another age-related medications. In turn, a person’s chance of ending up in the
neurologic disorder—have two or more of the following symp- hospital because of an adverse reaction to a medication
toms: resting tremor of an extremity, slowness of movement increases with the number of drugs taken. Ultimately, the best
(bradykinesia), rigidity or stiffness of the extremities or trunk, dosage of a drug for an elderly patient is the lowest dosage
and poor balance. Parkinson’s disease is caused by degenera- that will achieve a therapeutic effect.
tion of the substantia nigra, an area of the brain that controls Medication noncompliance in older patients is also associ-
voluntary movement by producing the neurotransmitter ated with negative effects on health. Many patients—not just
dopamine. Cells use dopamine to transmit impulses, so a loss older patients—do not follow instructions or advice on the use
of dopamine results in the loss of muscle function. Parkinson’s of their medications. Because elderly people use more medica-
disease can affect one or both sides of the body and produces a tions than the rest of the population, noncompliance issues are
wide range of functional loss. more likely. Noncompliance issues include failure to fill a pre-
The incidence of seizures (including status epilepticus) is scription (for example, the patient doesn’t have the money to
also increased in elderly people, partly because of the increase pay for the drug or doesn’t see the benefits of it), improper
in risk factors such as stroke, dementia, primary or metastatic administration of medication (for example, the patient
brain tumours, and acute metabolic disorders (such as hyper- decreases the dosage to make the prescription last longer), dis-
glycemia, hyponatremia, alcohol withdrawal). Prehospital continuation of medication (for example, the patient feels bet-
treatment for seizures is the same for younger and older ter and decides not to take the medication), and taking
patients. inappropriate medications (for example, the patient had med-
ication left over from a previous prescription or shares the
Toxicology medicine with family or friends).
As the number of uses for medications increases, there is a pro- Geriatric patients are predisposed to medicine-related
portional increase in the likelihood of adverse drug reactions reactions owing to the previously mentioned age-related physio-
and interactions. Elderly people are particularly prone to logic changes that occur in body systems and body composition.
adverse reactions, even when they take drugs at doses that For example, an increase in the proportion of adipose tissue can
would be safe in younger people. This increased incidence of prolong the half-life of a drug. In particular, medications that
adverse drug reactions among elderly people seems to reflect affect the CNS are the most common source of adverse or unex-
changes in drug metabolism because of diminished hepatic pected reactions, and barbiturates and benzodiazepines are the
function; in drug elimination because of diminished renal drugs most often associated with toxic effects. A reduction in the
function; in body composition, including increased body fat nervous system response—especially the decrease in parasympa-
and decreased body water, altering the distribution of drugs thetic activity typically seen with the aging process—increases
through the various body compartments; and in the respon- the risk that adverse anticholinergic effects will occur. Reduced
siveness to drugs that affect the CNS. A change in any one of beta-adrenergic
these processes can lead to toxic effects in elderly people. receptor sensitivity
Other body changes may affect medication use by geriatric
patients in a more general way. As vision declines with age,
(which is responsible
for bronchodilation) Notes from Nancy
makes most bron- The best dosage of a drug for
reading small print becomes more difficult. Night vision
chodilator medica- an elderly patient is the lowest
becomes less acute, so reading labels in dim light can lead to dosage that will achieve a
errors. Short-term memory loss may lead to forgetfulness about tions less effective.
The use of diuretics therapeutic effect.
whether medications have been taken. An inability to distin-
guish flavors may cause patients to take multiple doses of med- and antihypertensive
ications before they detect problems. medications by geri-
Elderly people consume more than 20% of all pre- atric patients can cause hypotension and orthostatic changes
scribed and over-the-counter drugs sold in Canada. due to reduced cardiac output and a decrease in total body
Community-dwelling older persons take an average of three to water. Finally, decreased glucose tolerance may cause medica-
five medications per day. Nursing home patients take an aver- tions such as diuretics and corticosteroids to have hyper-
age of six to seven routinely scheduled medications daily glycemic effects.
(polymedicine) and two to three additional medications on an
as-needed basis. This kind of polypharmacy may be therapeu- Drug and Alcohol Maltreatment
tic when multiple drugs are needed to manage different med- Alcohol is the preferred substance of maltreatment among older
ical problems, but it may prove harmful when these persons, in whom its use is on the rise. A much smaller but
medications interact. Elderly patients are particularly prone to increasing segment of the geriatric population uses illicit drugs.
having multiple chronic diseases, which may lead to a vicious Most users are men, and more than half carry their addiction
circle: The presence of multiple disease states leads to the use into old age. About one third develop an maltreatment problem
of multiple medications, which increases the likelihood of after reaching 65 years, often in response to a life-changing event
adverse reactions, which in turn leads to treatment with more such as the loss of a spouse, declining health, or low self-esteem.
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The prevalence of alcohol and drug misuse among older Not surprisingly, about half of all deaths of hypothermia
people is also attributable to the multiplicity of medications occur in elderly people, and most indoor hypothermia deaths
that are prescribed for them and their heightened vulnerability involve geriatric patients. Although living where harsh winters
to maltreatment owing to the effects of aging. Decreased body occur is a risk factor, hypothermia can develop at temperatures
mass and total body water means higher concentrations of above freezing when an older person is exposed for a pro-
blood alcohol; at the same time, the combination of digestive, longed period.
renal, and hepatic system changes means slower elimination of The death rates from hyperthermia are more than doubled
alcohol from the body. in elderly people compared with younger persons; people
As the geriatric population continues to grow and experi- older than 85 years are at highest risk.
ences even more chronic disabilities, the likelihood of substance
maltreatment–related problems in this group will increase. Rec- Trauma in Elderly People
ognizing substance maltreatment in older people can be difficult. Trauma is one of the top 10 causes of death among elderly peo-
If they have engaged in this behaviour for a long time, it may be ple. The mortality rate for trauma in patients older than 65
well hidden from—or even accepted by—family and friends. years is 623 per 100,000, versus 148 per 100,000 for all other
Because substance maltreatment can complicate your initial age groups. Deaths from injury in people older than 65 years
assessment and treatment, it is important to ask about this issue. account for 39% of all trauma deaths in Canada.
Several factors place an elderly person at higher risk of
Psychiatric Conditions trauma than a younger person—namely, slower reflexes, visual
and hearing deficits, equilibrium disorders, and an overall
Depression is not part of normal aging, but rather a medical
reduction in agility. In particular, changes in the body’s homeo-
disease that occurs in about 6% of the population older than
static compensatory mechanisms combined with the effects of
65 years. The good news is that it is treatable with medication
aging on body systems and any preexisting conditions usually
and therapy. The bad news is that if depression goes unrecog-
add up to less-than-favourable outcomes in trauma situations.
nized or untreated, it is associated with a higher suicide rate in
Compensation in trauma is successful when increased heart
the elderly population than in any other age group. Depression
rate, increased respiration, and adequate vasoconstriction make
in elderly patients can mimic the effects of many other medical
up for trauma-related deficits. Reduced cardiac reserve,
problems (such as dementia). Risk factors for depression in
decreased respiratory function, impaired renal activity, and
older people include a history of depression, chronic disease,
ineffective vasoconstriction, by contrast, may lead to unsuc-
and loss (function, independence, or significant others). This
cessful recovery from traumatic situations. Furthermore, an
condition may be difficult to recognize in older people because
elderly person is more likely to sustain serious injury in case of
many don’t want to complain about feeling sad, worthless, or
trauma because stiffened blood vessels and fragile tissues tear
unwanted.
more readily, and brittle, demineralized bone is more vulnera-
Disturbingly, the majority of elder suicides occur in people
ble to fracture.
who have recently been diagnosed with depression. In addi-
tion, the majority of suicide victims have seen their primary
care physician within the month before the event. Unlike
At the Scene
younger people, geriatric patients typically do not make suici-
dal gestures or attempt to get help. Instead, the rate of com- Compensatory mechanism changes + aging systems
pleted suicide is disproportionately high in the geriatric + preexisting conditions = bad outcomes.
population. Many geriatric patients see no other way out when
they have a terminal illness or debilitating cardiac or neuro-
logic condition (such as severe heart disease or stroke). At
highest risk are white men 85 years and older who use firearms Most geriatric trauma cases involve falls or motor vehicle
as their suicide method of choice. collisions. The incidence of falls, for example, increases with
increasing age. Although most falls do not produce serious
Injury in Elderly People injury, elderly people account for 75% of all fall-related deaths.
Environmental Injury This increased mortality in geriatric patients is directly related
Internal temperature regulation is slowed in elderly people and to the patient’s age, preexisting disease processes, and compli-
gets slower with increasing age. The body’s ability to recognize cations related to the trauma. Falls are associated with a higher
fluctuations in temperature becomes delayed owing to a incidence of anxiety and depression, a loss of confidence, and
slowed endocrine system. Heat gain or loss in response to envi- postfall syndrome. With this syndrome, geriatric patients
ronmental changes is delayed by atherosclerotic vessels, slowed develop a lack of confidence and anxiety about potential falls.
circulation, and decreased sweat production in the skin. In Ultimately, they may become immobile, risk incontinence, and
addition, thermoregulation can be adversely affected by develop pneumonia or pressure ulcers from lack of movement.
chronic disease, medications, and alcohol use, all of which are Falls among elderly people are evenly divided between
more frequent in elderly people. those resulting from extrinsic (external) causes, such as
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Table 42-2 Causes of Falls in the Elderly

Sometimes the headache occurs
on the same side of the head as the
Cause Clues to Suggest This Cause blood clot. With increasing
Extrinsic (accidental) Obvious environmental hazard at the scene, such as poor lighting, scatter intracranial pressure, the state of
rugs, uneven sidewalk, ice or other slippery surface consciousness becomes depressed,
Intrinsic drop attacks Sudden fall; patient found on the ground somewhat confused, often and the patient becomes increas-
temporarily paralyzed and unable to get up; no premonitory symptoms ingly drowsy.
Postural hypotension Fall when getting up from a recumbent or sitting position (Check Elderly people are also more
medications the patient is taking, and ask about occult blood loss, such vulnerable than their younger
as presence of black stools. Measure blood pressure in recumbent and counterparts to cervical spinal
sitting positions.)
cord injury and cord compression,
Dizziness or syncope Marked bradycardia or tachyarrhythmias even after apparently minor
Stroke Other characteristic signs of stroke, such as hemiparesis, hemiplegia, trauma. Degenerative changes in
or aphasia the cervical spine (cervical
Fracture Patient felt something snap before falling. spondylosis) cause arthritic “spurs”
and narrowing of the vertebral
canal; the nerve roots exiting from the cervical spine gradually
tripping on a loose rug or slipping on ice, and those resulting become compressed, and pressure on the spinal cord increases.
from intrinsic (internal) causes, such as a dizzy spell or a syn- Any injury to the cervical spine, therefore, is much more likely
copal attack Table 42-2 . The risk of falls increases in peo- to injure the already compromised spinal cord. Even a sudden
ple with preexisting gait abnormalities (such as from movement of the neck may result in spinal cord injury.
neurologic or musculoskeletal impairment) and cognitive Injuries to the chest in elderly people are much more likely
impairment. Older patients with osteoporosis have lower-den- to produce rib fracture and flail chest, owing to the brittleness
sity bones, so even a sudden, awkward turn may fracture a of the ribs and overall stiffening of the chest wall as the costo-
bone. When treating a patient who has fallen, you need to take chondral cartilage becomes calcified. Abdominal trauma often
a careful history. Although the patient often attributes the fall produces liver injury, perhaps because the liver is less pro-
to an accidental cause (“I must have tripped over the rug”), tected by abdominal musculature.
meticulous questioning often reveals a period of dizziness or Orthopedic injuries are a common result of falls in geriatric
palpitations just before the fall, suggesting a different cause. patients, with hip fractures the most common acute orthopedic
Home safety assessments by EMS—during a routine visit or as injury, followed, in severity and frequency, by fractures of the
part of an outreach program—may reduce fall incidence. femur, pelvis, tibia, and upper extremities. Hip fracture may also
After falls, motor vehicle accidents are the second leading occur without trauma, simply because of vigorous contracture of
cause of accidental death among elderly people. Of licensed driv- the hip musculature. The most important risk factor for hip frac-
ers, 10% are elderly people. They account for 10% of all traffic ture is osteoporosis: Approximately half of older women and one
deaths, 11% of all vehicle occupant deaths, and 16% of all pedes- of eight older men will have an osteoporosis-related fracture (hip
trian deaths. Impaired vision, errors in judgment, and underlying or other). An estimated 1.4 million Canadians suffer from osteo-
medical conditions contribute to the higher risk. Impairments in porosis. Treatment of osteoporosis-related fractures costs the
vision and hearing, along with diminished agility, also contribute Canadian health care system about $1.3 billion per year and is
to pedestrian deaths involving elderly people. estimated to increase to at least $32.5 billion by 2018.
Burns are a significant risk of morbidity and mortality in
Types of Injuries Commonly Seen in Elderly People
elderly people because of physiologic and pathophysiologic
Changes associated with normal aging and with diseases of aging
changes. The risk of mortality is increased when preexisting
make elderly people particularly vulnerable to certain types of
medical conditions exist, defence mechanisms to protect against
injuries. In particular, head trauma or injury is a serious prob-
infection are weakened, and fluid replacement is complicated by
lem. The increased fragility of cerebral blood vessels, enlarge-
renal compromise. In the assessment of a burn patient, para-
ment of the subdural space, and a decrease in the supportive
medics need to monitor the patient’s hydration status by assess-
tissue of the meninges all contribute to make an elderly person
ing current vital signs, mucous membranes, and urine output,
more vulnerable than a younger person to intracranial bleeding,
which is typically 50 to 60 ml/h or 1 to 2 ml/kg/h.
particularly subdural hematoma. In many cases, the hematoma
develops slowly, during days or weeks. By the time the patient
becomes symptomatic, the person or his or her caretakers may
not remember the incident, or the family or caretakers may feel Assessment of Geriatric Patients
guilty about their own negligence in the incident. As a result, it
may be difficult to obtain an accurate history of the initial Although illness is common among elderly people, it is not an
trauma. The most important early symptom of a subdural inevitable part of aging. Complaints of elderly people cannot
hematoma is headache, which may be worse at night. be ascribed simply to “getting old.” Aging is a continuous
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process and a normal development sequence that affects people illnesses—from congestive heart failure to an acute abdomen—
in multiple ways. The normal wear-and-tear concept and may present simply as delirium.
genetic makeup are two theories that have been suggested to Another challenge relates to the fact that the older the
explain the biological patient, the more likely are multiple problems—medical, psy-
effects of aging. chological, and social. Interestingly, the proportion of older
Notes from Nancy Along the same
lines, there is a wide-
people with a disability has decreased; however, the total num-
ber of older people with a chronic disability has increased sim-
Getting old is not a disease, spread misconcep- ply because there are more elderly people. Debilitating health
and it does not by itself produce tion that elderly conditions often found in this population include hyperten-
symptoms of disease. people tend to be sion, arthritic symptoms, heart disease, cancer, diabetes,
hypochondriacs, stroke, and COPD. The incidence of depression also increases
with dozens of imag- with age, with 15% to 20% of people older than 85 years hav-
inary or minor complaints. In reality, hypochondria is far less ing some form of depression.
common among elderly than among younger patients. Indeed, The co-occurrence of multiple pathologic conditions has
older patients tend not to complain, even when they have legit- several consequences for patients and health care providers
imate symptoms. When an elderly person calls for an ambu- alike. The symptoms of one disease or disability may alter or
lance, he or she hide the symptoms of another condition. The patient with
usually has a very severe leg pain from arthritis, for example, may not pay much
Notes from Nancy

real problem. attention to new pain caused by thrombophlebitis. In addi-
Knowing what is tion, when several organ systems are in borderline condition,
When an elderly person calls for and what is not part a disturbance in function in only one of the systems may have
an ambulance, there is usually a of the aging process repercussions throughout the body, leading to failure of mul-
very good reason, even if it is not constitutes the first tiple organs in a dominolike manner. The presence of multi-
the reason the patient tells you. challenge in assessing ple underlying illnesses also makes it much more difficult for
elderly people. A sec- health professionals to sort out which problem is causing
ond challenge is that which symptom. Furthermore, chronic comorbidities may
signs and symptoms of disease may be altered from their pres- make it much more difficult to treat the patient’s acute prob-
entation in younger patients as a consequence of the aging lem. For example, the medication a patient needs for a car-
process. An MI may present without chest pain; fever may be diac problem may be contraindicated because of a renal or
minimal in pneumonia; uncontrolled diabetes is more likely to hepatic problem or, at the least, may require major modifica-
present as HHNK coma than as ketoacidosis. A variety of acute tion in dosage.

After gathering the information from the nurse and Mrs. Jessup, you ask Mike what he found during his physical examination. He tells
you that he found the patient to have signs of dehydration as demonstrated by tenting of the skin and dry mucous membranes, dimin-
ished breath sounds bilaterally with rales at the right base, a slightly elevated irregular heartbeat, and an oral temperature of 39°C. He
asks what treatment you would like him to give.
At this point you ask your partner to establish IV access so that you can administer fluids to help with the dehydration and fever. He is
able to successfully insert a 20-gauge needle in the left hand. Supplemental oxygen is administered via nasal cannula at 3 l/min, and
the cardiac monitor is applied.
Reassessment Recording Time: 11 Minutes

Skin Pink, hot, and dry
Pulse 106 beats/min, weak
Respirations 22 breaths/min, regular
SpO2 98% with supplemental oxygen at 3 l/min by nasal cannula
ECG Atrial fibrillation with no ectopy
Pupils PERLA
Blood glucose level 14 mmol/l
4. What are some specific respiratory illnesses commonly seen in elderly people?
5. What are the risk factors for pneumonia in elderly people? Are any present here?
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“S” stands for social assessment. Older people may have

The GEMS Diamond less of a social network, because of the death of a spouse, fam-
ily members, or friends. Older people may also need assistance
There are many acronyms in the prehospital setting to help you
with activities of daily living, such as dressing and eating.
remember steps in your assessment and treatment. The GEMS
There are numerous social agencies that are readily available to
diamond was created to help paramedics recall key themes
help geriatric patients. Consider obtaining information pam-
when dealing with geriatric patients Table 42-3 . It was
phlets about some of the agencies for older people in your area.
designed to assist the prehospital professional in the assess-
If you have these brochures with you and encounter a person
ment and treatment of elderly patients.
in need, you can provide this valuable information. Social
“G” of the GEMS diamond is to recognize that the patient
agencies that deal with the older population will be more than
is a geriatric patient. The paramedic’s thought process needs to
happy to share a listing of the services they provide.
be geared to the possible problems of an aging patient. When
The GEMS diamond provides a concise way to remember
responding to an emergency involving an older patient, you
the important issues for older patient. Using this concept will
should consider that older patients are different from younger
help you make appropriate referrals, and as a result, you will
patients and may present atypically.
help older patients maintain their quality of life.
“E” of the GEMS diamond stands for an environmental
assessment. Assessment of the environment can help give clues
to the patient’s condition or the cause of the emergency. Is the Scene Assessment and Initial Assessment
home too hot or cold? Is the home well kept and secure? Are As you move from
there hazardous conditions? Preventive care is also very impor- scene assessment to
Notes from Nancy

tant for a geriatric patient, who may not carefully study the the initial assessment
environment or may not realize where risks exist. of a patient, gather
“M” of the GEMS diamond stands for medical assessment. information that may Always assume that an elderly
Older patients tend to have a variety of medical problems and prove relevant to the patient’s mental status is
may be taking numerous prescription, over-the-counter, and case. Look for poten- normal until you have evidence
herbal medications. Obtaining a thorough history is very tial clues from the to the contrary.
important in older patients. patient’s social history;
Table 42-3 The GEMS Diamond
G—Geriatric Patients M—Medical Assessment

I Present atypically. I Older patients tend to have a variety of medical
I Deserve respect. problems, making assessment more complex.
I Experience normal changes with age. Keep this in mind in all cases—both trauma and
medical. A trauma patient may have an
E—Environmental Assessment underlying medical condition that could have caused or may be
I Check the physical condition of the patient’s exacerbated by the injury.
home: Is the exterior of the home in need of I Obtaining a medical history is important in older patients,
repair? Is the home secure? regardless of the chief complaint.
I Check for hazardous conditions that may be I Initial assessment
present (for example, poor wiring, rotted floors, unventilated I Ongoing assessment
gas heaters, broken window glass, clutter that prevents
S—Social Assessment
adequate egress).
I Are smoke detectors present and working? I Assess activities of daily living (eating, dressing,
I Is the home too hot or too cold? bathing, toileting).
I Is there an odour of feces or urine in the home? Is bedding I Are these activities being provided for the
soiled or urine-soaked? patient? If so, by whom?
I Is food present in the home? Is it adequate and unspoiled? I Are there delays in obtaining food, medication, or other
I Are liquor bottles present? If so, are they lying empty? necessary items? The patient may complain of this, or the
I If the patient has a disability, are appropriate assistive devices environment may suggest this.
(for example, a wheelchair or walker) present? I If in an institutional setting, is the patient able to feed himself or
I Does the patient have access to a telephone? herself? If not, is food still sitting on the food tray? Has the
I Are medications out of date or unmarked, or are prescriptions patient been lying in his or her own urine or feces for prolonged
for the same or similar medications from many physicians? periods?
I If living with others, is the patient confined to one part of the I Does the patient have a social network? Does the patient have a
home? mechanism to interact socially with others on a daily basis?
I If the patient is residing in a nursing facility, does the care
appear to be adequate to meet the patient’s needs?
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Special Considerations Special Considerations

Be patient when interviewing older people,
recognizing that physical, intellectual, and psychological Interviewing Techniques
barriers may slow or interfere with effective communication. I Introduce yourself.
I Speak to the patient first rather than family or
bystanders.
general living conditions; availability of social and family support; I Be aware of your body language.
activity level; medications; overall appearance with respect to I Look directly at the patient.
nutrition, general health, cleanliness, personal hygiene; and atti- I Speak slowly and distinctly.
tude and mental well-being. Paramedics also need to be aware of I Explain what you are doing.
the numerous factors that affect the assessment process in geriatric I Allow time for the patient to answer.
patients: sensory alterations, verbal communication skills, mental I Show the patient respect, and preserve dignity.
I Do not talk about the patient with others in front of
and physical capabilities, and the ability of health care providers to
accommodate and comprehend these conditions. the patient.
I Be patient.
I Locate hearing aids or eyeglasses if needed.
Patient History
I Turn on lights.
Explain everything you plan to do, especially if the patient
seems confused. Is this confused state normal, a new manifes-
tation of a preexisting medical problem, or a patient’s lack of
understanding? A comprehensive patient history includes facial expressions, and touch communicate a message. When
many elements—the patient’s chief complaint, present illness speaking with patients, get face to face with them and make
or injury, pertinent medical history, and current health care sta- sure there is plenty of light. Have patients put in hearing aids
tus and needs. Pertinent medical history would not include or wear glasses to facilitate better communication, and be sure
information about the removal of a patient’s appendix more to take these aids with the patients to the hospital so other
than 50 years ago but would consider current cardiovascular health care providers can communicate as well.
health (such as palpitations or flutters), exercise tolerance, diet Part of your task in the assessment is to determine whether
history, medications, smoking and drinking habits, sleep pat- this confused state is normal, a new manifestation of a preexist-
terns, and other intrinsic and extrinsic factors. ing medical problem, or a result of the patient’s lack of under-
The ability to elicit a good patient history comes from edu- standing. Preserve the patient’s dignity during exposure and
cation and experience. The object is to reduce anxiety, not when discussing his or her history around others.
increase it—and if you simply whip out a lot of strange equip-
Chief Complaint
ment and start, for example, sticking electrodes onto the
Obtaining the chief complaint would seem to be a straightfor-
patient’s chest, the patient may well become frightened and
ward procedure, but it may not be simple with some elderly
wonder what is going to happen.
patients. Older patients tend not to report significant symptoms
Communication for several reasons. Many share the misconception that illness
The ability to elicit a thorough patient history reflects education and assorted aches and pains are simply part of aging. Other
and experience. Good communication skills will help you gather older people may not mention even legitimate symptoms to
the information you need during your assessment. Without good avoid being identified as old and a hypochondriac. Some
communication skills, you could frighten, alienate, insult, anger, patients fear that mentioning a symptom will lead to a diagnosis
or even harm your patients. Your first words should focus on or treatment that will jeopardize their independence. “If I men-
gaining the patient’s trust. Introduce yourself. Use respect when tion those pains in my stomach,” the old person may reason,
addressing the patient; use his or her name, if you know it; and “they’ll put me in the hospital, and I may never come out of that
avoid terms such as “honey,” “dear,” and “grandma” when place again.”
addressing an older patient. Speak slowly, distinctly, and respect- Whereas elderly patients tend to underreport serious
fully. Attempt to get the patient history from the patient, rather symptoms, the symptoms they do report are often vague and
than family and bystanders, whenever possible. apparently trivial. Furthermore, elderly patients are likely to
Communication is not just talking; it is also listening. have several chief complaints, each of which may have a differ-
When asking questions of older patients, wait for their ent source.
answers. Older people may need more time to process your When a patient’s chief complaint seems trivial, it may be
questions, and they may speak slowly when responding. Active necessary to go through a standard list of screening questions
listening also involves paying attention to the patient’s tone, to confirm that you are not missing important pieces of infor-
especially if it conveys fear or confusion. mation. In such a review of systems, questions are designed to
Nonverbal communication is just as important as verbal evaluate the functions of the body’s major organ systems. In the
communication. Eye contact, hand gestures, body position, prehospital setting, there is not sufficient time to conduct a
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complete review of systems, but a few well-chosen questions Most important, you should obtain the most detailed his-
can provide a great deal of information about the function of tory possible of the patient’s medications, because medications
the patient’s more important systems: account for a significant percentage of medical problems in el-
derly people. A medication history should include all medica-
Cardiovascular
tions, not just prescription drugs, because many people do not
I Have you had any pain or discomfort in your chest? When?
think to mention common over-the-counter preparations such
I Have you noticed any fluttering in your chest or fast
as aspirin, antacid tablets, and herbal medicines. Ask the
heartbeats?
patient to list the medications by name, and determine the dos-
Respiratory ing and frequency for each one. Also, inquire about medica-
I Do you ever get short of breath? When? tions that are prescribed but not taken (such as because of cost
I Have you had a cough lately? issues or side effects) and medications that may have been pro-
vided by other sources (such as a spouse’s medication). Obtain
Neurologic
the patient’s permission to take medications to the hospital,
I Have you had any dizzy spells? Have you fainted?
and then collect them all—prescription and nonprescription
I Have you had any trouble speaking?
drugs. If the patient cannot tell you where the medicines are
I Have you had headaches recently?
stored, check the bathroom medicine cabinet, the bedside
I Have you noticed any unusual weakness or funny
table, the kitchen table and counters, and the refrigerator.
sensations in your arms or legs?
Gastrointestinal Physical Examination
I Have there been any changes in your appetite lately? The physical examination of an elderly patient may be fraught
I Have you gained or lost any weight? with difficulties. Poor cooperation and easy fatigability may
I Have there been any changes in your bowel movements? require that you keep manipulations of the patient to a mini-
Genitourinary mum. You may have to peel many layers of clothing off an
I Do you have any pain or difficulty urinating? elderly patient to perform an adequate examination. Despite
I Have you noticed any change in the colour of your urine? these obstacles, an ill or injured geriatric patient deserves as
thorough an evaluation as a younger counterpart.
If any of these screening questions yields a positive answer, fol- Begin by observing the patient’s general appearance,
low up with further questions. For example, if the patient including dress and grooming. In some cases, inattention to
states that he has been coughing lately, find out whether he is appearance may be one of the first signs of depression or a
bringing up sputum and, if so, what the sputum looks like (for serious medical condition. Evaluate the level of consciousness
example, Is there blood in the sputum?). as you would for any patient. In a critically ill or injured
Once you have elicited what you believe to be the chief patient, use the AVPU scale. If you have more time, try to per-
complaint, go through the usual process of assembling the form a more detailed assessment of the patient’s cognitive
history of the present illness. This history may be compli- function. Is the patient fully alert? Is he or she oriented to
cated if other chronic problems are affecting the acute prob- place and time? Does the patient’s affect seem appropriate to
lem. To sort out which symptoms relate to the current chief the situation? Are there obvious disorders in thinking, such as
complaint and which are chronic difficulties, try asking ques- delusions (false beliefs)?
tions such as “How
does this problem
Notes from Nancy differ from what it At the Scene
Cover the patient with a blanket to protect pri-
Monitor every elderly patient, was like last week?”
or “What happened vacy and keep the patient warm. This action
regardless of chief complaint.
today to make you shows respect for the patient and will improve
decide to get help?” your examination.
Obtaining a history from an elderly patient requires
patience. You must be prepared to listen, often for an extended
Note the patient’s position and degree of distress. Check
period. But your listening will be rewarded—not only by help-
the colour, moisture, and temperature of the skin, bearing in
ing you discover the patient’s problem, but also by allowing
mind that the loss of elasticity in the skin of elderly patients
you to provide part of the solution to the problem. Listening is
may produce apparent signs of dehydration (such as tenting)
a demonstration of caring, and your caring can mean a great
when hydration is normal.
deal to a lonely or frightened older person.
If you are examining the patient in his or her home, take a
Other Medical History good look at the patient’s surroundings, as well as at the
Just as it is not practical to go through a comprehensive review of patient. Try to assess the patient’s self-care capability. Is every-
systems in the prehospital setting, it is not usually feasible to obtain thing neat and well maintained? Or is the home a mess, with
a complete medical history in the prehospital setting. Nevertheless, dishes piled in the sink and rubbish accumulating? Do you see
you should inquire about recent hospitalizations and allergies. evidence of alcohol consumption (such as empty bottles)? Are
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there signs of violence, such as broken glassware, that might

provide clues to elder maltreatment? Are the patient’s quarters At the Scene
adequately heated or cooled? Is the patient living alone? Does If the patient is hypotensive and is wearing a
the patient have pets? (If so, you should make arrangements nitroglycerin patch, remove it. The patient’s
for someone, such as a neighbour, to assume their care until complaint could be caused by too much or too
the patient returns.) Record these observations on the patient little of this medication.
care report to enable social service personnel to make appro-
priate arrangements for follow-up care.
Measure the patient’s vital signs carefully. Postural changes
As in all prehospital emergencies, paramedics must prioritize
in blood pressure vary among elderly people, but changes
the patient’s airway, breathing, and circulatory status. Nitro-
increase with increasing frailty and heighten the person’s risk
glycerin and morphine may produce more hypotension or res-
for falls. Marked postural changes in blood pressure and pulse
piratory compromise than in younger patients or may react
may indicate hypovolemia or overmedication. As you measure
adversely with long-term medications. Aspirin may increase
the vital signs, bear in mind that normal blood pressure for a
bleeding in a patient who is already taking anticoagulants. For
young person may represent significant hypotension in an
patients 75 years or older with ST-segment elevation infarcts,
elderly patient. If possible, determine the patient’s baseline
angioplasty offers a better outcome than peripheral fibrinolysis.
blood pressure. When obtaining a patient’s blood pressure, be
The presentation of heart failure in an older person can be
aware of the possibility of significant hypertension and ortho-
confused by symptoms and signs symbolic of old age and
static changes. Consider taking vital signs in both arms and
shared by a number of chronic diseases—for example, dyspnea
checking pulses proximally and distally in all extremities. This
on exertion, easy fatigability (especially with left-sided heart
process will allow you to gather information and observe for
failure), confusion, crackles on lung examination, orthopnea,
signs of dependent edema, dehydration, and the patient’s circu-
dry cough progressing to productive cough, and dependent
latory status without raising his or her anxiety level.
peripheral edema in right-sided heart failure. Acute exacerba-
Pay attention to the respiratory rate. Tachypnea can be a
tions of heart failure are often related to poor diet, medication
very sensitive indicator of acute illness in elderly people—
noncompliance, onset of arrhythmias such as atrial fibrillation,
especially pulmonary infection—even when patients show few, if
or acute myocardial ischemia.
any, other signs. When assessing the patient’s respirations, listen
Prehospital treatment is unchanged from that of younger
to lung sounds in all
patients, although greater consideration is given to becoming
fields, noting adventi-
familiar with the patient’s medications and their implications
Notes from Nancy tious sounds that
might aid in develop-
for your proposed treatment. For example, the patient taking
Consider the possibility of long-term furosemide (Lasix) may not respond to the usual
ment of a treatment
hypovolemia in any elderly person dose of the same drug that you administer as an acute therapy.
plan. You can also
whose systolic blood pressure is Additional treatments by paramedics should include close
use the stethoscope
less than 120 mm Hg. monitoring of fluids and avoidance of excessive fluid overload,
to listen for carotid
use of beta blockers in patients with systolic dysfunction (low
bruits; note jugular
ejection fraction), use of digoxin or diltiazem (Cardizem) in
vein distension.
patients with atrial fibrillation or atrial flutter, and, possibly,
Detailed Physical Examination use of anticoagulation therapy in patients with atrial arrhyth-
mias to prevent thromboembolism.
Conduct the detailed physical examination as you would for
Nonperfusing rhythms receive the same treatment as given
any other patient. When examining the mouth, make a note of
to younger adults. Survival depends on the prearrest health of
any upper or lower dentures. In the chest examination, keep in
the patient and the usual factors: early recognition, prompt and
mind that elderly people may have pulmonary crackles with-
effective CPR, and early defibrillation.
out apparent pathology—so don’t lunge for the nitroglycerin
Thoracic aneurysms generally remain asymptomatic until
and furosemide at the first crackle you hear in the chest. Simi-
they become large or rupture. Early symptoms may be related
larly, edema in the legs may be the result of chronic venous
to compression by the aneurysm, such as difficulty swallowing
insufficiency and not right-sided heart failure.
or hoarseness from laryngeal nerve pressure. Abdominal aortic
aneurysms present typically with abdominal pain or possibly
only with back pain. Asymptomatic thoracic and abdominal
Assessment and Management of aneurysms that do not exceed a certain size and are not
Medical Complaints in Elderly People expanding are generally treated without surgery but are
reassessed on a regular schedule. In an older patient with back
Cardiovascular Complaints pain, examine the chest and abdomen carefully. The treatment
Prehospital treatment for chest pain remains essentially of abdominal emergencies is surgical, so early recognition,
unchanged in elderly patients, albeit with extra cautions assessment, stabilization, and rapid transport to an appropriate
because of the increased potential for medication side effects. medical facility are essential.
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Esophagus
Liver
Gallbladder
Duodenum
Pancreas
Jejunum Stomach
Figure 42-6 A patient having an asthma attack may have a Colon

bronchodilator medication in a metered-dose inhaler. Older
patients often do not use an inhaler correctly, so you may need
to help with its use if your protocols allow it.
Ileum
The usual treatments for systolic hypertension usually

Rectum
prove safe and effective in geriatric patients. In case of rapid
onset of symptomatic systolic hypertension, treatment aims to
reduce the systolic pressure with antihypertensive therapy,
Figure 42-7 Upper GI bleeding occurs in the stomach,
which can minimize cardiovascular and cerebrovascular mor- esophagus, and duodenum.
bidity and mortality.
Respiratory Complaints venous thrombosis, which is a common cause of pulmonary

An older patient with pneumonia often does not have the clas- embolus. If deep venous thrombosis might be present, handle
sic presentation of chills, fever, and productive cough. Instead, the leg gently and monitor the patient for respiratory changes.
these symptoms are often supplanted by acute confusion (delir- Prehospital treatment is largely supportive after ensuring that air-
ium), normal temperature, and a minimal to absent cough. Pre- way and ventilation are adequate. Lysing the thrombus and use
hospital treatment is supportive and includes oxygen and IV of anticoagulation therapies may be considered after a risk
access as indicated. At the receiving facility, providers will deter- assessment is performed, with these measures being followed by
mine whether antibiotics or admission is appropriate. rapid transport.
Asthma clinical practice guidelines are the same for
younger and older patients Figure 42-6 . On rare occa- GI Complaints
sions, epinephrine may be indicated for a life-threatening Many causes are possible for gastric complaints. Constipation
asthma exacerbation. and its accompanying abdominal pain, for example, are some of
In a patient of any age, treatment goals for COPD are to the more common complaints of geriatric patients. In your
reduce the symptoms and complications. Along with short- assessment of a gastric emergency, ask the patient about food
ness of breath, presenting symptoms may include fatigue and and fluid intake, history of abdominal complaints, current
a decreased activity level. Treatment consists of immediate bowel and bladder habits, and medications and supplements
assessment and correction of respiratory difficulties with the before proceeding with a physical examination. Symptoms are
application of supplemental oxygen. The patient may also often vague and manifest only as diffuse abdominal pain with
receive bronchodilators to decrease the shortness of breath, no particular point of origin. Abdominal and gastric complaints
inhaled or oral steroids to decrease inflammation, and anti- often require surgical treatment, so early recognition and rapid
biotics to treat infection. transport for definitive hospital care are the best practice.
Many pulmonary emboli are silent or present with tachyp- Upper GI hemorrhage occurs when there is bleeding from
nea alone—that is, the classic triad of dyspnea, chest pain, and the esophagus, stomach, or duodenum Figure 42-7 .
hemoptysis is often altered or absent. If you suspect a pul- When severe, this condition is a true medical emergency
monary embolus, check for swelling, erythema, and warmth or that must be recognized and assessed quickly. Not only are
tenderness of the lower leg; all of these are signs of a deep older people more prone to upper GI bleeding, they are also
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at a greater risk of complications, the need for urgent surgery,

and death.
It is not possible to determine the cause of upper GI bleed-
ing without an endoscopic examination (inspection of the Esophagus
inside of a hollow organ or body cavity) of the esophagus,
stomach, and duodenum. However, the history can offer clues
to the cause. Regular use of NSAIDs or alcohol may result in
bleeding from irritation of the lining of the stomach or from
ulcers (a hollowing out or disintegration of tissue) in the stom-
ach or duodenum. Forceful vomiting can cause tears in the
Liver
esophagus that may bleed. Cirrhosis of the liver from long-
term alcohol use or chronic infectious hepatitis may cause Gallbladder
enlargement of the veins (varices) in the esophagus. These Duodenum
varices can rupture and result in massive bleeding. Stomach Pancreas
cancer or esophageal cancer can also produce upper GI bleed-
ing. Recent weight loss or difficulty swallowing would raise the Jejunum Stomach
suspicion of cancer as the source of bleeding.
On arrival at the scene, even more important than Colon
knowing the cause of bleeding is being able to assess its
severity. Slower bleeding is characterized by emesis with
coffee-grounds appearance. With minor bleeding, the heart Ileum
rate and systolic blood pressure are normal. Brisk bleeding
presents with hematemesis (vomiting red blood) or melena
Rectum
(black, tarlike stools). It is important to note that melena,
not pain, is the most common presenting symptom of GI
bleeding. Prehospital treatment is supportive, including Figure 42-8 Lower GI bleeding takes place primarily in the
adequate pain control. colon and rectum.
Lower GI hemorrhage primarily describes bleeding from
the colon and rectum Figure 42-8 and should never sim-
ply be attributed to hemorrhoids. Colon polyps and colon
cancer are also possible causes, among others. Minor lower GI
Documentation and Communication
bleeding is characterized by small amounts of red blood cov-
ering formed brown stools or scant amounts of red blood A stroke is a traumatic and emotional event for the
noticed on the toilet paper. Severe lower GI bleeding is char- patient, and a sensitive and compassionate approach is
essential. Even though the patients may not be able to com-
acterized by passing significant amounts of red blood or
municate with you, they can often understand. Communi-
maroon-coloured stools.
cate with them as you would any other patient—in a calm
Assessment should begin with identifying risk factors such and reassuring manner.
as a history of previous lower GI bleeding, symptoms or signs
suggestive of colon cancer, recent constipation or diarrhea, and
use of medications such as blood thinners. Treat for shock.
Severe lower GI bleeding requires immediate transportation to
syncope and for changes in these symptoms and in mood and
the nearest emergency department.
sleep patterns.
Dementia signs and symptoms take months to years to
Neurologic and Endocrine Complaints become apparent and may include short-term memory loss or
Effective prehospital acute stroke care includes early recogni- shortened attention span, jargon aphasia (talking nonsense),
tion, discovery of stroke-mimics such as hypoglycemia or hallucinations, confusion, disorientation, difficulty in learning
hypoxia, and timely transport to the most appropriate facility. and retaining new information, and personality changes such
Use a stroke assessment tool as appropriate, taking the as social withdrawal or inappropriate behaviour. Dementia is
patient’s history into account when assessing the components not synonymous with delirium, however, and a patient with
of the scale. An older person with severe arthritis may not dementia can also have delirium. In delirium, assess for recent
move as well on one side, or damage from a previous stroke changes in the patient’s level of consciousness or orientation.
may make his or her speech difficult to assess. Always ask Specifically, look for an acute onset of anxiety, an inability to
family or caregivers for information that may help you identify think logically or maintain attention, and an inability to focus.
deviations from the patient’s normal pattern of behaviour or Also assess for changes in vital signs, temperature (indicating
activity. Assess for new weakness, fatigue, syncope, and near infection), glucose level, and medications—all frequent causes
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of delirium. Use the mnemonic “DELIRIUMS” to identify other As mentioned earlier, many elderly people take a variety of
causes of delirium: drugs. Patients may be taking medications prescribed by more
D Drugs or toxins than one physician, each dispensing prescriptions without
E Emotional (psychiatric) knowledge of the others’ orders. Patients may also take over-
L Low PaO2 (carbon monoxide poisoning, COPD, congestive the-counter medications or medications prescribed for a family
heart failure, acute myocardial infarction, pneumonia) member or friend.
I Infection (pneumonia, urinary tract infection, sepsis) Another factor contributing to the toxic effects of drugs in
R Retention of stool or urine elderly people is aging-related alterations in pharmacokinetics
I Ictal (seizures) (that is, the absorption, distribution, metabolism, and excre-
U Undernutrition or underhydration tion of drugs). Pharmacokinetics may also be influenced by
M Metabolism (thyroid or endocrine, electrolytes, kidneys) diet, smoking, alcohol consumption, and use of other drugs.
S Subdural hematoma Drugs such as digoxin that depend on the liver and kidney for
Altered mental status is a symptom, not a disease. As a metabolism and excretion are particularly likely to accumulate
consequence, the assessment and subsequent management of to toxic levels in older patients. With most drugs, we know lit-
its numerous causes is complicated. Always consider head tle about the optimal dosage for elderly people because nearly
injury (medical or traumatic), heart rhythm disturbances, all clinical trials to establish the safe dosages of drugs are per-
dementia, medications, fluid balance changes (such as blood formed in young populations. For the most part, dosages for
loss), respiratory disorders (such as hypoxia), endocrine elderly people need to be reduced compared with those for
changes (such as blood glucose level fluctuations), hyperther- younger patients (“Start low, go slow”).
mia or hypothermia, and infection. Most important, para- Although almost any drug can produce toxic effects in an
medics need to consider neurologic causes (such as Alzheimer’s older person, certain drugs and classes of drugs are implicated
disease and Parkinson’s disease) and endocrine changes (such more often than others; Table 42-4 lists the “dirty dozen.”
as diabetes). Typically toxic effects present with psychiatric symptoms (such as
In Alzheimer’s disease, symptoms may present as confusion hallucinations, para-
(lack of familiarity with surroundings), changes in personality or noia, delusions, agita-
Notes from Nancy

judgment, and extreme difficulty with daily activities, such as tion, and psychosis)
feeding, bathing, and bowel and bladder control. Parkinson’s dis- and cognitive im-
ease may present as dyskinesia (involuntary movements or pairment (such as Bring all of the patient’s
tremors affecting one or both sides of the body), dementia, depres- delirium, confusion, medications—prescription
sion, autonomic dysfunction (bladder and GI problems), and pos- disorientation, amne- and nonprescription—to the
tural instability (loss of reflexes or inability to “right oneself”). sia, stupor, and coma) hospital.
Many endocrine changes may have occurred earlier in life Figure 42-9 .
and been diagnosed before intervention by paramedics became
necessary. Geriatric patients may have diseases such as Grave’s Sepsis
disease (hyperthyroidism), Addison’s disease (hypoadrenalism), Infections in older persons can be severe and dangerous. Sepsis
Cushing’s syndrome (hyperadrenalism), osteoporosis, is the disease state that results from the presence of microorgan-
or diabetes. In the isms or their toxic products in the bloodstream. This is a serious
assessment of geri-
Notes from Nancy atric patients with
diagnosed diabetes,
Delirium in the elderly is always look for signs of
a sign of physical illness or drug dehydration or hyper-
intoxication and is always an glycemia (the three
emergency. Ps: Polyuria, Polydip-
sia, and Polyphagia).
New-onset diabetes in geriatric patients is often a mild progres-
sion that produces no symptoms.
Toxicologic Complaints
The most common therapeutic error in cases of reported poi-
son exposure is “inadvertently took/given medication twice” or
“double dosing.” In essence, medications are poisons with ben-
eficial side effects. This definition emphasizes the need for
Figure 42-9 The toxic effects of drugs may initially manifest in
obtaining a careful history and collecting and transporting all the form of confusion.
medications with the patient.
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Table 42-4 Drugs Most Commonly Causing Toxic Reactions in Elderly People
and general malaise. Cellulitis can
cause warmth, swelling, redness,
Medication Symptoms tenderness, and enlarged nodes in
Anti-inflammatory agents Drowsiness, dizziness, confusion, anxiety, the affected area. Blood tests may
(NSAIDs, steroids) bradypnea, tachypnea, GI bleeding show elevation of the white blood
Antibiotics GI signs, altered mental status, seizures, coma cell count and the presence of
Anticholinergics and Urination difficulty, constipation, drowsiness, bacteria. Treatments include
antihistamines restlessness, irritability, hypertension antibiotic therapy, ensuring ade-
Anticoagulants (warfarin) Ecchymosis, epistaxis, hematuria, abdominal pain, quate fluid intake, and local
vomiting, fecal blood dressings if there is an open sore.
Antiarrhythmics Restlessness, hypotension, bradycardia,
(amiodarone, lidocaine) tachycardia, palpitations, angina Psychological
Antidepressants (tricyclics, long-acting Confusion, delirium, disorientation, memory Complaints
selective serotonin reuptake inhibitors) impairment
Depression can be a normal,
Antihypertensives (diuretics, alpha blockers, Hypotension, palpitations, angina, fluid retention,
short-term reaction to a particu-
beta blockers; angiotensin-converting headache
enzyme inhibitors) lar event. When sadness, restless-
Antipsychotics (phenothiazines, atypicals) Drowsiness, tachycardia, dizziness, restlessness
ness, fatigue, and hopelessness
persist for weeks, however, it
Digoxin Headache, fatigue, malaise, drowsiness, depression
becomes a larger concern.
Insulin and oral antidiabetic medications Hypoglycemia presenting as confusion
Depression in the geriatric popu-
Narcotics Delirium, respiratory depression, apnea, involuntary lation is a major health problem
muscle movements
with an incidence growing in tan-
Sedative-hypnotics (benzodiazepines, Incoordination, dizziness, disturbances in dem with the progressive aging of
barbiturates) cognitive function
the population. This trend can be
attributed to increases in poly-
pathology, psychosocial stress, and aging-related changes in
problem that every paramedic should know how to recognize the brain that collectively lead to greater cognitive impair-
and treat. Think of sepsis whenever you see a hot, flushed ment, increased medical illness, dependency on health care
patient who is also tachycardic and tachypneic. Other signs of services, and more suicide attempts Figure 42-11 .
sepsis include an oral temperature greater than 38°C or less Depression may also occur when a patient takes a variety of
than 36°C, a respiratory rate of more than 20 breaths/min or medications; such polypharmacy is more likely when the per-
PaCO2 less than 32 mm Hg, and pulse rate of greater than 90 son has multiple medical conditions that result in more vul-
beats/min. Sepsis can be caused by bacteria, fungi, and viruses. nerability to toxic effects.
When dealing with psychological emergencies with geri-
Skin Complaints atric patients, paramedics need to determine whether the situa-
Herpes zoster (shingles) is caused by the reactivation of varicella tion is a true behavioural emergency or a behavioural crisis.
virus on nerve roots. This condition is more common in the A behavioural emergency implies a significant risk of serious
older population. Most people with herpes zoster are in good
health, but people with cancer or immunosuppression are at
higher risk. This condition affects any nerve in the body, but the
thoracic nerves and the ophthalmic division of the trigeminal
nerve are most common. The disease usually starts with pain in
the affected area. Subsequently, a cluster of tiny blisters (vesi-
cles) erupts on reddened skin in the same area. The rash is typi-
cally unilateral; it rarely crosses the midline.
One of the most common complications of herpes zoster is
pain, or postherpetic neuralgia. During the acute phase of the
infection, the person may have severe pain and require narcotic
pain relievers. Antiviral medications such as acyclovir and fam-
ciclovir can be used, preferably within 48 hours of the activa-
tion of the disease. These medications decrease healing time,
new lesion formation, and pain.
Cellulitis is an acute inflammation in the skin caused by a
Figure 42-10 Cellulitis is a diffuse, acute inflammation in the
bacterial infection Figure 42-10 . This condition usually skin caused by bacterial infection.
affects the lower extremities. Symptoms include fever, chills,
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Management of Medical
Emergencies in Elderly People
The assessment and management of medical emergencies in
geriatric patients can be complex. If you are well prepared to
deal with these complex situations, you will not feel quite so
overwhelmed and helpless.
In every emergency, you should first complete a scene size-
up to confirm the scene safety, determine the nature of the call,
identify the number of potential patients, and ascertain the
need for additional resources. Next, you should perform an ini-
tial assessment, which consists of several quick, yet complex
observations. First, formulate a general impression based on
the patient’s mental status and the status of his or her airway,
Figure 42-11 Isolation and chronic medical problems are among breathing, and circulatory systems. Then, determine trans-
the factors that contribute to depression in older adults.
portation priorities.
With the exception of patients who require immediate
interventions to maintain a patent airway, adequate and sup-
portive breathing, or circulatory status, most prehospital care is
supportive and focuses on pain relief and palliative interven-
tions. Additional steps in the patient treatment plan will
depend on the patient’s specific medical emergency and chief
complaint.
Table 42-5 reviews common medical complications
encountered with geriatric patients and their management
strategies.
Assessment and Management

of Trauma in Elderly Patients
Begin the assessment by looking at the mechanism of injury.
Figure 42-12 A patient in a behavioural crisis may be searching Falls account for the largest number of injuries in elderly
for alternative methods of coping. people, followed by injuries related to motor vehicles
(including passenger and pedestrian trauma) and then burns
and other injuries. Always look for signs or symptoms that
harm to self or others unless intervention is undertaken imme- the patient may have experienced a medical problem before
diately. Examples include serious suicidal states, potential vio- the trauma. A syncopal event while driving, for example,
lence, and impaired judgment that could leave a person at risk may result in a collision.
of injury or death. In a behavioural crisis, the patient’s ability to The initial management of an injured elderly patient fol-
cope is insufficient and becomes overwhelmed, sending the lows the basic ABC pattern of trauma care with some special
patient in search of alternative methods of coping concerns.
Figure 42-12 . While securing the airway, check for dentures. If they are
When dealing with a patient’s mental illness or psychotic intact and in place, leave them where they are; if the dentures
episodes, always remember that a person who is psychotic is out are broken or loose in the mouth, remove them and place them
of touch with reality. Many forms of psychotic behaviour are in a safe container. Aggressive suctioning of blood or secretions
possible, including schizophrenic and paranoid behaviours. All is required because of the older patient’s lessened airway and
symptoms associated with psychotic conditions may not be pres- gag reflexes Figure 42-13 .
ent when a patient is having an episode, however. Clues to psy- When assessing breathing, check for rib fracture. If
chotic behaviour might include the patient becoming excited or assisted ventilation is required, use a bag-valve-mask gently,
angry for no apparent reason, engaging in antisocial activity or exerting just enough pressure to inflate the lungs so as to
being a loner, and sleeping during the day and staying awake at lessen the chance of creating a pneumothorax. Administer
night. Information about changes in the patient’s normal routine supplemental oxygen early to assist the body in compensating
may be obtained from family, friends, or caregivers. for early states of trauma.
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Table 42-5 Common Medical Complications in Elderly People and Their Management
Medical Complication Management

Incontinence Some cases are managed surgically. Other considerations include absorptive devices for fecal and urinary
incontinence, placement of catheters, and awareness of the patient’s self-esteem and social issues.
COPD Nebulizer treatment with a bronchial dilator could include metaproterenol (Alupent), racemic epinephrine,
isoetharine (Bronkosol), ipratropium (Atrovent), and salbutamol (Ventolin) or an IV dose of
methylprednisolone (Solu-Medrol).
Pulmonary emboli Lysing the thrombus and anticoagulation therapies are indicated. Once all risk factors for bleeding have
been reviewed, anticoagulants such as heparin or enoxaparin (Lovenox) can be considered.
Heart failure Heart failure that produces signs and symptoms of pulmonary edema can be managed with sublingual
nitroglycerin, IV furosemide (Lasix), and IV morphine. Paramedics can also consider a vasoactive
medication such as dopamine (Intropin) for patients with hemodynamically unstable hypotension.
Arrhythmias Unless a patient is in unstable condition, arrhythmias are handled with supportive care only. Unstable
arrhythmias are treated following current CPR and electrocardiographic guidelines.
Aneurysm Treatment is handled surgically, and prehospital interventions focus on supportive care.
Hypertension Hypertensive emergencies require a controlled decline in blood pressure, which is not often feasible in
prehospital care. A hypertensive crisis or urgency may be addressed by using labetalol (Trandite) or
sodium nitroprusside (Nipride).
Cerebral vascular disease Prehospital management targets recognition and support. Definitive treatment is surgery.
Delirium Recognize and treat the underlying cause, and provide supportive interventions.
Dementia, Alzheimer’s disease, Provide supportive care.
Parkinson’s disease
Diabetes In hypoglycemia, treatments address the elevation of the blood glucose level with intramuscular or IV
injections when not contraindicated. In hyperglycemia, treatment aims to eliminate additional glucose
by using fluid boluses for patients with adequate renal function.
GI problems Few treatments using medications for GI problems are possible in the prehospital environment,
other than antiemetics. For nausea and vomiting, consider promethazine (Phenergan), dimenhydrinate,
or prochlorperazine (Gravol) (Stemitil).
Drug toxic effects • Lidocaine: CNS depression may occur, so be alert for respiratory changes. No antidote is used in
prehospital care to reverse its effects.
• Beta blockers: Provide supportive care; give activated charcoal; and consider the use of atropine,
epinephrine, and glucagon in symptomatic patients.
• Antihypertensives: Provide supportive care. No antidote is used in prehospital care to reverse the
drugs’ effects.
• Diuretics: Provide supportive care. Consider treatments aimed at restoring volume depletion and
electrolyte imbalance. No antidote is used in prehospital care to reverse the drugs’ effects.
• Digitalis: Provide supportive care. Consider fluid replacement, vasoactive medications such as
dopamine, and activated charcoal.
• Psychotropics: Provide supportive care. Consider aggressive fluid replacement.
• Antidepressants: Provide supportive care. Give fluid therapy for hypotension and sodium bicarbonate.
Alcohol maltreatment Provide supportive care. Later care includes identification of maltreatment potential and referral to an
appropriate treatment facility.
Behavioural disorders Use psychological support and communication strategies. Consider haloperidol (Haldol), droperidol
(Inapsine), or chlorpromazine (Largactil).
Depression, suicide Provide supportive care. Later care includes identification of the potential condition and referral to an
appropriate treatment facility.
When evaluating circulation, remember that what is a nor- expose the entire injured area, even if it means peeling away
mal blood pressure in a younger person may mean hypoten- many layers of clothing.
sion in an older person. If possible, try to determine the Once the initial assessment is complete, try to obtain a
patient’s normal baseline blood pressure and circulatory status. complete history of the trauma event from the patient and from
The initial assessment of disability (neurologic status) anyone who may have witnessed the event Figure 42-14 .
should include an evaluation of the pupils and the level of con- If the patient fell, from what height? Did the patient have any
sciousness, according to the AVPU scale. Finally, be sure to symptoms beforehand, such as dizziness? If the patient was
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A B C
Figure 42-13 The airway should initially be addressed using simple techniques, such as (A) the modified jaw-thrust, (B) placement of an
oropharyngeal or nasopharyngeal airway, and (C) suctioning.
struck by a car, how fast was the car moving? If the patient was
the driver of a car involved in an accident, did he or she feel
dizzy or black out before the collision? Did the patient have
chest pain? Did witnesses notice the car moving erratically
before it collided?
Obtain a complete list of all medications the patient takes
regularly. Inquire in particular about beta blockers, antihyper-
tensives, and medications for diabetes because they may
affect the patient’s response to resuscitation measures and to
anesthesia.
Conduct the focused physical examination as usual, stay-
ing particularly alert for signs of injuries to the head, cervical
spine, ribs, abdomen, and long bones. Pain from fractures or
peripheral injury may be difficult to assess if the patient has
Figure 42-14 History is especially important in older patients
who have lost consciousness.
decreased pain perception.

You place your patient on a stretcher in a semi-Fowler’s position and move her to the ambulance. While en route to the hospital, she
begins to complain of being “a little winded.” A reassessment reveals no changes in her status. Your partner suggests administering a
nebulizer treatment with salbutamol. You agree, and the patient receives a nebulizer treatment with 2.5 mg of salbutamol with 2.5 ml
of normal saline. Report is called en route to the emergency department, and no further orders are given.
As you arrive at the emergency department your patient says that she is breathing easier and thanks you for being so caring. She is
observed in the emergency department for a few hours, and right lower lobe pneumonia is diagnosed by chest radiograph. She is
admitted to the hospital for treatment with IV antibiotics and is discharged to the nursing home on the fifth day.
Reassessment Recording Time: 20 Minutes

Skin Pink, hot, and dry
Pulse 113 beats/min, strong and irregular
Respirations 22 breaths/min regular
SpO2 95% with supplemental oxygen at 3 l/min by nasal cannula
ECG Atrial fibrillation
6. Does pneumonia present the same in elderly people as in younger people?

7. How is pneumonia managed in the prehospital setting?
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Additional treatment will depend on the patient’s specific

injuries, although there are a few general principles to keep
in mind:
I Insert an IV cannula and give an isotonic solution, but use
caution. It is very easy to overload an elderly person with

sodium, and you must balance that with the need to
maintain adequate perfusion pressure. Use small boluses,
and reassess the patient frequently, especially for signs of
pulmonary edema.
I Monitor cardiac rhythm throughout prehospital care of the
patient, and be alert for changes. Previous or continuing

cardiac disease predisposes a person to ECG changes.
I Take steps to preserve temperature in elderly trauma
patients. Regulation of temperature is slowed in elderly

people, and the blood in cold patients does not clot as well.
I Frail elderly patients may not do very well with a traction Figure 42-15 Take time to listen patiently to older patients.
splint for a femoral fracture. If possible, place the patient
on a well-padded backboard and buttress him or her well
with pillows secured firmly in place. personnel and remain with the patient only if the scene
I Immobilize the cervical spine before transporting the
remains safe to do so.
patient. Pad the backboard generously, because the skin of Across Canada, different laws apply in different types of
an older person may be damaged by the direct trauma of maltreatment situations. Four main types of laws help to pro-
the pressure and the decrease in blood flow. Target areas tect older adults from maltreatment and neglect. Nevertheless,
where the bone is near the surface, from top to bottom: most elder maltreatment cases are never reported. In Canada,
occiput, scapula, spinous processes, elbows, sacrum, and certain categories of maltreatment are crimes under the Crimi-
heels. A pressure ulcer can develop in as little as 45 nal Code of Canada, and some types of maltreatment are also
minutes and can complicate the original injury. offences under provincial jurisdiction. You should become
familiar with the legislation that applies to your area. However,
regardless of the legislation, if you have any reason to suspect
Elder Maltreatment elder maltreatment in a given case of geriatric injury—for
example, if you found evidence of gross patient neglect in the
One category of geriatric trauma that deserves special mention patient’s residence—carefully document your observations and
is elder maltreatment—that is, any form of mistreatment that report your findings and suspicions to the receiving facility. For
results in harm or loss to an older person. Five types of mal- more information on this topic, see Chapter 43.
treatment are distinguished: physical, sexual, emotional, neg-
lect, and financial. The first four are similar to the forms found
in child maltreatment. Financial maltreatment involves End-of-Life Care
improper use of an older person’s funds, property, or assets.
The average victim of elder maltreatment is 80 years old, is You will inevitably be involved with end-of-life care for many
female, and has multiple chronic conditions. These conditions patients. Of course, “do not resuscitate” (DNR) does not mean
make patients unable to function on their own, leaving them “do not respond to the needs of a terminal patient.” There is
dependent on others for at least part of their care. The mal- much you can do, beginning with demonstrating a caring and
treater is almost always known to the victim and is often a concerned attitude and approach. Many of your visits may be
family member (such as adult children or a spouse). “no transport” decisions and may not be perceived as valuable
One clue to elder maltreatment is unexplained injuries that by those who decide on reimbursement, but they prove no less
do not fit the stated cause. Assessment of elder maltreatment
must include not only the physical examination, but also the
environmental and social clues. Look at the patient’s overall Controversies
hygiene, and review how he or she interacts with caregivers. Many jurisdictions have implemented advance direc-
Take adequate time to listen patiently to any concerns tives and “do not resuscitate” (DNR) orders in the
expressed by older patients about their care (or lack of it) community setting. These are similar to those used in the
Figure 42-15 . If the patient’s condition is stable but the hospital setting. You should be aware of what policies are in
situation is unsafe, see if the patient will accept transportation place in your region and adhere to them, because they are
to the hospital. If the patient refuses transport, see if he or she the patient’s expressed wishes in the setting of a cata-
will accept help from the local adult protective services. If the strophic or terminal event.
situation is immediately unsafe, notify law enforcement
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valuable to the patient than more aggressive measures. Many

communities have a local hospice, an organization that pro-
vides terminal care for patients and support for their families.
If one exists in your community, consider how you or your
service might collaborate on providing quality care for a person
at the end of life Figure 42-16 .
Figure 42-16 Hospice care allows people with terminal illnesses

to receive palliative care in their own homes.
You are the Paramedic Summary

1. Why is it important to review common medical problems of 4. What are some specific respiratory illnesses commonly seen
elderly people? in elderly people?
Well, like it or not, we are not getting any younger. As a matter of Respiratory illnesses commonly seen in elderly people include
fact, more than 4.3 million Canadians are older than 65 years; pneumonia, COPD, and pulmonary embolism.
that is 13% of the population! It is predicted that by the year
5. What are the risk factors for pneumonia in elderly people?
2026, the older population will have increased from 4.3 million to
Are any present here?
8 million. As we age, our bodies undergo numerous physical
changes that affect the way we respond to illness and disease. Residing in an institutional environment, chronic illness, and a com-
Keeping up-to-date with medical problems of elderly people is just promised immune system are all risk factors for contracting pneu-
as important as staying current on other kinds of emergencies. monia. In our case, Mrs. Howard resides in a nursing home and has
diabetes, which increases her chances of getting pneumonia.
2. Which organ systems are greatly affected by age-related
changes? 6. Does pneumonia present the same in elderly people as it
does in younger people?
Although the aging process affects all body systems, the organ
systems most relevant to older patients are the respiratory, car- If you are expecting to find a patient presenting with fever, pro-
diovascular, renal, nervous, and musculoskeletal. ductive cough, chest discomfort, and chest congestion, keep
looking! The clinical presentation of pneumonia in elderly people
3. Why might obtaining an accurate medical history and will fool you. Rather than presenting with the “classic clinical
history of the present illness be challenging when picture” described above, an elderly person with pneumonia
interviewing an elderly patient? might present with altered mental status, cough, fever, short-
The elderly patient can present with numerous challenges that ness of breath, tachycardia, and tachypnea.
might make patient assessment tricky. These include having
7. How is pneumonia managed in the prehospital setting?
more than one chronic illness, not feeling pain the same way a
younger person might, difficulty distinguishing acute from Prehospital management of pneumonia is aimed at supportive
chronic problems, fear of being hospitalized, and fear of losing care. Ensuring an adequate airway and oxygenation and a little
control over their ability to care for themselves. It is important tender loving care will go a long way for most of your patients.
to be patient and look for subtle clues when assessing an older Definitive treatment for pneumonia is the administration of
person. antibiotics.
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Ready for Review deficiencies, and infections such as urinary tract infections and
pneumonia.
I Elderly people constitute an ever-increasing proportion of I Unlike delirium, dementia is a disease that produces irreversible
patients presenting to the health care system, particularly to the brain failure. Disorders that cause dementia include conditions that
emergency care sector. impair vascular and neurologic structures within the brain, such as
I The health problems of older people are quantitatively and quali- infections, stroke, head injuries, poor nutrition, and medications.
tatively different from those of younger people. The special prob- I The two most common degenerative types of dementia in older
lems of older people require special approaches. people are Alzheimer’s disease and multi-infarct or vascular
I The aging process is accompanied by changes in physiologic func- dementia, both of which cause structural damage to the brain.
tion. The decrease in the functional capacity of various organ sys- I Elderly people are particularly prone to adverse drug reactions
tems can affect the way in which the patient responds to illness. because of changes in the following: drug metabolism because of
I A variety of changes occur in the cardiovascular system as a per- diminished hepatic function; drug elimination because of dimin-
son ages. The heart hypertrophies (enlarges), arteriosclerosis (the ished renal function; body composition, including increased body
stiffening of vessel walls) develops, and the electric conduction fat and decreased body water, altering the distribution of drugs
system of the heart deteriorates. through the various body compartments; and the responsiveness
I A person’s respiratory capacity also undergoes significant reduc- to drugs of the central nervous system.
tions with age due to decreases in the elasticity of the lungs and in I Alcohol is the preferred substance of maltreatment among older
the size and strength of the respiratory muscles, calcification of cos- persons, in whom its use is on the rise. A much smaller but
tochrondral cartilage in the chest wall, and musculoskeletal changes. increasing segment of the geriatric population uses illicit drugs.
I Geriatric patients may experience renal system changes. Although I Depression in elderly patients can mimic the effects of many other
the kidneys of an elderly person may be capable of dealing with medical problems (such as dementia). Risk factors for depression
day-to-day demands, they may not be able to meet unusual chal- in an older person include a history of depression, chronic disease,
lenges, such as those imposed by illness. Therefore, acute illness and loss (function, independence, or significant others).
in elderly patients is often accompanied by derangements in fluid I Several factors place an elderly person at higher risk of trauma
and electrolyte balance. than a younger person: slower reflexes, visual and hearing
I Changes in the endocrine system may lead to diabetes and thy- deficits, equilibrium disorders, and an overall reduction in agility.
roid abnormalities in older patients. I Most geriatric trauma cases involve falls or motor vehicle colli-
I Aging brings a widespread decrease in bone mass in men and sions. Falls among elderly people are evenly divided between
women, but especially among postmenopausal women. Bones those resulting from extrinsic (external) causes, such as tripping
become more brittle and tend to break more easily. on a loose rug or slipping on ice, and those resulting from intrinsic
I Changes in the nervous system lead to a decrease in the perform- (internal) causes, such as a dizzy spell or a syncopal attack.
ance of sense organs, as evidenced by visual changes (glaucoma I Knowing what is and what is not part of the aging process consti-
and cataracts are common) and hearing loss. tutes the first challenge in assessing elderly patients. A second chal-
I Diseases of the heart remain the leading cause of death among lenge is that signs and symptoms of disease may be altered from
older adults in Canada. Heart attack is the major cause of morbid- their presentation in younger patients as a consequence of aging.
ity and mortality in people older than 65 years, and its potential I When a patient’s chief complaint seems trivial, it may be necessary
for mortality increases significantly after 70 years. to go through a review of systems to confirm that you are not miss-
I Stroke is a significant cause of death and disability in elderly peo- ing important pieces of information. If any of the screening ques-
ple. More than 80% of all stroke deaths occur in persons older tions yields a positive answer, follow up with further questions.
than 65 years, and stroke is the leading cause of long-term dis- I The physical examination of older patients can be difficult. Poor
ability at any age. cooperation and easy fatigability may require that you keep
I Chronic lower respiratory disease, influenza, and pneumonia manipulations of the patient to a minimum. You may have to peel
remain in the top five causes for geriatric deaths. many layers of clothing off elderly patients to perform an ade-
I A geriatric patient with diabetes is at increased risk for hypo- quate examination.
glycemia for several reasons: medications, inadequate or irregular I Infections in older persons can be severe and dangerous. Consider
dietary intake, inability to recognize the warning signs due to cog- sepsis whenever you see a hot, flushed patient who is also tachy-
nitive problems, and/or blunted warning signs. Delirium may be cardic and tachypneic.
the only indication of hypoglycemia in an elderly patient. I Elder maltreatment is any form of mistreatment that results in
I Older diabetics whose blood glucose levels tend to be high are harm or loss to an older person. Five types of maltreatment are
prone to hyperosmolar hyperglycemic nonketotic (HHNK) coma. distinguished: physical, sexual, emotional, neglect, and financial.
The most frequent cause for HHNK is infection. Presentation is
likely to be acute confusion with dehydration.
I Gastrointestinal problems in elderly people include peptic ulcer Vital Vocabulary
disease, small bowel obstruction due to gallstones, and stomach bereavement Sadness from loss; grieving.
or duodenal ulcers (peptic ulcer disease).
delirium An acute confusional state characterized by global impair-
I Osteoporosis is characterized by a decrease in bone mass leading
ment of thinking, perception, judgment, and memory.
to reduction in bone strength and greater susceptibility to frac-
ture. Osteoarthritis is a progressive disease process of the joints dementia A chronic deterioration of mental functions.
that destroys cartilage, promotes the formation of bone spurs in geriatrics The assessment and treatment of disease in someone 65
joints, and leads to joint stiffness. years or older.
I In elderly people, delirium often replaces or confounds the typi- homeostasis A tendency to constancy or stability in the body’s inter-
cal presentation caused by a medical problem, an adverse med- nal milieu.
ication effect, or drug withdrawal. Disorders that cause delirium hospice An organization that provides end-of-life care to patients
may also include poisons, electrolyte imbalances, nutritional with terminal illnesses and their families.
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osteoporosis A decrease in bone mass and density. review of systems A systematic survey of the patient’s symptoms
polypharmacy The use of multiple medications. according to the major organ systems.
presbycusis Progressive hearing loss, particularly in the high fre- sepsis A disease state that results from the presence of microorgan-
quencies, along with lessened ability to discriminate between a par- isms or their toxic products in the bloodstream.
ticular sound and background noise. spondylosis Immobility and consolidation of a vertebral joint.
proprioception The ability to perceive the position and movement of
one’s body or limbs.
Assessment in Action
You are dispatched to a private residence for a fall. When you arrive on scene, you find an elderly man lying on his
back. A large pool of blood is around his head. The patient is conscious, alert, and oriented to person, place, and
day. He denies experiencing any loss of consciousness. He states that he was trying to get around the corner and
tripped over his feet. His wife tells you that he has neuropathy to both his lower legs, bilateral knee replacements,
and a hip replacement. He also has a history of blood clots and hypertension. His medications include lisinopril
(Zestril) and warfarin (Coumadin). He has a large laceration to the back of his head. His vital signs are stable.
1. A common change seen in the cardiovascular system of 5. For what reasons are elderly persons particularly prone to
the elderly patient is: adverse drug reactions?
A. neuropathy. A. Changes in drug metabolism because of diminished
B. hypertrophy. hepatic function
C. increased inotropy. B. Changes in drug elimination because of diminished renal
D. increased automaticity. function
C. Changes in body composition, increased body fat, and
2. Changes in thinking, speed, memory, and postural
decreased body water
stability are effects of the:
D. Changes in responsiveness to drugs that affect the
A. cardiovascular system.
central nervous system
B. nervous system.
E. All of the above
C. pulmonary system.
D. renal system. 6. The underlying causes of falls among the elderly are
classified as being:
3. What is homeostasis?
A. extrinsic and intrinsic.
A. Maintaining the constancy of the external environment
B. medical illness and trauma.
B. An acute confusional state
C. extrinsic and external.
C. A decrease in bone mass and density
D. intrinsic and internal.
D. Maintaining the constancy of the internal environment
7. In the elderly, _________________________ are MOST
4. What is osteoarthritis?
common after a fall.
A. A progressive disease process of the joints resulting in
A. epidural hematomas
the destruction of cartilage
B. subdural hematomas
B. A condition that affects only women and is characterized
C. intracerebral aneurysms
by a decrease in bone mass
D. ruptured cerebral arteries
C. Atrophy of the supporting structures of the body
D. A condition in which muscle fibres are smaller and fewer Challenging Question
in numbers
8. Why do many geriatric patients present atypically when
they experience an injury or illness that causes shock?
73991_CH42_002_031.qxp 6/13/09 5:44 AM Page 31

Points to Ponder
It’s 19:00 hr and your shift has just begun. You are dispatched to the pulse oximetry, 95% on room air. The patient tells you that this pain
assisted-living facility across town for an 86-year-old woman with began after she received a phone call from her daughter, who was
chest pain. You recognize the address and apartment number as one supposed to come and visit her and is now unable to do so.
that you have been to on several occasions. When you arrive, the Does this patient need to be transported immediately? How will you
patient’s condition appears stable, but she has chest pain on palpa- manage this patient?
tion, inspiration, and movement. Her vital signs are as follows: pulse
Issues: Being an Advocate for the Elderly, Recognizing the Need for
rate, 58 beats/min with sinus bradycardia on the cardiac monitor;
Independence in the Elderly.
blood pressure, 110/72 mm Hg; respiratory rate, 16 breaths/min; and

Competency Areas: Area 2: Communication

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qxp 6/10/09 9:54 AM Page 2

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Competency Areas H. Musculoskeletal System

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owing to the larger number of older persons in Canada, a

You are the Paramedic Part 1

Initial Assessment Recording Time: 0 Minutes

1. Why is it important to review common medical problems of elderly people?

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Figure 42-1 EMS professionals should be familiar with available Calcium

who is unaware of the normal changes of aging may mistake

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You are the Paramedic Part 2

Vital Signs Recording Time: 5 Minutes

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The opposite of incontinence is urinary retention or diffi-

Changes in the Digestive System

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changes in the musculoskeletal system most often translate into

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excess heat is transferred from the body to the environment.

A specific illness or injury in the no fever in elderly

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Table 42-2 Causes of Falls in the Elderly

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Notes from Nancy

You are the Paramedic Part 3

Reassessment Recording Time: 11 Minutes

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“S” stands for social assessment. Older people may have

Notes from Nancy

Table 42-3 The GEMS Diamond

G—Geriatric Patients M—Medical Assessment

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Special Considerations Special Considerations

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there signs of violence, such as broken glassware, that might

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Figure 42-6 A patient having an asthma attack may have a Colon

The usual treatments for systolic hypertension usually

Respiratory Complaints venous thrombosis, which is a common cause of pulmonary

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at a greater risk of complications, the need for urgent surgery,

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Notes from Nancy

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Assessment and Management

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Medical Complication Management

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You are the Paramedic Part 4

Reassessment Recording Time: 20 Minutes

6. Does pneumonia present the same in elderly people as in younger people?

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Additional treatment will depend on the patient’s specific