Geriatrics

1. 46 Geriatrics

2. Objectives • Discuss statistics relating to the geriatric imperative. • Discuss pathophysiologic changes that occur to the body due to aging. • Integrate assessment findings with related pathophysiology. • Review current treatment strategies for geriatric patients.

3. Introduction • People over the age of 65 make up the fastest-growing segment of the population. • Changes in physiology due to aging have an effect on pathophysiology as compared to younger adults.

4. Introduction (cont’d) • Geriatric patients typically have more than one disease and take more than one medication.

5. Epidemiology • Almost 40 million in 2008, or 12.8 of the population. • Cardiovascular disease is the leading cause of death, followed by cancer, strokes, and COPD. • They use ⅓ of all prescriptions. • The average geriatric patient takes 4.5 medications per day.

6. Pathophysiology • Human body changes with age: cellular, organ, and system functions. • Changes in normal physiology start around age 30. • Process can be slowed with diet and exercise, but it cannot be stopped entirely.

7. Pathophysiology (cont’d) • Cardiovascular system • Degenerative process to the myocardium • Damage to valves • Thickening of the walls • Loss of artery elasticity • Decrease in baroreceptor activity

8. Pathophysiology (cont’d) • Respiratory system • Size and strength of respiratory muscles decrease. • Alveolar surfaces degrade, impairing gas exchange. • Chemoreceptors begin to fail. • More turbulent airflow through the bronchioles.

9. Pathophysiology (cont’d) • Nervous system • Nerve cells degenerate and die as early as in the mid-20s. • Reflexes slow, proprioception falters. • Brain atrophies with a resultant increase in CSF. • Regulation of basal bodily functions becomes less sensitive.

10. Pathophysiology (cont’d) • Gastrointestinal system • Sense of taste and smell is diminished. • Cardiac sphincter becomes weaker. • Hepatic function decreases. • Lining of GI system degenerates, resulting in lesser absorption of nutrients.

11. Pathophysiology (cont’d) • Endocrine system • Hormones that elevate blood pressure and those that regulate fluid balance become deranged. • Stimulation of adrenergic sites diminishes due to failure of sensitivity of receptor cells.

12. Pathophysiology (cont’d) • Musculoskeletal system • Loss of minerals from the bones. • Vertebral disks narrow. • Joints lose flexibility. • Synovial fluid thickens.

13. Pathophysiology (cont’d) • Renal system • Decrease in nephrons, kidneys shrink • Diminished ability to filter blood • Fluid and electrolyte disturbances

14. Pathophysiology (cont’d) • Integumentary system • Skin becomes thinner from a loss of subcutaneous layer. • Replacement cells generate more slowly. • Sense of touch is dulled, less perspiration. • Less effectiveness as an external barrier.

15. Changes in the body systems of the elderly.

16. Clues to Illness Found in the Scene Size-Up

17. Special Considerations in the Primary Assessment of the Geriatric Patient

18. Special Considerations in the Primary Assessment of the Geriatric Patient

19. Special Considerations in the Primary Assessment of the Geriatric Patient

20. Potential Differential Diagnoses Based on Clinical Findings in Geriatric Patients

21. Potential Differential Diagnoses Based on Clinical Findings in Geriatric Patients

22. Potential Differential Diagnoses Based on Clinical Findings in Geriatric Patients

23. Potential Differential Diagnoses Based on Clinical Findings in Geriatric Patients

24. Emergency Medical Care • Manual cervical spine considerations • Assess and maintain the airway. • Determine breathing adequacy. • High-flow via NRB with adequate breathing. • High-flow via PPV @ 10-12/min if inadequate. • Maintain saturation >95%.

25. Emergency Medical Care (cont’d) • Assess circulatory components. • Check pulse, skin characteristics. • Control major bleeds.

26. Emergency Medical Care (cont’d) • Initiate transport with Paramedic intercept. • Position the patient: • Sitting up if able to maintain own airway. • Lateral recumbent with altered mentation. • Supine if immobilized.

27. Emergency Medical Care (cont’d) • Constantly monitor airway, breathing, and circulation. • Mental status changes are key to determining improvement or deterioration.

28. Case Study • Your EMS unit is dispatched for a “possible cardiac arrest” in the low-income housing district. Upon arrival, police escort you into a single-bedroom dwelling where an unresponsive elderly male is found in bed. The report is that the neighbor hasn't seen him in a few days so he asked the building manager to gain access.

29. Case Study (cont’d) • Scene Size-Up • Standard precautions taken. • Scene is safe, no entry or egress problems. • 70–75-year-old male, about 200 pounds.

30. Case Study (cont’d) • Scene Size-Up • Patient dressed in pajamas, time is 1430 hrs. • NOI is unknown/unresponsive, possible arrest. • Friend is on scene, but is not much help regarding history.

31. Case Study (cont’d) • Describe possible ways to learn of the patient's medical history. • For each body system, name at least one differential that could cause unresponsiveness. • Nervous • Respiratory • Cardiac • Endocrine

32. Case Study (cont’d) • Primary Assessment Findings • Patient unresponsive. • Pupils reactive, membranes dry, tongue furrowed. • Some vomitus in airway, gurgling with breathing.

33. Case Study (cont’d) • Primary Assessment Findings (continued) • Respirations rapid and deep. • Carotid pulse 120/min, peripheral pulse absent. • Peripheral skin warm and dry.

34. Case Study (cont’d) • How would you prioritize this patient? • What are the patient's life threats, if any? • What care should be administered immediately?

35. Case Study (cont’d) • Medical History • Unknown • Medications • Glucophage found in bathroom • Allergies • Unknown

36. Case Study (cont’d) • Pertinent Secondary Assessment Findings • Pupils reactive to light, membranes dry. • Airway patent, patient breathing fast and deep. • Central pulse present, peripheral absent. • Skin is dry, delayed capillary refill.

37. Case Study (cont’d) • Pertinent Secondary Assessment Findings (continued) • No bruising, guarding or rigidity to abdomen. • BGL 710mg/dL, SpO2 96% on high flow. • B/P 82/62, HR 112, RR 28 and deep. • No other findings contributory to this report.

38. Case Study (cont’d) • Is this a structural or metabolic cause of unresponsiveness? • What is the likely underlying cause for the emergency? • Explain the pathology for the following: • Unresponsiveness • Rapid heart rate, dehydration findings

39. Case Study (cont’d) • Care provided: • Patient immobilized as a precaution. • High-flow oxygen via NRB mask. • Patient loaded on wheeled cot and taken to ambulance. • Initiated intravenous access. • Emergent transport to the hospital.

40. Summary • Geriatric patients, like pediatric patients, have an altered physiology that needs to be considered given illness and injuries. • The normal decline in the body systems renders them susceptible to a multitude of emergencies.

41. Summary (cont’d) • Carefully manage and closely watch elderly patients, as they may deteriorate suddenly.