geriatric patients

© 2011 National Safety Council 22-1

GERIATRIC PATIENTSLESSON 22


Introduction

• Older adults are an increasingly large proportion of American population

• Have more chronic health conditions that may lead to an emergency

• Much emergency care given to geriatric patients

• Be aware of possible age-related changes in geriatric patients and implications for assessment and treatment


Age-Associated Changes

• Changes gradually occur throughout lifespan

• By 65, human body has age-related changes in all body systems

• Changes generally continue throughout lifespan

• Rate and extent of changes depend on many factors

• Never make assumptions about any patient based on age

• Discrimination based on individual’s age is illegal


Changes in Sensory System

• All senses become less acute with aging


Changes in Vision

• Decreased general visual acuity

• Reduced ability to differentiate colors

• Diminished night vision

• Diminished near vision

• Decreased depth perception

• Visual impairments are more common


Changes in Hearing

• Decreased general hearing ability

• Increased use of hearing aids

• Diminished ability to hear high-pitched sounds

• Hearing impairments are more common


Changes in Touch and Pain

• Decreased sense of balance

• Diminished ability to differentiate temperature

• Decreased tolerance of hot and cold

• Diminished perception of pain


Changes in Smell and Taste

• Diminished smell and taste

• May cause reduced appetite and nutritional deficiencies


Changes in Cardiovascular System

• Heart muscle less powerful and blood vessels less elastic

• Rising blood pressure over the years may result in hypertension

• Diminished heart output

• Decreased functional blood volume


Changes in Cardiovascular System (continued)

• Reduced circulation and lower perfusion in some body areas such as legs

• Reduced ability of heart to beat faster when needed

• Increased risk of heart attack

• Increased risk of stroke


Changes in Respiratory System

• Less flexible alveoli in lungs, reduced gas exchange

• Less effective muscles for breathing

• Inhaled substances (such as tobacco smoke) cause other changes in lungs and airways


Changes in Respiratory System (continued)

• Diminished breathing capacity

• Decreased forcefulness of coughing (and reduced ability to cough out an airway obstruction)

• Increased risk of respiratory infections


Changes in Gastrointestinal System

• Stomach and intestines function less well

• Mouth changes, including use of dentures or other dental appliances, affect chewing and swallowing

• Difficulties chewing and swallowing increase risk of foreign body airway obstructions

• Digestive difficulties


Changes in Nervous System

• Slower reflexes increase risk of falls

• Diminished cough or swallowing reflexes

• Diminished short-term memory

• Other cognitive changes may affect behavior

• Dementia, Alzheimer’s and senility are not normal changes of aging but occur more commonly in older adults


Changes in Musculoskeletal System

• Decreased bone density: bones fracture more easily, even without trauma

• Osteoporosis decreases bone density

• Diminished size and strength of muscles

• Joint changes make arthritis more likely

• Curvature of upper spine is more common


Other Age-Related Changes

• Immune system and other changes may cause:

- Increased risk of many types of infections

- Less apparent signs and symptoms of infection when present (less likely to seek early treatment)

• More frequent loss of bladder or bowel control (preserve patient’s privacy and dignity)

• Less perspiring when warm (making heat emergencies more likely)


Chronic Disease

• Many chronic conditions are more common in geriatric patients

• Contributes to greater risk of injury or emergency illness

• Medications for chronic illness may have assessment and treatment implications


Age Implications for Assessment and Treatment

• Do not assume older individual is automatically different from other adults

• Be aware of age-related changes and implications for assessment and treatment


Primary Assessment

• Neck arthritis makes airway management more difficult

• Do not remove patient’s dentures for ventilation or rescue breathing unless they interfere

• Increased risk for airway obstructions caused by foreign body or swollen tissues from infection

• Pulse may be irregular due to arrhythmia

• If patient seems to have altered mental status or diminished cognition, ask family members about pre-emergency mental status


The Secondary Assessment

• Ensure lighting is adequate

• Position yourself at the patient’s eye level

• Speak slowly and distinctly

• Give patient time to respond

• Some geriatric patients may deny symptoms be thorough and use good communication skills

• Older adults are more susceptible to traumatic injury

• With reduced pain perception, injuries may not be immediately apparent


The Secondary Assessment(continued)

• Chronic medical conditions may increase likelihood of fall or other trauma

• Trauma more likely to cause bone fracture

• Normal vital signs depend on general physical and health status

• Vital signs may change rapidly with bleeding

• Seek detail about medications taken

• Medications may affect vital signs, blood clotting and other aspects of emergency care

• Patient may not show severe signs of illness even when very ill


• Depression is common and may affect patient’s behavior and communication

• Nutrition may be inadequate or home poorly heated or cooled

• Size up the scene for clues to patient’s condition

• With suspicious injuries, consider possibility of elder abuse

• Do not let many layers of clothing prevent you from adequate examination

• Reassess frequently because patient may deteriorate quickly

The Secondary Assessment(continued)


Implications for Treatment

• Handle patient very carefully

• With upper spine curvature, padding may be needed during spinal immobilization

• With decreased cough reflex, suctioning may be needed

• Prevent hypothermia in a cool environment

• Provide reassurance and support


Trauma

• Trauma often has more serious effects in geriatric patients

• Never assume any injury is minor based on mechanism of injury or because signs and symptoms do not seem severe

• Falls are a particular concern

- Cause fractures of hip, spine or other bones

- Treat all falls as severe or possibly life-threatening


Trauma (continued)

• Carry out physical examination carefully

• Manually stabilize or splint area

• Coinciding medical and traumatic emergencies more likely

• Never assume injury is only issue to be addressed

• Perform full secondary assessment with complete history

• Closely monitor vital signs and breathing

• Reassess more frequently


Medical Emergencies

• May be caused or exacerbated by chronic illness

• Common reason for EMR calls

• Signs and symptoms may not be classic picture

• Heart attack may not cause pain or chest symptoms

• Keep an open mind during assessment


Special Considerations in Medical Emergencies

• Denial of symptoms does not mean patient feels nothing

• Patient may not consider symptoms a concern

• Heart attack and stroke may produce minimal symptoms

• Never dismiss respiratory symptoms in geriatric patients


Special Considerations in Medical Emergencies (continued)

• Take thorough history of medications, consider accidental overdose or drug interaction

• Do not move patient from bed or wheelchair except for lifesaving care

• Remember dementia is not normal consider altered mental status related to illness


Elder Abuse

• Half a million elders in United States abused or neglected each year

• In 90% of cases, abusing person is family member

• The older a person is, the greater the risk for abuse

• Most likely abused are those who:

- Need help with daily activities

- Have lost bladder control

- Behave unusually because of altered mental status


Most Important Signs of Elder Maltreatment

• Frequent, unexplained crying

• Unexplained fear of or suspicion of particular person in the home


Signs and Symptoms of Physical Abuse

• Bruises, black eyes, welts, lacerations and rope marks

• Bone fractures, skull fractures

• Open wounds, cuts, punctures, untreated injuries, injuries in various stages of healing

• Strains, dislocations and internal injuries or bleeding

• Broken eyeglasses, physical signs of being subjected to punishment, signs of being restrained


Signs and Symptoms of Physical Abuse (continued)

• Medication overdose or underuse of prescribed drugs

• Elder’s report of being hit, slapped, kicked or mistreated

• Elder’s sudden change in behavior

• Caregiver’s refusal to allow visitors to see elder alone


Signs and Symptoms of Sexual Abuse

• Bruises around the breasts or genital area

• Unexplained venereal disease or genital infections

• Unexplained vaginal or anal bleeding

• Torn, stained or bloody underclothing

• Elder’s report of being sexually assaulted or raped


Signs and Symptoms of Emotional/Psychological Abuse

• Emotional upset or agitation

• Extreme withdrawal, lack of communication and responsiveness

• Elder’s report of being verbally or emotionally mistreated


Signs and Symptoms of Neglect

• Dehydration, malnutrition, untreated bed-sores and poor personal hygiene

• Unattended or untreated health problems

• Hazardous or unsafe living conditions

• Unsanitary or unclean living conditions

• Elder’s report of being neglected


Signs and Symptomsof Abandonment

• Desertion of elder at hospital, nursing facility or similar institution

• Desertion of elder at shopping center or other public location

• Elder’s own report of being abandoned


Signs and Symptomsof Self-Neglect

• Dehydration, malnutrition, untreated medical conditions, poor personal hygiene

• Hazardous or unsafe living conditions

• Unsanitary or unclean living quarters

• Inappropriate or inadequate clothing, lack of necessary medical aids

• Grossly inadequate housing or homelessness


Emergency Care for Suspected Victims of Elder Abuse

• Perform standard assessment

• Perform standard patient care

• Give emergency care for injuries or illness found

• Ensure privacy while providing care

• Provide emotional support

• Do not directly confront patient with your suspicions, especially if family members are present

• Note everything patient says about cause of injuries


Emergency Care for Suspected Victims of Elder Abuse (continued)

• If you see physical abuse occurring or a crime committed, or if someone at the scene is threatening and potentially violent, call law enforcement personnel

• Tell responding EMS personnel in private about your suspicions

• Elder abuse is a mandatory reportable event

• Follow local protocol to document your observations and file appropriate report

• Be especially careful in your documentation

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