EMS 2014 – Geriatric Medicine

1. EMS 2014 – Geriatric Medicine

2. Introduction • With advancing age various organ systems in body begin to fail or show decreased function • Elderly have less reserve in their organ systems • Loss of function (for example renal, cardiac, endocrine or respiratory function) makes person more vulnerable to injury or illness • It is estimated organ systems lose approximately 1% of capacity per year starting at about 30 years of age • Consider the following: • Increasing cholesterol will lead to more heart attacks • Decrease in cardiac output will lead to more falls and syncopy • Decrease in lung elasticity lead to more respiratory infections • Decrease in bone and muscle mass leads to more falls and fractures • Multiple medical conditions leads to increased medication interactions

3. Introduction • Good way to approach elderly patients – assume they are more vulnerable to injury or illness • Examples: • Pneumonia in someone 80 years of age is likely to be far more serious than in someone age 25 • Fall in someone 85 may be very serious whereas in a younger person the fall may lead to no harm

4. Course Objectives • Identify unique characteristics of the elderly patients. • Identify examples of diminishing stroke volume in the elderly patient. • Identify factors that affect outcome of the elderly patient in trauma. • Identify signs and symptoms of dementia and or the pathophysiology. • Identify signs and symptoms of cardiovascular emergencies. • Identify emergency care for a traumatized elderly patient. • Identify emergency care for the medical elderly patient.

5. Terms • Diuretic - A drug such as Lasix (furosemide) and HCTZ (hyrdrochlorothiazide) used primarily to treat hypertension and congestive heart failure. Diuretics may cause dehydration, making the patient more susceptible to syncope or heat stress. • Dysrhythmia - Irregular or abnormal heart rate, also sometimes referred to as cardiac arrhythmia. • Elderly - There is no general agreement when a person becomes “old”. The common use of a calendar age to mark the threshold of old age assumes that everyone ages at the same rate which is not true. • Metabolism - The process by which cells take in energy (food and oxygen) so they can function. All bodily functions such as digestion, muscle contractions, and breathing require energy. Heat is a by-product of these processes.

6. New Terms • Bradypnea - Slow breathing. It is defined as a respiratory rate of less than 10 breaths per minute. Things to consider are ingestion of central nervous system (CNS) depressants (eg, narcotics, benzodiazepines), stroke, or per terminal conditions. • Dementia - (meaning "deprived of mind") is a serious loss of brain function that lead to problems in memory, thinking, language, behavior, and judgment. Dementia may be progressive or stable. The incidence of dementia increases with advancing age. • Elder Abuse - Harmful treatment toward an elderly person, includes physical, sexual, or emotional abuse, financial exploitation, and neglect.

7. Hematemesis - Vomiting blood. The source is generally the upper gastrointestinal (GI) tract. This can be confused with hemoptysis (coughing up blood). The spectrum of upper GI bleeding varies from occult (meaning not readily seen) bleeding that presents as anemia to acute, life-threatening hemorrhage resulting in hypotension and shock. Sources of life-threatening upper GI bleeding include peptic ulcer disease, esophageal varices, and Mallory-Weiss tears. Huntington's disease, chorea, or disorder (HD) - Progressive neurological genetic disorder, which lead to loss of muscle coordination and some cognitive problems. Its onset is typically in middle age. It is the most common genetic cause of abnormal involuntary writhing movements called chorea and is much more common in people of Western European descent. New Terms continued

8. Hyperosmolar nonketotic state (HKS) - An uncommon type of diabetic coma. It has a high mortality. Other commonly used names are hyperosmolar hyperglycemic nonketotic coma (HHNKC) or hyperosmotic non-ketotic coma (HONKC). Patients with this condition have very high sodium caused by severe dehydration. Neglect - Failure of a caretaker to provide goods or services necessary to avoid physical harm or mental anguish, such as abandonment, denial of food or health related services. It can be intentional of unintentional through ignorance or lack of training. Vulnerable Adult - adults age 60 and older who cannot care for themselves. Also, includes adults age 18 and older who, have a legal guardian, are developmentally delayed, live in a DSHS licensed facility, receive in home care services, or have a personal care aide who is paid for their services. New Terms continued

9. Geriatrics • Geriatric: derived from the Greek word GERON meaning “old man” • When does a patient become “geriatric”? There is no clear answer to this question. Some consider age 65 to be the boundary between adult and geriatric. Others consider the person’s underlying physical condition and mental function to mark this border. This boundary may from one individual to the next. • As a general concept a geriatric patient is someone who is more vulnerable to physical, mental, and medical issues as a result of their age. • The goal of geriatric care is to promote health by preventing and treating disease and disability in older people, and improving quality of life

10. Future needs • Our population is is getting older as the “baby boom” generation ages. • In 2009, people 65 years or older, who numbered 40 million, represented 13% of the U.S. population. • By 2030, it is predicted that there will be 70 million older people, increasing to almost 20% of the population. • As medical care continues to improve, the numbers and age of older patients will increase.

11. Cardiovascular Aging

12. Heart Disease • Almost all cardiac diseases more common in elderly • Includes higher incidence of coronary heart disease, congestive heart failure, cardiomyopathy & heart dysrhythmias

13. Valvular heart disease leads to heart failure by causing impaired cardiac filling and then chronic volume overload, which results in secondary heart failure Infection can cause endocarditis (infection of the heart valves) More likely to occur in older persons Increase is due to number of factors including higher number of prosthetic valves & increased hospitalizations with associated hospital-acquired infections in the elderly Valves in the Heart

14. Degeneration of the Cardiac Conductive System • Heart contraction – initiated by signal coming from SA node in atria • Signal then travels to AV node by special conducting cells • Signal then conducted through bundle of His to bundle branches in ventricular walls which in turn signal muscle fibers in walls to contract

15. Degeneration of the Cardiac Conductive System • Block occurs when signal cannot progress or its progress delayed • Three degrees of block • 1st degree (slow conduction in the atria) • 2nd degree (Mobitz 1 and 2) (partial block in the AV node) • 3rd degree (complete block in the AV node) • Stokes Adams Syndrome: slowing of heart & often leads to syncope • Patient may become pale before fainting • Normally syncope short lived • Seizures may occur with associated fall in blood pressure • Often less than 30 seconds in duration

16. Stroke Volume • Stroke volume (SV) – volume of blood ejected with each contraction • Ejection fraction (EF) – blood ejected by left ventricle during contraction divided by total volume of left ventricle • Normal EF is approximately 60-65% Video explanation available at EMS Online: http://www.emsonline.net/geriatric2011/strokevol.asp

17. Congestive Heart Failure • In heart failure, heart cannot pump enough blood through body • Can affect right, left, or more commonly both sides of heart • Can be chronic or acute • Common symptoms of heart failure include: • Shortness of breath or difficulty breathing • Feeling tired • Swelling of the lower legs • Elevated jugular venous pressure

18. Coronary Implications • Aging heart has diminished stroke volume, increased atherosclerosis, increased calcification in the valves & less effective conduction • Results may present as angina, myocardial infarction, heart failure, atrial fibrillation, aortic stenosis • Elderly patients often do not present with typical symptoms of acute myocardial infarction • May be due to loss of sensory fibers though exact reasons are not known

19. Coronary Implications • Acute myocardial infarction in elderly may include any combination of following symptoms: • Fatigue • Shortness or breath • Syncope • Hypotension Be especially alert to atypical symptoms of MI in elderly patients

20. Respiratory System

21. Emergencies • Older patients more likely to have conditions like emphysema & heart failure (pulmonary edema) and/or combination of these diseases • Less ability to compensate compared to younger patients • Acute pulmonary edema often a result of acute myocardial infarction (MI)

22. Pneumonia • Common & significant health problems for elderly • Fourth leading cause of death in this age group • Nosocomial (hospital acquired) pneumonia fairly common among older patients • Especially for thoracic or abdominal surgery, on a respirator, or undergoing tube feeding • Serious underlying illness – major risk factor for developing pneumonia in elderly

23. X-Ray of Lungs with Pneumonia

24. Pulmonary Embolism • Pulmonary embolism (PE) – obstruction of pulmonary artery caused by blood clot • Travels to pulmonary artery from another location (atria or lower leg) • Incidence of PE increases with age • Risk factors: • Prolonged bed rest • Underlying cancer • Recent surgery Video DVT & PE: http://www.emsonline.net/geriatric2011/pulmonary.asp

25. COPD • Chronic condition caused by damage to alveoli • Usually caused by smoking • Patients may be chronically short of breath and on home oxygen. • Acute exacerbations may present with shortness of breath, productive sputum, and noisy lung sounds (wheezing, rhonchi) • Patients often take inhalers and steroids

26. Asthma • Typically chronic disease caused by episodic bronchospasm (constriction) of lung’s small airways • Treated with two kinds of medicines: • Quick-relief medicines to stop bronchospasm & reduce inflammation • Long-term control medicines to prevent recurrence Nebulizers often prescribed

27. Neurovascular System

28. Disorders • Disorders & conditions of neurovascular system include: • Blood vessel aneurysms in brain • Stroke syndromes • Vascular malformations of brain & spinal cord • Dementia (Alzheimer’s type dementia is most common) typically associated with atrophy of brain cells • Exact causes of dementia largely unknown

29. Delirium • State of confusion that can last days, weeks or even months • Associated with hospitalization & may last from hours to days • Onset of delirium usually fairly sudden • Can be treated & often temporary, even in people with advanced illness • Precipitating cause of delirium include: • Drug side effects • Dehydration • Pain • Urinary or other infections • Poor vision or hearing • Strokes • Bleeding • Heart problems • Breathing problems

30. Dementia • Show signs of disorientation • May not know what day of week, day of month, or even what year it is • May not know where they are • May not know relatives or people around them • Often loss of memory especially short term memory • Progressive & largely untreatable

31. Caused by series of small strokes Two most common types of dementia Vascular dementia Alzheimer’s Disease People with advanced Parkinson's disease may also develop dementia Dementia

32. Alzheimer’s Disease • Alzheimer’s type dementia has no cure • Most common type of dementia & accounts for up to 70 percent of cases • As many as 5.3 million Americans living with Alzheimer’s type dementia • Sixth-leading cause of death in United States Video Information re: brain changes: http://www.emsonline.net/geriatric2011/delirium.asp

33. Stroke (also known as a cerebral vascular accident – CVA) is a medical emergency Occurs when blood flow to portion of brain stops Two major types of strokes Ischemic strokes –blood clot in vessel or artery in brain (80%) Hemorrhagic strokes – blood vessel bursts & bleeds into brain (20%) Blood supply to brain is interrupted, cells begin to die due to lack of oxygen, glucose & other nutrients Strokes

34. TIAs • Transient ischemic attacks (TIAs) – blood supply to brain temporarily interrupted • Symptoms of TIA resolve within 24 hours • While person is having stroke symptoms – impossible to distinguish stroke from TIA

35. Thrombolytic Therapy & CVA • Selected patients with CVA can benefit from rapid thrombolytic therapy designed to dissolve clot causing CVA • Effective thrombolytic therapy – should be given within 4.5 hours of onset of stroke • Hospital requires one hour for evaluation & CT this means symptoms onset to arrival at hospital should generally be <3.5 hours • Most hospitals in King County designated as stroke centers & equipped & staffed to rapidly make diagnosis & treat acute CVA

36. Thrombolytic Therapy & CVA • FAST Narrative to rapidly determine if patient has experienced a stroke • A short telephone report to the hospital should include items 1— 4

37. Means of measuring & monitoring level of consciousness Calculate score based on best eye, verbal, & motor response Lowest score possible is 3, highest is 15 GCS part of Code CVA Glasgow Coma Scale Score

38. Glasgow Coma Scale Score

39. Parkinson's Disease • Disorder affects part of brain that controls muscle movement • Symptoms may include: • Trembling of hands, arms, legs, jaw & face • Stiffness of the arms, legs & trunk • Slowness of movement • Poor balance & coordination • People may have trouble walking, talking or doing simple tasks • Disease slowly progresses

40. Huntington's Disease • Huntington's disease (also known as Huntington’s Chorea) – progressive disease causes brain cell damage leading to uncontrolled movements & mental deterioration • Inherited disease • Signs & symptoms typically develop in middle age • Disease usually progresses slowly though it can progress rapidly in younger patients

41. Genitourinary System

42. Geriatric patients experience general decline in renal function Renal filtration falls average of 50% between ages of 20 & 90 Kidney mass decreases by 20% Many drugs eliminated through renal filtration Underlying renal dysfunction often cause of decreased drug efficacy & other medication-related problems in older patients Disorders

43. Urinary incontinence, inability to maintain bladder control, more common in older patients Some causes of incontinence in the elderly are: Decrease in bladder capacity Involuntary bladder contractions Decreased ability to delay voiding Medications that affect bladder control Decline in sphincter muscle control Prostate cancer Severe dementia Disorders

44. Endocrine System

45. Diabetic Issues • Incidence of type 2 diabetes increases with age • Complications of diabetes include: • Kidney failure • Blindness • Heart disease • Stroke • Lower extremity amputations

46. Type 2 Diabetes • Type 2 diabetes associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity & race or ethnicity • More children have been diagnosed with type 2 diabetes • Believed obesity & insulin resistance are to blame • Unknown if resistance is due to obesity itself or a combination of inactivity & increased consumption of refined sugars

47. Type 2 Diabetes • Because the mechanism is different than for an insulin-dependent diabetic, type 2 diabetics require special care when they become hypoglycemic. • Even if you are able to increase the blood sugar of a type 2 diabetic with sugar or food, that person must still be monitored in a medical facility. It is not uncommon for the blood sugar to fall again.

48. Approximately 0.5% to 5% of older adults have hypothyroidism 5% to 10% have subclinical hypothyroidism Most cases in elderly people due to chronic autoimmune inflammation of thyroid Hypothyroid Issues

49. Hypothyroid Issues • Symptoms of hypothyroidism often nonspecific in older adults & may include: • Dry skin • Slowed thinking • Weakness • Constipation • Anemia • Symptoms usually have insidious onset & slow rate of progression • Result, diagnosis of hypothyroidism often missed • Elderly patients with mild hypothyroidism may become severely hypothyroid if they experience serious illness

50. Musculoskeletal System