Transcript Chapter_036 610KB Jan 14 2015 08:21:50 AM

Chapter 36
Geriatric Emergencies
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 1
Case History
You respond to a nursing home for a “heart attack.”
On arrival, you find a 64-year-old female complaining
of “crushing” chest pain and shortness of breath for
the last 40 minutes. The patient tells you that she has
had two heart attacks but does not want to go to the
hospital. Her vital signs are pulse 58 and regular,
respirations 24 and labored, and blood pressure
190/110. She has rales in her lungs and swollen
ankles. She takes Inderal and Lasix.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 2
Overview of Geriatric Patients

More prone to serious respiratory and cardiovascular
problems

Less ability to compensate for severe illness

More difficult to diagnose due to multiple illness and
problems with assessment

Subject to falls and serious injury with less severe
mechanism of injury
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 3
Statistics on Aging

Increased mean survival rate of older persons

Declining birth rate

Absence of major wars or other catastrophes
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 4
Statistics on Aging

Population over 65 years of age grows each year.

Percent of population 65 years of age and over



3% in 1900
12.1% in 2000
Life expectancy

49 years in 1900
 76.9 years in 2000
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 5
Leading Causes of Death –
Geriatric Population
1. Heart disease
2. Cancer
3. Stroke
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 6
Decline in Organ Systems
with Age
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 7
Respiratory System

Vital capacity decreases 50%.

Decreased recoil of the lungs

Loss of bronchiole muscle to maintain patency



Air trapping from collapse of bronchiole
Unchanged capillary circulation
Shunting results
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 8
Heart

Stroke volume declines.

Heart’s conduction system degenerates.


Fewer pacemaker cells
Maximum pulse decreases (220 minus age).
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Slide 9
Vessels

Increased peripheral vascular resistance


Less elasticity
Atherosclerosis

More prone to embolism

Decreased ability of vessels to respond to changes
such as shock
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10
Musculoskeletal System

Decrease in total skeletal muscle weight

Widening and weakening of bones

Osteoporosis — increased potential for fractures

Greater probability of fractures with minor
mechanisms of injury
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11
Thermoregulatory Issues

More susceptible to environment

Decreased ability to respond

Decreased heat production

Decreased heat loss
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12
Dehydration/Feeding

Decreased thirst

Increased dependence

Decreased mobility

Decreased body fat and water
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13
Factors That Complicate
Patient Assessment
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14
Geriatric Patient May Have
Multiple Diseases

Study identified average of 3.26 problems at a time in
elderly men.


Difficult to differentiate cause of immediate emergent
problem
Symptoms of chronic illness may be confused with
symptoms of acute problem.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15
Aging Changes Response
to Illness or Injury
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16
Chronic vs. Acute Problems

Rales may be caused by bedridden state.

Do not confuse with pulmonary edema

Loss of skin elasticity may give appearance of
dehydration.

Ankle edema may caused by varicose veins and
inactivity/position.

Do not confuse with congestive heart failure.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17
Diminished Pain Response

Elderly have decrease response to pain.

“Silent” heart attacks are more common in elderly.

Major abdominal complaints may be masked.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18
Temperature Regulation
Diminished

Minimal or absent fever with severe infection

Decreased shivering response

Prone to environmental thermal conditions
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19
Drug-Related Factors

Study found 59% medication errors

26% serious medication errors

May confuse directions

May have multiple medications from various physicians

Bring drugs to hospital whenever possible.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20
Drugs Alter Cardiovascular
Function

Slow pulse rate


Beta blockers
Calcium channel blockers

Diuretics may affect body chemistry

Anticoagulants may precipitate severe bleeding
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21
Considerations in
Taking Patient History

Probe for significant symptoms.

Chief complaint may be trivial.

Patient may not volunteer significant information.

Denial may impair objectivity.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 22
Impaired Sight

Increased anxiety


Inability to exert control over situation
Inability to see surroundings

Talk to patient calmly and explain procedures.

Position yourself so patient can best see you.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 23
Diminished Hearing

Can make obtaining history difficult for patient

Don't assume patient is deaf without inquiring.



Don't shout — distorts sounds if patient has some hearing
Doesn't help if patient is deaf
Write notes if necessary
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 24
Diminished Hearing

If patient can read lips, speak slowly and directly
toward patient.

Whenever possible, verify history with reliable friend
or relative.

Seek assistance from these individuals to
communicate with patient.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 25
Diminished Mental Status

Patient often confused and unable to remember
detail.

Noise of radios, ECG, strange voices add confusion

Do not assume senility is cause of delirium,
confusion, distractibility, restlessness, excitement, or
hostility.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 26
Diminished Mental Status

Does mental status represent a change from normal?

Alcoholism is more common in elderly.


Patient may deny alcoholism.
Verify with family.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 27
Past Medical History and
Medications

May be complicated


Try to determine what is significant.
Obtaining medication history is important.




Usually taking multiple drugs
Medication errors and noncompliance are common.
Find all drugs and take to hospital with patient.
Try to establish old vs. current drugs.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 28
Information from Environment


Attempt to verify patient history with reliable
family/neighbors.
Observe surroundings for indication of patient’s ability
to care for self.



Social services
Home care
Psychiatric care
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 29
Information from the Environment

Observe for evidence of drug/alcohol ingestion.

Be conscious of potential for heat-related disorders.

Look for

Medical alert tags
 Vial of life

Observe for signs of violence/abuse.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 30
Considerations During
Physical Examination
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 31
Physical Examination

Patient may be easily fatigued.



Commonly wear excessive clothing


Breath sounds
Motor examination
May hamper examination
Explain actions clearly before initiating exam.

Important in patients with diminished sight
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 32
Physical Examination

Patient may minimize or deny symptoms.


Fear of being bedridden, institutionalized, or losing selfsufficiency
Peripheral pulses may be difficult to evaluate
because of arteriosclerosis.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 33
Psychosocial Issues

Fear of death

Lack of family support

Sensitivity to loss of independence

Potential for suicide
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 34
Social and Emotional Factors

Denial of serious illness

Fear of loss of independence

Fear of dying

May increase possibility of denial response
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 35
Communication Barriers

Avoid overfamiliarity.

Avoid tendency to treat like a child.

Provide sincere empathetic approach.

Win confidence and cooperation.

Compassion and patience are key.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 36
Common Presenting Problems
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 37
Fatigue and Weakness

Chronic vs. acute onset

Cardiovascular disease

CHF
 Bleeding
 Dysrhythmias

Respiratory illness

COPD
 Pneumonia
 Cancer
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 38
Dizziness and Fainting –
CNS Causes

Stroke or TIA

Flexion of carotid arteries
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 39
Dizziness and Fainting –
Cardiovascular Causes

Postural fainting

Slowed vessel and pulse response
 Increased vascular rigidity
 Drugs preventing compensatory
mechanisms

Abnormal heart rhythms

Slow heart rates
 Rapid heart rates

Bleeding conditions

GI bleeding
 Aneurysms
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 40
Major Causes of Falls

General inattentiveness

May trip over objects
 May fall down stairs

Fainting




Note chronology of events.
Did fall cause symptoms?
Did symptoms cause fall?
Posture maintenance


Loss of ability to regain balance
Common to small children and elderly
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 41
Fractures Due to Osteoporosis

Minimal mechanism of injury is likely to cause a
fracture.

Maintain a high index of suspicion.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 42
Headache

Migraines and tension headaches are less common
in elderly.

Take headache complaint very seriously.

Consider serious cause of headache.


Subdural hematoma
Hemorrhagic stroke
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 43
Dehydration

Elderly are more prone to dehydration.




Decreased kidney function
Less fluid intake due to mobility
Diuretic therapy
Check for signs of dehydration.



Dry skin turgor
Dry oral mucosa
Sunken eyes
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 44
Thermoregulatory Problems

Most common in infants and persons over 75 years

Lessened ability to regulate heat production and heat loss

Decreased basal metabolic rate

Decreased ability to shiver

Effects of medications

Lessened ability to detect heat or cold
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 45
Hypothermia

Rarely self-reported

Reliance on EMT to note on examination
 Need not be extreme environment

May be complicated by drugs and alcohol

Major causes

Falls on ice and remains immobile for period time
 Falls at home and left undetected by others for a long period of time
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 46
Heat Emergencies

Need not occur in outdoor environment

May be bedridden

Less ability to lose heat

Signs and symptoms

Apathy
 Weakness
 Fainting
 Environmental clues
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 47
Depression

Suicide is increased among elderly white men in U.S.

Depression may mimic senility/organic brain
syndrome.

May inhibit patient’s cooperation
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 48
Depression

Patient may be malnourished, dehydrated,
overdosed, and/or contemplating suicide.

May simply be imagining physical ailments for
attention

Question about drug ingestion and suicidal thoughts
if appropriate.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 49
Summary

Become familiar with the common ailments
associated with aging.

Consider the key differential diagnoses when
presented with a geriatric patient.

Be aware of the special considerations associated
with communicating with the geriatric patient.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 50
Summary

Maintain a systematic approach.

Avoid overlooking significant problems.

Be conscious of reduced ability to compensate for
serious illness.
Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 51