GERIATRICS

1. GERIATRICS Gerontology: The study of the problems of all aspects of aging EMT297 Summer 2008

2. Three stages of life • You believe in Santa Claus • You don’t believe in Santa Claus • You are Santa Claus

3. Great truths about growing old • Wrinkles don’t hurt • Growing old is mandatory; growing up is optional • When you fall down, you wonder what else you can do while you’re down there… • You know all the answers, but nobody bothers to ask the questions.

4. ELDERS ARE WELL ABLE TO APPRECIATE WHAT IT MEANS TO LIVE IN THE PRESENT….. WHAT THEY HAVE TODAY IS ALL THEY HAVE.

5. MAKING THE MOST OF TODAY IS AN ART WE SHOULD ALL CULTIVATE - AND AN OLD PERSON IS COMPELLED TO CULTIVATE.

6. Aging in America • Old is only how you feel and what you are still able to do!!!

7. Geriatrics • Ageism • What age makes a person geriatric? • 20 years older than me! • How old will you be in 2025?

8. A Look at Life in 2025 Who Ages the best? • People with long-lived parents • Satisfying job • Plenty of money • Married OR with close friends

9. Some Stats • 50% of Auto vs. Pedestrian involve the pedestrian being an elderly person

10. Statistics • Geriatric population grew by 74% between 1970 – 1999 – to almost 35 million • 30% of the $800 billion health care budget • 40% of hospital bed days • 1998 - @ 41% of all ambulance transports to ED’s are with elderly • 2030-Magic year. Average baby boomer turns 80 years old - 20% population 65 or older

11. ALL OF THE RULES FOR ASSESSING AND TREATING YOUNGER PATIENTS DO NOT NECESSARILY APPLY TO ELDERS • Infections may not be accompanied by a fever. • An abdominal catastrophe may not cause abdominal pain • Forgetfulness may indicate a brain tumor • Incontinence can be a sign of a heart attack • 1/3-1/2 of elderly heart attack victims do NOT feel crushing chest pain; primary symptoms are confusion, syncope.

12. Aging in America

13. We really do fall apart when we get old…. 1% rule • Total body fat decreases by as much as 15-30% • Total body water significantly decreases • 25% all suicides reported are patients over 65.

14. Homes are a Menace • Area Rugs • High Shelves • Stairways without railings • Bathtubs • Sharp Counter Corners • Still doing crazy things

15. Keys • We lose reserve as we age • Our margin of error gets smaller and smaller • Fluid mobilization impaired with age

17. A and P changes -General decline in organ systemsand stress response Skin • Loss of elasticity, collagen • Increased injury • Dryness • Age spots

18. Eyes • Cataracts • Glaucoma • Poor peripheral vision • Arcus senilis • Loss of accommodation • Hyperopia • Decreased depth perception

19. Hearing • Ossicle degeneration • Loss of high frequency hearing • Atrophy of cochlear hair cells and auditory neurons • Decreased acuity and pitch discrimination • Decreased sense of balance

20. Respiratory system • Vital capacity decreases 50% • Maximum breathing capacity decreases 60% • Maximum work rate and oxygen uptake decreases 70% • PaO2 70 torr (nl 90 torr) • Loss of cilia, diminished cough reflex and impaired gag reflex = pulmonary diseases

21. Cardiovascular System

22. CV System • Heart - less flexible • Decreased Cardiac Output • Less responsive to catecholamines • Altered electrical function

23. CV System • Arterioschlerosis • Cholesterol deposits • Vessel Narrowing • Varicose Veins • Medications: To compensate for CV condition

24. Renal system • 30-40% decrease in number of functioning nephrons • Renal blood flow decreases 50% • Increased risk of toxicity from all drugs and toxins Genitourinary • Loss of bladder control • urinary infections • Prostate enlargement • Tumors and urinary retention

25. Nervous system • As much as 45% brain cell loss in certain cortical areas • 6-7% reduction in brain weight • Decreased cerebral blood flow & increased resistance • Decreased cerebral oxygen consumption • 15% reduction in nerve conduction

28. Musculoskeletal system • Decrease in height of 2-3 inches due to narrowing of vertebral discs • Posture changes - slight flexion of knee and hip joints, spine deterioration • Kyphosis- exaggeration of the normal posterior curvature of the spine • Spondylosis - abnormal rigidity, fixation of joint

29. Decrease in total skeletal muscle weight • Widening and weakening of certain bones • Osteoporosis-softening of bone tissue due to the loss of essential minerals, esp.. calcium

31. Endocrine System • >20% of older adults develop diabetes • Unrecognized thyroid and parathyroid problems

33. GI system and Metabolic • Volume of saliva decreases 1/3; gastric secretions diminish • Structural changes occur throughout GI tract • Esophageal motility decreases • Fecal impactions

34. Psychological/Social • Loss of physical function • Decreased activity • Loss of friends/family • Depression • Loss of social support • Increased isolation and anxiety • Increased risk of suicide attempts

35. Assessment Complicating factors • Chief complaint may be trivial • Patient may fail to report important symptoms • Paramedic may fail to note important symptoms

36. Complicating Factors (cont.) • Likely to suffer from more than one disease at a time • Aging changes the patient’s response to illness or injury • Pain may be diminished or absent • Thermoregulatory system may be depressed • Social and emotional factors may have greater impact on health

37. When Assessing the Older Adult • Position yourself at eye level, facing patient, in their visual field • Speak slowly and distinctly • Listen to their ENTIRE answer • Use a gentle touch • Go slowly and explain

38. Communications Diminished sight • Increases anxiety • Talk to patient calmly • Position yourself so patient can see you

39. Try to determine if patient’s mental status is changed • Don’t assume confused, disoriented patient is “just senile” • Alcoholism is more common than you think

40. Diminished hearing • Don’t assume the patient is deaf • Don’t shout • Write notes if necessary • Speak slowly and directly to the patient • Whenever possible, verify history

41. Diminished mental abilities • Patient often confused, can’t remember details • Noise of radio, ECG, strange voices add to confusion • Senility and/or acute organic brain syndrome look similar; delirium, confusion, restlessness, excitement, hostility

42. Depression • May keep patient from cooperating • Pt. may be malnourished, dehydrated, overdosed, contemplating suicide, or imagining ailments for attention.

43. History taking - Common patient complaints • Fatigue, weakness • Dizziness, vertigo, syncope • Falls • H/A • Insomnia • Dysphagia • Loss of appetite • Inability to void • Constipation/diarrhea

44. PMH - complicated, important • Usually multiple drugs • Medication errors and noncompliance are common • Find all drugs and record to take to hospital with patient (try to leave) • Try to establish old vs new drugs incl. OTC • Try to verify Hx with reliable family/neighbors

45. PMH • Observe surroundings for indication of pt’s ability to care for self • Observe for evidence of drug/alcohol use • Look for medic-alert tags, POLST form, etc • Observe for signs of violence/abuse

47. Physical Exam In Elders • Pt. may tire easily; Assessment usually takes longer • Commonly wears excessive clothing • Be aware that pt. may minimize or deny sx due to fear • Peripheral pulses may be difficult to evaluate

48. Physical Exam • Must distinguish sx of chronic disease from acute problems, i.e., • loss of skin elasticity and mouth breathing; aging vs dehydration • Pay attention to impairments • Make eye contact • Grasp the hand - feel for temperature, grip, skin condition

49. Physical Exam • Address the patient by last name • Use open-ended questions • Observe for • Behavior • Dress/grooming • Ease of rising/sitting • Fluency of speech • Involuntary movement • Nourishment

50. Physical Exam • Breathing - adequate? • Circulation - adequate? Irregularity? Check bilateral radial pulses, Auscultate both carotids for bruits • BP - systolic <90 or >140 mmHg: diastolic <60 or >90 mmHg may indicate problems • Level of consciousness