Beyond the Basics: Geriatric Care

CEU Review Form Geriatric Care (PDF)Valid until November 6, 2006

While there have been specialized pediatric courses for many years, only recently have we begun to recognize important issues with our geriatric patients. These patients account for a large percentage of our runs and pose some important challenges in patient care. This article highlights some of these issues as they pertain to our day-to-day care of geriatric patients in the field.

Every call is an opportunity for prevention
     Many years ago, the fire service began prevention activities and saw a significant decrease in fires and lives lost due to fire. If EMS were to embrace prevention on geriatric calls, we could literally add years to the lives of our patients, reduce suffering and save millions in healthcare costs.

     Jumping down from the soapbox, let's look at how EMS prevention activities can make a difference in the geriatric population.

     Falls are a leading cause of injury-related emergency department visits across all age groups. In the geriatric population age 75 and older, falls account for 75% of accidental deaths. Ninety percent of hip fractures result from falls. Even falls from a standing height are associated with significant morbidity and mortality in the elderly.

     Falls occur for a number of reasons. Some are due to changes associated with aging, including reduced senses (hearing, eyesight), physical conditions (arthritis, osteoporosis) and poor balance. External factors, such as poor lighting, inappropriate footwear and throw rugs, also increase the risk of falls. Finally, medications can cause dizziness, drowsiness or confusion, further increasing the risk of falls. It is not unusual for some patients to have many, if not all, of these risk factors.

     EMS providers can perform injury prevention on any call-not just when called for a fall. If you are treating a patient with a medical complaint and you notice a hazard, this is the time for prevention. These hazards may include an unsecured throw rug or a stubborn patient who refuses to use a walker. Prevention might mean advising a patient to get up more slowly to prevent dizziness and subsequent falls. Table I lists some prevention tips and observations to make on your next call.

Bodies change with age
     Bodies gradually change through adulthood and into the geriatric years. Systems that were once efficient are no longer so. These inefficiencies result in signs and symptoms of injury and illness earlier and more frequently than seen in younger patients. For example, decreased lung elasticity and increased chest wall stiffness will cause shortness of breath with a lower level of exertion than in a younger patient. Table II on page 130 describes some of the changes that commonly occur in the elderly patient.

Be aware of polypharmacy
     Many geriatric patients take multiple medications. This is referred to as polypharmacy. The term may also imply that the combination of medications may not be ideal or could cause harm to a patient. It is not uncommon for an elderly patient to have hypertension, type II diabetes, arthritis and prostatic hypertrophy-all requiring medications.

     Polypharmacy may result in problems caused by interactions between medications prescribed by different physicians. Compliance with medications is also an issue when elderly patients are easily confused or forgetful. One of the authors recently treated an elderly patient with an altered mental status whose daughter came in several times per week and placed her mother's medications in a container with four compartments for each day of the week. Instead of taking medications out of the container from top to bottom, the patient went across the top, taking morning meds four times per day for almost two days. She had taken dangerously high doses of medications for hypertension, diuresis and depression. (This is another opportunity to help with prevention strategies.)

     Geriatric patients may have reduced hepatic function, which slows clearance of medications. While liver function and drug clearance can vary even in younger patients, caution should be used in the emergent field setting when administering medications such as lidocaine to the elderly. Lidocaine is metabolized primarily in the liver and, as such, should be administered in reduced doses to those with reduced hepatic function.

     Commonly prescribed medications can cause side effects in the elderly patient. These include: aspirin (gastrointestinal bleeding), digitalis preparations (toxicity, depression), antidepressant medications (altered mental status, cardiac, seizures), loop diuretics (incontinence), OTC sympathomimetics (urinary retention), medications for hypertension (dizziness, syncope), benzodiazepine sedatives (falls) and narcotic analgesics (altered mental status, constipation/impaction).

Multiple medical conditions pose diagnostic challenges
     We have heard much about the different presentation of myocardial infarction in elderly patients, who may not feel the classic pain patterns. There are many other confounding factors like the following example:

     You are called for an elderly patient complaining of altered mental status. On assessment you find an afebrile patient with a blood sugar of 202, blood pressure of 102/58 and pulse of 56, who has become incontinent of urine. None of these factors have anything to do with the patient's current problem. In this case, he has been (unknowingly) experiencing elevated blood glucose, and he also takes medications for hypertension and angina (which lower his pulse and blood pressure) and has benign prostatic hypertrophy causing slight incontinence. His current complaint of altered mental status is caused by sepsis-brought on by pneumonia and worsened by the fact that his lungs no longer expand well. (Remember that many elderly patients with infection will not present with fever.)

     Yes, his blood sugar will need to be regulated and his pulse may be bradycardic, but these aren't the problems today. It is common for providers to uncover myriad diagnostic information. The challenge is to place the relevance appropriately to the patient's acute complaint.

     One clue to differentiating expected changes of aging from a pathology is by determining the onset. Age-related changes progress slowly in most cases. Medical conditions generally present more acutely. Eyesight will deteriorate with age; however, a sudden change in eyesight or in the field of vision may indicate a more acute condition, such as stroke.

Trauma is devastating to the elderly
     Trauma isn't fun at any age, but to the elderly patient with decreased bone density and paper-thin skin that tears easily, even a standing fall that would be a mere annoyance to a younger person can be truly life-threatening. Falls consistently rank in the top 10 leading causes of death in the elderly and are first in accidental causes.

     Other considerations when treating trauma in the elderly patient:

• A medical condition may be the cause of the trauma you are treating. Syncope may have caused a motor vehicle collision. Orthostatic hypotension secondary to a recent change in blood pressure medications may have caused a fall.
• Elderly patients may experience a subdural hematoma after an apparently minor head injury. The brain atrophies with age, causing stretching of veins between the cortex and the dura within the skull that may tear and bleed with much less force than in a younger patient. Aspirin and anticoagulant therapy will worsen the problem.

     These subdural hematomas are often chronic (rather than acute) and develop over time. The gradual onset (generally 3-20 days) may be mistaken for anything from dementia to normal aging. Signs and symptoms will depend on the extent of the hematoma, but may include alterations in speech, gait and mentation. A careful history will elicit the relatively sudden change and a traumatic event that will distinguish SDH from chronic conditions of aging.

• Trauma to the chest has the potential to be more severe. As mentioned previously, the more rigid chest cavity may result in fracture and severe pulmonary contusions. Even minor injuries may cause pain and prevent full lung expansion, resulting in pneumonia.
• Bony changes in the spine make spinal injury and fracture during trauma more likely, especially in the cervical spine.
• Fractures to the hip and other bones are more common because of decreasing bone density.

Depression is common in the elderly
     Some factors linked to depression include death of a spouse or close friend, decreased quality of life (dependence on others, loss of mobility and/or serious illness) and loss of cognitive function.

     Patients who are depressed commonly present with flat affect and other typical "depressed" behaviors. Elderly patients may also present with anxiety and somatic complaints (general weakness, malaise and more specific physical complaints) that are caused by depression.

     Medications play a role in depression in two ways. First, side effects of certain medications can cause depression or the appearance of depression (digitalis preparations, narcotics, benzodiazepines). Second, some medications used to treat depression (tricyclic antidepressants) can have significant side effects, which can cause secondary medical issues, as well as intentional noncompliance with medications to avoid the unpleasant side effects-further worsening the depression.

     Suicide in the elderly population is surprisingly high. Often fueled by the sequelae that cause depression (loss of quality of life, bereavement, loss of cognitive function), depression is disproportionately high among the elderly. Comprising 13% of the population, those over 65 years of age account for 18% of suicides. The greatest increase is seen in males 85 years of age and older, who are five times more likely to commit suicide than the national average (per the National Institute of Mental Health).

     As a prevention note, 75% of the elderly who committed suicide had seen their physician within the past 30 days. Extrapolating this to EMS and the likelihood that an acute illness or exacerbation of an existing serious condition caused contact with EMS personnel provides another opportunity for screening and prevention.

Elderly patients deserve respect
     No article would be complete without mentioning that, while aging brings changes to the body, there are millions of active, alert and vibrant older people. Regardless of the elderly patient's condition-and whether active or resident in a skilled nursing facility-all patients deserve our respect and best clinical care.

     A corollary to this rule is to make no assumptions. Never assume a patient can't hear or think clearly. Start every call with an attempt to communicate and reassure the patient. If we are lucky, we'll all be elderly some day.

CEU Review Form Geriatric Care (PDF)Valid until November 6, 2006

Bibliography
Birnbaumer DA. Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th Ed., pp. 2485-2490. Marx JA, Hockberger RS, Walls RM, eds. Mosby; 2002.
Bledsoe B, Porter R, Cherry R. Paramedic Care Principles and Practice, 2nd Ed. New Jersey: Prentice Hall, 2006.
Braunwald E, et. al., eds. Harrison's Principles of Internal Medicine, 15th Ed. New York, NY: McGrawHill, 2001.
Conwell Y. Suicide in later life: A review and recommendations for prevention. Suicide and Life-Threatening Behavior 31(Suppl):32-47, 2001.
Fuller GF. American Family Physician 61:2159-2169, 2173-2174, 2000.
Office of Statistics and Programming, NCIPC, CDC. Web-based Injury Statistics Query and Reporting System (WISQARSTM).

Daniel D. Limmer, AS, EMT-P, is a paramedic with Kennebunk Fire-Rescue in Kennebunk, Maine, and a faculty member at Southern Maine Community College. He is the author of several EMS textbooks and a nationally recognized lecturer.

Joseph J. Mistovich, MEd, NREMT-P, is a professor and the chair of the Department of Health Professions at Youngstown (OH) State University, author of several EMS textbooks and a nationally recognized lecturer.

William S. Krost, BSAS, NREMT-P, is an operations manager and flight paramedic with the St. Vincent/Medical University of Ohio/St. Rita's Critical Care Transport Network (Life Flight) in Toledo, Ohio, and a nationally recognized lecturer.

Geriatric Connections
     While on a call at an assisted-living facility, I encountered a woman in her mid-80s who had an urgent but non-life-threatening complaint. While we usually transported to a hospital less than 10 minutes away, this woman requested transport to a hospital 30 minutes away. While this was less than popular with the crew, her request was honored, and we settled in for the ride.

     After assessing the patient, obtaining vitals and starting the IV, there were more than 20 minutes left in the trip. The woman was very pleasant, and we talked about the fact that she had been a nurse. I asked where she had worked and she explained that she had worked in a prestigious hospital in a large metropolitan area for many years at a time when nursing was one of the accepted roles for women. But this was only after she got back from her service in the Army.

     My interest was piqued. I have always had profound respect for veterans and this unlikely veteran was no different. Our conversation revealed that she had enlisted in the Army during World War II and, after stateside service, was sent to North Africa.

     Questions raced through my mind. "What was the most difficult transition in going to war in North Africa?"I asked. I expected casualties, homesickness, heat... But her answer surprised me, both in content and delivery.

     My patient looked around the ambulance to assure there was no one she could offend (we were the only two there) before she offered her answer in a whisper: "Going to the bathroom in the desert." I was both amused by her candor and in awe of her elegance. Our conversation continued with my respectful questions followed by my patient's insightful answers. I was literally on the edge of the bench seat the entire ride.

     While I have always prided myself on treating patients well, I realized that my 30-minute ride to the hospital that day was a gift to me. The time society has to spend with this generation is very limited.

     That day, I learned a lesson in class, humility and history...and the hidden gems in our geriatric patients.-Dan Limmer