Transcript Geriatrics - faculty at Chemeketa

GERIATRICS
Gerontology: The study of
the problems of all aspects
of aging
EMT297
Summer 2008
1
Three stages of life
• You believe in Santa Claus
• You don’t believe in Santa Claus
• You are Santa Claus
2
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.
3
ELDERS ARE WELL ABLE
TO APPRECIATE WHAT IT
MEANS TO LIVE IN THE
PRESENT….. WHAT THEY
HAVE TODAY IS ALL THEY
HAVE.
4
MAKING THE MOST OF TODAY IS AN
ART WE SHOULD ALL CULTIVATE AND AN OLD PERSON IS
COMPELLED TO CULTIVATE.
5
Aging in America
• Old is only
how you feel
and what you
are still able to
do!!!
6
Geriatrics
• Ageism
• What age makes a person geriatric?
– 20 years older than me!
– How old will you be in 2025?
7
A Look at Life in 2025
Who Ages the
best?
• People with longlived parents
• Satisfying job
• Plenty of money
• Married OR with
close friends
Some Stats
• 50% of Auto vs.
Pedestrian involve
the pedestrian being
an elderly person
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
10
• 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.
11
Aging in America
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.
13
Homes are a Menace
• Area Rugs
• High Shelves
• Stairways without
railings
• Bathtubs
• Sharp Counter
Corners
• Still doing crazy
things
Keys
• We lose reserve as
we age
• Our margin of error
gets smaller and
smaller
• Fluid mobilization
impaired with age
16
A and P changes -General
decline in organ systems
and stress response
Skin
– Loss of elasticity,
collagen
• Increased injury
• Dryness
• Age spots
17
Eyes
– Cataracts
– Glaucoma
– Poor peripheral vision
– Arcus senilis
– Loss of accommodation
– Hyperopia
– Decreased depth perception
18
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
19
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
20
Cardiovascular System
CV System
• Heart - less flexible
• Decreased Cardiac
Output
• Less responsive to
catecholamines
• Altered electrical
function
CV System
• Arterioschlerosis
– Cholesterol deposits
– Vessel Narrowing
• Varicose Veins
• Medications: To
compensate for CV
condition
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
24
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
25
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27
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
28
• 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
29
30
• Endocrine System
– >20% of older adults develop
diabetes
– Unrecognized thyroid and
parathyroid problems
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32
– GI system and Metabolic
• Volume of saliva decreases 1/3; gastric
secretions diminish
• Structural changes occur throughout GI
tract
• Esophageal motility decreases
• Fecal impactions
33
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
34
Assessment
Complicating factors
• Chief complaint may be trivial
• Patient may fail to report important
symptoms
• Paramedic may fail to note important
symptoms
35
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
36
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
37
Communications
Diminished sight
• Increases anxiety
• Talk to patient calmly
• Position yourself so
patient can see you
38
• 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
39
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
40
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
41
Depression
• May keep patient from
cooperating
• Pt. may be malnourished,
dehydrated, overdosed,
contemplating suicide, or
imagining ailments for
attention.
42
History taking - Common
patient complaints
– Fatigue, weakness
– Dizziness, vertigo,
syncope
– Falls
– H/A
– Insomnia
– Dysphagia
– Loss of appetite
– Inability to void
– Constipation/diarrhea
43
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
44
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
45
46
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
47
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
48
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
49
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
50
Case study
• On a hot, humid day you are called to the
neighborhood park where a 68 y/o man is c/o
weakness. On arrival you see the man sitting
on a park bench in shorts and a T-shirt. He is
very diaphoretic and leaning with his arms
and head in his lap. You discover that the
patient has been playing tennis. He normally
plays 2-3 hrs/day. After two sets today, he
could barely run down the ball and was
missing point after point.
51
• He c/o he was very dizzy and fell while
playing. The patient c/o feeling
generally weak. He denies any chest
pain or SOB.
• PMH:
– Bursitis or right shoulder
– “Weak kidneys”
• Meds: OTC Advil prn
• As you talk to the patient you note that
he is having trouble concentrating and
you sometimes have to shout or shake
him to get his attention.
52
• PE:
–
–
–
–
–
–
–
BP 100/60
P 130
R 26
T hot to touch
Skin, hot, diaphoretic, flushed
CBG: 126
Neuro: active, alert, oriented x 3, coherent but
lethargic, PERRL; moves all ext. spont. – note a
diffuse trembling of right forearm muscles
– EKG: sinus tachycardia
– BBS: =, clear
53
• DDX:?
• Tx:?
54
Trauma
• More at risk, esp. falls, assault
• 100% mortality in elders with BP
<80mmHg for 15 min. or more
• Slower reflexes/reaction time
• Poor eyesight and hearing
• Arthritis
• Blood vessels less elastic
55
• Tissue and bones more fragile
• More prone to head injury, even with
minor trauma
• Signs of brain compression may
develop more slowly
• Impaired balance and mobility
56
• Often significant spondylosis; frequent
spinal injury
• Arthritic spine changes compress nerve
roots
• If injury to cervical spine, cord injury
more likely
• Sudden neck movement may cause
cord injury; often less than usual
amount of pain
• Idiopathic fractures
57
Case Study
• You are called to assess a 92 y/o woman who
tripped and fell at her home. She c/o pain to
her left wrist. You see a thin, elderly woman
in obvious pain holding her left hand and
forearm. She says that she did not see the
throw rug in the hallway and tripped over it.
She did not fall down because she braced
herself on the wall with her left hand.
• PMH: cataracts, htn, osteoporosis
• Meds: Vasotec and calcium
58
• PE:
– Swollen left wrist with cyanosis; PMS
normal; no movement.
– Large abrasion to elbow
– Vitals:
• BP 186/106; P 112; RR 18
• Cap refill normal except for left hand
• Pt has poor vision on exam
– DDX?
59
• Tx:
– Splint, ice, elevate left wrist
– Transport
60
Cardiovascular system
• May require higher arterial pressures
for organ perfusion
• Hypovolemia and hypotension are
poorly tolerated
• Response to drugs may be altered
• Syncope - increased morbidity in pt
over 60
61
• MI less likely to present with classic sx
• CHF -acute and chronic
• Dysrhythmias - degeneration of
conduction system
• Aortic dissection
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Respiratory system
•
•
•
•
•
•
•
•
Asthma/COPD common
Danger of alkalosis with PPV
Danger of ruptured bullae with PPV
Rib fractures common with CPR
CA
PE
Pulmonary edema
Respiratory infections
63
Renal system
• Decreased ability of kidneys to maintain
normal acid-base balance
• Decreased renal function puts elder at
risk for fluid overload and pulmonary
edema secondary to IV therapy
64
Neurological disorders
• Coma
• CVA - more common in elders; at
higher risk because of atherosclerosis,
HTN, immobility, CHF, atrial fibrillation
• TIA’s common
• Seizures may be mistaken for CVA; not
all major motor seizures
65
• Dizziness common complaint; common
causes are alcohol and drug effects
• Senile dementia; loss of neurons begin
slowly in 40’s and 50’s
• Sundowning
66
Delirium
– Acute, reversible, potentially life-threatening
– Abrupt disorientation for time, place
– Hallucinations, illusions
Dementia
– Slow, progressive loss of awareness for time,
place
– Unable to learn new things or remember recent
events
– Long-term memory may be intact
Organic Brain Syndrome
– Acute or chronic disease or injury
– Causes: infection, intoxication, trauma, circulatory
disturbance, epilepsy, metabolic, endocrine
67
diseases
Case History
• You are called to the front yard of a
house where PD is calming a screaming
elderly man. They were driving by,
when they saw him running aimlessly
around the street. You see the man
making aimless grabbing movements in
the air above his head and are barely
able to understand him saying
something about birds and money.
68
• Slowly you approach him and are able to get
him to sit on the grass. For a few words he
seems to follow what you say, then again he
grabs over his head. His name is Thompson,
he says, but you can’t get more than that. The
people in the house have never seen the man
before.
• PE
– BP 192/110, P 136, RR 24, PERL
– No facial droop, no focal weakness
– Large abrasion on the left parietal area. You
notice tears on the knees of his pants with fresh
abrasions on his knees. Rest of exam is normal.
69
• Impression?
• Is he a danger to himself?
• Is he a danger to others?
• How sudden was his deterioration?
• Tx?
70
• Tx:
– Restrain
– IV
– CBG
– Naloxone
– C-spine immobilization
– Transport
71
Environmental emergencies
(50-60,000/yr)
• Constant high or low temps poorly
tolerated
• Predisposing factors for hypothermia;
–
–
–
–
–
Accidental exposure
Drugs
CNS disorders
Endocrine disorders
Low income
72
Predisposing Factors For
Hyperthermia
• Decreased
thermoregulatory
functioning
• Commonly prescribed
meds inhibit sweating
• Low income
73
Case study
• A 68-year-old woman is found
unresponsive in her kitchen. You smell
gas fumes from the stove. There is no
sign of trauma. CBG is 120 mg/dcL.
• DDX?
• TX?
75
Case study
• A man in his 70’s is found unresponsive
in his apartment basement. You note
empty pints of alcohol near the pt, and
that the room is very cold.
• DDX?
• Tx?
76
Gastrointestinal disorders
• GI bleed most common
– Upper GI
• Peptic ulcers
• Esophageal varices
• Mallory-Weis syndrome
– Lower GI
• Diverticulitis (70% of life-threatening
bleed in elders)
• Tumors
• Ischemic colitis
77
Pharmacology
• Elders use 25% of all prescribed and
OTC drugs sold in U.S.
• Absorption, metabolism, etc. altered
• Compensatory mechanisms less
effective
• Underdose, Overdose a problem; may
be accidental
78
• 30% all hospital admissions related to
drug-induced illness
• Common toxic drugs:
– Digitalis, Antiparkinsonian drugs, Diuretics,
Anticoagulants, Lidocaine, Quinidine,
Propranolol, Theophylline, Narcotics,
Sedatives, Phenothiazines, Tricyclic
antidepressants
79
Case study
• A 72 y/o woman is found unresponsive
and apneic in her bedroom You
discover an empty bottle of Placidyl in
the medicine cabinet. There is no sign
of trauma. CBG is 100
• DDX?
• Tx:?
80
Common Atypical Presentation of
Illness
• Infection – frequent falls rather than fever or
↑WBCs
• Acute abdomen – constipation and
↓decreased appetite rather than severe pain
• Pneumonia – vague chest pain and dry
mouth rather than fever
• CHF – fatigue rather than dyspnea
• MI – dyspnea and confusion rather than fever
• UTI – confusion
81
Normal Therapies That Can Be
Worse Than The Problem
•
•
•
•
•
•
•
Lying flat
High flow oxygen
Fluid therapy
Immobilized joints
Ice packs
Medications
Multiple questioners
82
Abuse
• The infliction of physical pain, injury,
debilitating mental anguish,
unreasonable confinement, or willful
deprivation by a caregiver of services
necessary to maintain the mental and
physical health of a geriatric client.
83
• S/S:
– Average age 80
– Pt may have chronic
diseases/disorders
– Unexplained trauma is primary finding
• Profile of potential geriatric abuser
– Stressed - sleep deprivation, marital
discord, etc.
– Life may be in disarray; as patient
deteriorates, abuse develops
84
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Injury and Illness Prevention
• Take supplements, especially calcium
and vitamin D
• Increase physical activity and exercise
• Alter environment to improve safety
–
–
–
–
Grab bars in bathroom
No throw rugs
Better lighting
Unobstructed paths
86
Prevention
• Regular vision screening
• Driving cautions
–
–
–
–
–
–
Seatbelt use
Reduce speed
Day time driving
Avoid in bad weather
Avoid left turns
Early screening
87
88
Summary
• Respect your patients modesty and
other needs
• Explain actions clearly
• Geriatric patients may minimize or deny
symptoms
• Gather medication list to take with you,
but try to leave meds at home
89
Observed changes in older adults
frequently represent the normal
aging process. These changes
may also represent a body system
that is malfunctioning.
90
91
More great truths about aging
• Forget the health food… you need all
the preservatives you can get.
• You find time may be a great healer, but
it’s a lousy beautician.
• Wisdom comes with age, but
sometimes age comes alone.
92
Life is not a journey to the grave with the
intention of arriving safely in a pretty
and well preserved body, but rather to
skid in broadside thoroughly used up,
totally worn out and proclaiming -
“Wow, what a ride”
93