South Carolina AHEC Emergency & Disaster Medicine Summit August 15 & 16, 2008

Emergencies in the Elderly

Patient

William E. Gandy, JD, LP

Copyright 2008, All Rights Reserved

READING MATERIAL
• Hogan, Geriatric Emergencies
• Bledsoe, Paramedic Emergency Care, 3rd
Edition
• Sanders, Mosby’s Paramedic Textbook
• Tintinalli, Ruiz and Krome, Emergency
Medicine 6th Edition

INTRODUCTION
The elderly (those over 65) comprise over
12% of the population of the US.

The numbers of the “old-old” (over 75) are

increasing as medicine improves the ability
to prolong life.

Life expectancy is increasing

South Carolina AHEC Emergency & Disaster Medicine Summit August 15 & 16, 2008

The birth rate is declining and the percentage
of elderly : youth is increasing.
GERIATRICS IS THE STUDY OF ALL
ASPECTS OF AGING, INCLUDING
– PSYSIOLOGICAL
– PATHOLOGICAL
– PSYCHOLOGICAL
– ECONOMIC
– SOCIOLOCICAL PROBLEMS
In aging, there is a decline in every organ
system, beginning at the cellular level.
There is a decline in Total Body Water from
around 60% of body weight to perhaps 40-
50% of body weight.
Body fat decreases 15-30% but metabolic rate
remains fairly constant

Total number of body cells decreases

Every body system is affected.

These processes begin early in life.
The overall appearance changes:
• Loss of elasticity of skin
• Loss of connective tissue
• Loss of sweat glands
• Pigment deposition
• Damage from exposure to sun

Decubitus Ulcer Stage 2 Decubitus Ulcer Stage 3

South Carolina AHEC Emergency & Disaster Medicine Summit August 15 & 16, 2008

Decubitus Ulcer Stage 4 VISION CHANGES

• Hyperopia (presbyopia) = farsightedness
appears in many in middle age
• Decreased pupil size results in decreased
ability to compensate for changes in light
• The ability to focus (accommodation) is
decreased

Changes Affecting the Eyes EYE CHANGES WITH AGING

Clouding of lenses • Clouding of the lenses of the eye leads to:
• Cataracts – Cataracts
• Poor peripheral vision – Poor peripheral vision
• Pigmentation deposition
– Arcus senilis (bluish or grayish circle that
forms around the outer edge of the iris of the
eye)
– Has no clinical significance

Cardiovascular Changes
Aging produces thickening of the walls of
arteries and a lessening of the pliability of
arterial walls. (arteriosclerosis and
atherosclerosis).

Hypertension, fibrosis and ventricular

hypertrophy may result
South Carolina AHEC Emergency & Disaster Medicine Summit August 15 & 16, 2008

HEART DISEASE RESPIRATORY CHANGES

• Can lead to ischemia of: The lungs lose some of their elasticity and
– Lung surface area.
– Liver
– Bowel Compliance is decreased.
– Kidneys
– Brain
Ciliary activity is decreased.

Lung Tissue Changes from

Young to Old

PULMONARY PROBLEMS RENAL SYSTEM CHANGES

Chronic bronchitis The number of nephrons is decreased and
– Productive cough every day for 90 days in a there is less renal clearance of waste.
year for two consecutive years
There is decreased renal blood flow from
Bronchiectasis arterial disease.
– Damage to bronchioles

There is increased risk from drug toxicity and

Emphysema toxins that are normally removed by kidney
– Loss of elasticity and alveoli
South Carolina AHEC Emergency & Disaster Medicine Summit August 15 & 16, 2008

Renal changes
Bladder control is lost by many, especially
women
– Remember the “Depends” ads ?

– Men experience prostate enlargement, and

almost all have some prostate problems
eventually

NERVOUS SYSTEM
PROBLEMS
Aging results in loss of brain cells and loss of
brain weight. Nerve conduction velocity
decreases synapse time increases.

Reflexes slow down

Memory is affected, short term more than

long term

STROKE PATIENTS HEARING LOSS

• Patients exhibiting signs and symptoms of High frequency loss is first
CVA are at great risk for aspiration
Sense of balance can be affected
• Patients who can’t talk usually can’t
swallow:
– Reduced control of secretions = greater risk of
aspiration.
– Review cranial nerves V, IX, X, XII
South Carolina AHEC Emergency & Disaster Medicine Summit August 15 & 16, 2008

SKELETAL SYSTEM
CHANGES
Aging results in diminished height as
muscular tone fails.
Osteoporosis affects women more than men,
but men are also affected
Many falls occur from pathological fractures
rather than fractures resulting from falls
Kyphosis often results

Kyphosis GI SYSTEM CHANGES

Saliva production decreases significantly.
HCl production decreases (slower digestion of
food.)
Bowel motility decreases.
Taste buds fail.
Gums atrophy and chewing becomes difficult.

PSYCHOLOGICAL AND
SOCIAL EFFECTS OF AGING
The elderly often experience decreased levels
of activity.

There are exceptions to this: the individual

who maintains a healthy lifestyle with
exercise and diet, but these are the
exception to the rule
South Carolina AHEC Emergency & Disaster Medicine Summit August 15 & 16, 2008

PSYCHOLOGICAL/SOCIAL LOSS OF FRIENDS AND

EFFECTS FAMILY
• Decreased activity and • These effects can also As family and acquaintances die, the
socialization lead to: surviving elderly person becomes more and
• Loss of friends and – Depression more alone
family – Isolation
• Loss of social support – Anxiety
– Increased risk of There is less social support
suicide

Abrupt changes in lifestyle and abode create

great stress

ONE CONDITION LEADS TO

EXERCISE!!!
ANOTHER
ASSESS AND COMPARE: • You are called to a private gym to the
• LEVEL OF ACTIVITY handball court where a 70 year old man has
been playing handball.
• LOC
• He is sitting on a bench, looking very
• VITAL SIGNS
sweaty and red and leaning with his arms
• NEURO and head in his lap.
• HEART
• LUNGS

INITIAL IMPRESSION HISTORY

• What possibilities come to your mind • Patient says he was playing handball and
immediately? became weak and dizzy. He actually fell
while returning a volley but didn’t hurt
himself in the fall
• Denies chest pain
• Denies dyspnea
• Takes no meds but advil
South Carolina AHEC Emergency & Disaster Medicine Summit August 15 & 16, 2008

ASSESSMENT
• Bp 100/60, p 130, r: 30
• Skin: hot, diaphoretic, red
• Blood glucose: 126
• Neuro: A&A&O X 4; PEARLA
• Strength: weakness bilaterally with muscle
tremors
ASSESSMENT
• SENSORY: GOOD CMS IN ALL
EXTREMITIES
• HEART: S1 & S2, Sinus tach at 130
without ectopy, P’s and T’s upright, no ST
elevation or depression
• LUNGS: CLEAR & EQUAL BBS
• ABD: SOFT & NONTENDER

INTERVENTIONS
• WHAT WOULD YOU DO NOW?
WHAT’S YOUR IMPRESSION • WHAT OTHER QUESTIONS WOULD
SO FAR? YOU ASK?

COMMUNICATION WITH
PROBLEMS
THE GERIATRIC PATIENT
PEARLS: • Eyesight
– ASK ONE QUESTION AT A TIME – Glasses lost?
– GIVE TIME TO ANSWER • Hearing
– HISTORY WILL TELL YOU WHAT’S – Hearing aid lost or turned off?
HAPPENING MOST OF THE TIME
• Dentures
– ASK FOLLOWUP QUESTIONS
– Not in?
– In but can’t talk well with them?
South Carolina AHEC Emergency & Disaster Medicine Summit August 15 & 16, 2008

ESTABLISH RAPPORT PATIENT HAS DEMENTIA

• Introduce yourself • Continually orient them
• Touch • Touch may be your best communication
– Shake hands but be aware of psychiatric • Maintain gentle contact
patients who may not like it
• Keep your voice soft and soothing
• Reassure
• Reassure and reorient
– If blind
– If deaf

ADVANCE DIRECTIVES Questions? wegandy@aol.com

• Limits of care: DNR vs. Do Not Treat
• DNR vs. “Living Will”
• Do you know the legal requirements?