Geriatric Emergencies
description
Transcript of Geriatric Emergencies
![Page 1: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/1.jpg)
Geriatric Emergencies
![Page 2: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/2.jpg)
Demographic Imperative
Since 1900, life expectancy has increased 43% for all ages 1900: 50 years 1988: 75 years
Persons > 65 are fastest growing group in U.S. 1900: 4% of population 1980: 11% of population 2030: 22% of population
![Page 3: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/3.jpg)
Demographic Imperative
More Americans now are over 65 than under 18
Trend has led to increased incidence of chronic disease
![Page 4: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/4.jpg)
The Elderly: A Profile
Age Gender Race Education Geographic Distribution Living Arrangements Income/Assets/Poverty
![Page 5: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/5.jpg)
Age
Older population is becoming older 65-74 age group: 8 times larger than
in 1900 75-84 age group: 13 times larger 85+ age group: 24 times larger
Persons over 85 are fastest growing population group
![Page 6: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/6.jpg)
Gender
Number of males per 100 females is decreasing 50% of difference is genetic 50% due to social role differences
![Page 7: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/7.jpg)
Race
1989 90% white 8% black 2% others
![Page 8: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/8.jpg)
Education
54% have completed high school 11% have 4 or more years of college Persons over 65 are one of the best
educated segments of the population
![Page 9: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/9.jpg)
Geographic Distribution
52% live in nine statesCalifornia Illinois
New York Ohio
Florida Michigan
Pennsylvania New Jersey
Texas
![Page 10: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/10.jpg)
Living Arrangements
5% in nursing homes 65-74: 1% 75-84: 6% >85: 22%
![Page 11: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/11.jpg)
Income/Assets/Poverty
Median net worth: $60,300 vs. $32,000 for general
population 3.4 million below poverty (11.4%) There is almost no elderly “middle
class”
![Page 12: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/12.jpg)
Health and Health Care
Arthritis 49% Hypertension
37% Impaired Hearing 32% Heart Disease 30% Cataracts 17%
Sinusitis 17% Orthopedic 9% Impaired Vision 9% Diabetes 9%
Chronic illness is common
![Page 13: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/13.jpg)
Health and Health Care
1988 Older adults at 12.5% of population
accounted for 33% of all hospital stays 44% of all hospital days of care 36% of total health care expenditures
![Page 14: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/14.jpg)
Anatomy and Physiology of Aging
![Page 15: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/15.jpg)
General Changes
Total body water decreases 61% at 25 <53% at 70
Total body fat decreases Subcutaneous fat deposits decrease Fat deposits in organs increase
![Page 16: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/16.jpg)
General Changes
Generalized body tissue fibrosis Progressive loss of homeostatic
systems ability to adjust
![Page 17: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/17.jpg)
Specific Changes
Height Weight Skin Musculoskeletal Respiratory System Cardiovascular System Renal System Nervous System
![Page 18: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/18.jpg)
Height
Decrease of 2 to 3 inches Kyphosis (spinal curvature) Spinal disk narrowing Knee/hip joint flexion Joint space narrowing
![Page 19: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/19.jpg)
Weight
Males Increases to mid
50’s, then decreases
Females Increases to mid
60’s, then decreases
![Page 20: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/20.jpg)
Skin
Dermis thins by 20%; blood supply decreases What effect on severity
of burn injuries? What effect on wound
healing? What effect on
tolerance of cold?
Sweat glands decrease; sweating decreases What effect on
tolerance of heat?
![Page 21: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/21.jpg)
Musculoskeletal
Decreased muscle weight relative to body weight
Cartilage loses ability to adapt to repetitive stress
Increased bone resorption; especially in females
What effect in trauma?
![Page 22: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/22.jpg)
Respiratory System
Vital capacity decreases Maximum breathing
capacity decreases 60%
Maximum O2 uptake decreases 70%
What effect on respiratory reserve capacity?
What effect in chest trauma?
What effect in acute respiratory disease?
![Page 23: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/23.jpg)
Cardiovascular System
Stroke volume declines
Speed/force of myocardial contraction decreases
Cardiac conducting system deteriorates
What effect on myocardial reserve capacity?
![Page 24: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/24.jpg)
Cardiovascular System
Fibrosis occurs throughout blood vessels
What effect on ability to control PVR?
What effect on ability to regulate temperature?
![Page 25: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/25.jpg)
Renal System
30 to 40% decrease in number of functioning nephrons
50% decrease in renal blood flow
What effect on elimination of drugs?
![Page 26: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/26.jpg)
Nervous System
6 to 7% brain weight decrease
45% brain cell loss in some areas
15 to 20% blood flow reduction
15% conduction speed decrease
What effect on pain sensation?
![Page 27: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/27.jpg)
Incontinence
Common problem Urinary: 15% (home) to 50% (nursing home) Fecal: 16 to 60% (nursing home)
Can lead to rashes, skin infections, ulcer formation, UTIs, sepsis, falls, fractures
Causes include anatomical changes, underlying disease processes, medications
Respect patient’s modesty and dignity
![Page 28: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/28.jpg)
Problems with Elimination
May indicate serious underlying illness Straining can lead to TIAs, syncope Consider drugs as possible cause
Opiates Anticholinergics (antidepressants, antihistamines,
muscle relaxants, antiparkinson drugs) Cation containing agents (antacids, iron, calcium
supplements Anticonvulsants Diuretics
![Page 29: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/29.jpg)
Assessment of the Elderly
![Page 30: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/30.jpg)
Complicating Factors Variability Response to illness Presence of multiple pathology Altered illness/injury presentation Communication problems Polypharmacy
![Page 31: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/31.jpg)
Variability
Elderly are more heterogeneous than younger people
![Page 32: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/32.jpg)
Response to Illness
Seek assistance for only small part of symptoms
Perceive important symptoms as “getting old”
Delay seeking treatment Trivialize chief complaints
![Page 33: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/33.jpg)
Multiple Pathology
Of patients >65: 85% have one chronic disease 30% have >3 chronic diseases
![Page 34: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/34.jpg)
Multiple Pathology
One system’s acute illness may put stress on another’s reserve capacity
Symptoms of one disease process may mask another disease
Treatment of one disease process may mask another
![Page 35: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/35.jpg)
Altered Presentations
Pain diminished, absent Temperature regulation depressed
What effect on environmental illness? What effect on fever in infection?
Depressed thirst mechanisms What effect on hydration status?
![Page 36: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/36.jpg)
Altered Presentations
Increased susceptibility to Confusion Restlessness Hallucinations
Increased susceptibility to generalized deterioration
![Page 37: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/37.jpg)
Altered Presentations
Vague, poorly defined chief complaints
“The organs of the aged do not cry”
![Page 38: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/38.jpg)
Communication Problems
Diminished Sight Hearing Mental faculties
Depression Poor cooperation/limited mobility
![Page 39: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/39.jpg)
Polypharmacy
30% of geriatric hospitalizations are drug induced
![Page 40: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/40.jpg)
History Taking
Probe for significant complaints/ symptoms Chief complaint may be trivial/non-specific Patient may not volunteer information
![Page 41: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/41.jpg)
History Taking
Dealing with communication difficulties Talk to patient first If possible, talk to patient alone Formal, respectful approach Stay near middle of field of vision
![Page 42: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/42.jpg)
History Taking
Dealing with communication difficulties Light sources behind patient Face patient Reduce background noise Speak slowly Enunciate clearly
![Page 43: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/43.jpg)
History Taking
Dealing with communication difficulties Do not assume deafness Do not shout Do not assume confusion, disorientation
= “senility”
![Page 44: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/44.jpg)
History Taking
Obtain thorough medication history More than one MD More than one pharmacy Multiple medications Old vs current medications Shared medications Over the counter medications
![Page 45: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/45.jpg)
Physical Examination
Consider cold sensitivity; examine in warm area
May fatigue easily May have difficulty with positioning Consider modesty Decreased pain sensation requires
thorough exam
![Page 46: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/46.jpg)
Physical Examination
If they say something hurts,
evaluate carefully!
![Page 47: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/47.jpg)
Physical Examination
Misleading findings Inelastic skin mimics decreased turgor;
Assess over cheeks Mouth breathing mimics dehydration Pedal edema from inactivity, dependent
positioning of feet Non-pathological rales in lung bases Peripheral pulses difficult to feel
![Page 48: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/48.jpg)
Specific Problems
![Page 49: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/49.jpg)
Respiratory Distress
Emphysema Chronic Bronchitis Asthma Pulmonary Embolism Pneumonia
Acute MI Congestive Heart
Failure Pulmonary Edema
![Page 50: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/50.jpg)
Respiratory Distress
Pneumonia Fourth leading cause of death 50x more common in nursing home pts May have atypical presentation
Cough, fever may be absent Possibly abdominal pain rather than chest
pain
![Page 51: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/51.jpg)
Respiratory Distress
COPD Fifth leading cause of death in males
from age 55 to 74 Consider possible spontaneous
pneumothorax in COPD patient who suddenly decompensates
![Page 52: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/52.jpg)
Respiratory Distress
Pulmonary Embolism Sudden dyspnea + decreased mobility +
no other quickly identified causes = ? pulmonary embolism
![Page 53: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/53.jpg)
Respiratory Distress
Dyspnea may be primary symptom of silent MI
![Page 54: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/54.jpg)
Respiratory Distress
Lung Cancer U.S. has highest incidence in world 65% of cases occur in people >65 Dyspnea, hemoptysis, chronic cough,
weight loss
![Page 55: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/55.jpg)
Cardiovascular Disease
Acute Myocardial Infarction Silent MI much more common in elderly May present:
as dyspnea from CHF with signs/symptoms of acute abdomen,
including tenderness and rigidity
![Page 56: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/56.jpg)
Cardiovascular Disease Silent acute myocardial infarction
Weakness Fatigue Syncope Incontinence Transient ischemic attacks/stroke Confusion
![Page 57: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/57.jpg)
Cardiovascular Disease
Congestive Heart Failure Most common diagnosis in hospitalized
patients >65 Signs and Symptoms
Nocturia Paroxysmal nocturnal confusion Large blisters on legs, especially if patient
sleeps sitting up
![Page 58: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/58.jpg)
Cardiovascular Disease
Congestive Heart FailureBed-ridden patients may have fluid accumulations over sacral area rather than in feet, legs
![Page 59: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/59.jpg)
Cardiovascular Disease
Dysrhythmias Extreme rates not tolerated as well;
may lead to CHF, TIAs Sudden onset = ? silent MI Consider hypokalemia,
hypomagnesemia, especially in patients on diuretics
![Page 60: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/60.jpg)
Cardiovascular Disease
Dysrhythmias Consider drug toxicity
Digitalis Beta blockers Calcium channel blockers Antiarrhythmics (proarrhythmic effects)
![Page 61: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/61.jpg)
Cardiovascular Disease
Aortic Dissection/Aneurysm Thoracic: Tearing chest pain, often associated
with neurological S/S; asymmetry of upper extremity pulses, BPs
Abdominal: Tearing abdominal pain; pulsating mass; unexplained low back pain; lower extremity weakness, numbness, pallor, coolness; diminished lower extremity pulses
![Page 62: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/62.jpg)
Cardiovascular Disease
Hypertension Present in 50% of persons >65 Asymptomatic or associated with non-
specific symptoms Anti-hypertensive medications may mask
or complicate coexisting diseases
![Page 63: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/63.jpg)
Neurological Disorders
![Page 64: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/64.jpg)
Syncope
Altered mental status caused by transient interruption or decrease in cerebral blood flow
Morbidity/mortality higher than in younger people
![Page 65: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/65.jpg)
Syncope
Cardiogenic Silent MI Stokes-Adams attack Tachyarrhythmias Bradyarrhythmias Sick sinus syndrome Beta blocking agents
![Page 66: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/66.jpg)
Syncope
Transient ischemic attack Seizure disorders Vasomotor depression
Diabetic neuropathy Antihypertensive agents
Vasodilators Diuretics
![Page 67: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/67.jpg)
Syncope
Consider volume depletion Depressed thirst/inadequate fluid intake Occult bleeding
![Page 68: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/68.jpg)
Cerebrovascular Accident
Emboli/thrombi more common Atherosclerosis Hypertension Immobility/limb paralysis CHF Chronic A-fib
![Page 69: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/69.jpg)
Cerebrovascular Accident
Signs may be subtle: Dizziness Behavior change Altered affect Headache, especially if localized
Suspect CVA in any older person with altered mental status
![Page 70: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/70.jpg)
Cerebrovascular Accident
TIA’s common Frequent cause of syncope One third will progress to CVA
![Page 71: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/71.jpg)
Cerebrovascular Accident Cardiogenic mechanisms may
cause TIAs/CVAs Monitor EKG in all patients with
neurologic symptoms
![Page 72: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/72.jpg)
Cerebrovascular Accident
Symptoms may be due to intracranial bleeds from head trauma
Onset may be delayed
![Page 73: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/73.jpg)
Seizures
All first time seizures in geriatric population are danger sign
![Page 74: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/74.jpg)
Seizures
Possible causes CVA Syncope (transient hypoperfusion) Transient arrhythmias Alcohol or drug withdrawal Tumors Head trauma (onset may be delayed) Hypoglycemia
![Page 75: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/75.jpg)
Parkinson’s Disease
Fourth most common degenerative disease in elderly
Affects basal ganglia of brain Primary vs. secondary types Pill-rolling tremors; muscle rigidity;
shuffling gait; mask-like facial expression; slow, monotone voice; anxiety; depression
![Page 76: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/76.jpg)
Dementia and Delirium
Dementia Structural origin Chronic Slowly progressive Irreversible Impairs memory Global cognitive deficits
Delirium Metabolic origin Rapid onset Fluctuating course Reversible Impairs attention Focal cognitive deficits
15% of elderly have some degree of dementia or delirium
![Page 77: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/77.jpg)
Dementia and Delirium
Distinguish between acute delirium and chronic dementia
Never assume acute events are due to “senility”
![Page 78: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/78.jpg)
Dementia and Delirium
Head injury with subdural hematoma
Postconcussion syndrome
Tumor Alcohol or drug
intoxication/ withdrawal
CNS Infections Fever CHF Hypoglycemia Endocrinopathies Electrolyte imbalances Hypoxia Drug interactions
Possible causes of delirium
![Page 79: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/79.jpg)
Dementia and Delirium
Alzheimer’s Disease Most common cause of dementia in elderly Early stage: Loss of recent memory, inability to learn,
mood swings, personality changes, aggression, hostility, poor judgment
Intermediate stage: Complete inability to learn, wandering, increased falls, loss of self-care ability
Terminal stage: Inability to walk, loss of bowel/bladder control, loss of ability to eat/swallow
![Page 80: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/80.jpg)
Endocrine Disorders
![Page 81: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/81.jpg)
Diabetes Mellitus
20% of elderly have diabetes (primarily Type II)
40% have glucose intolerance Produces increased risk of
atherosclerosis, peripheral vascular disease, delayed healing, blindness, renal failure
![Page 82: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/82.jpg)
Thyroid Disorders
2 to 5% of elderly develop hypothyroidism <33% present with typical signs/symptoms Common complaints include anorexia,
confusion, falls, incontinence, decreased mobility, muscle and joint pain
![Page 83: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/83.jpg)
Thyroid Disorders
Hyperthyroidism is uncommon in elderly May result from thyroid hormone OD Common complaints include heat
intolerance, atrial fibrillation, weight loss, apathy, abdominal pain, diarrhea, exhaustion, depression
![Page 84: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/84.jpg)
GI Disorders
![Page 85: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/85.jpg)
GI Disorders
Abdominal pain frequently indicates surgical emergency
May present only with: Altered mental status, or Unexplained signs of shock
![Page 86: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/86.jpg)
GI Disorders
Other pathology may mimic acute abdomen Acute MI Pneumonia Genitourinary/retroperitoneal disease Metabolic disease
![Page 87: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/87.jpg)
GI Disorders
Most common problem is GI hemorrhage
![Page 88: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/88.jpg)
GI Disorders
Peptic ulcer Gastritis Esophageal varices Mallory-Weiss
syndrome NSAID abuse
Diverticulosis Tumors Ischemic colitis Arteriovenous
malformations
Common GI bleed causes include:
![Page 89: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/89.jpg)
GI Disorders
GI Bleeding Signs Coffee ground emesis Dark or bloody stool Orthostatic
hypotension Confusion Increase in angina
symptoms Weakness Dyspnea
Beta blockers may mask signs/symptoms of GI bleeds!
![Page 90: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/90.jpg)
GI Disorders
Bowel Obstruction Typically involves small bowel Causes: tumors, surgery, medications,
vertebral fractures Diffuse pain, distension, nausea, vomiting,
decreased bowel sounds, fever, weakness, shock
![Page 91: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/91.jpg)
GI Disorders
Mesenteric/Bowel Infarct Risk factors: atherosclerosis, A-fib Bloody diarrhea, tachycardia, abdominal
distension Pain out of proportion to physical exam findings Hypotension, peritonitis, sepsis
![Page 92: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/92.jpg)
Skin Disorders
![Page 93: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/93.jpg)
Skin Diseases
Pruritis (itching) is common complaint May be caused by dermatitis or drying May indicate underlying liver or kidney
disease Slower healing increases infection risk Incidence of fungal infections, herpes
zoster increases
![Page 94: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/94.jpg)
Skin Diseases
Skin disorders may be medication related Beta blockers worsen psoriasis Antibiotics may cause skin eruptions Topical “home remedies” may cause skin
disorders Antihistamines, corticosteroids 2 to 3x more
likely to provoke adverse reactions
![Page 95: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/95.jpg)
Decubitus Ulcers
Occur in up to 25% of nursing home patients
Mostly in people over 70 Typically below waist, over bony
prominences, in bedridden patients
![Page 96: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/96.jpg)
Decubitus Ulcers
Risk factors Pressure Altered sensation Tissue maceration Decreased activity,
mobility Poor nutrition Friction or shearing
forces
Management Frequent position changes Use of draw sheets Padding of skin before
movement Clean, dry areas of
excessive moisture Clean ulcers with saline,
cover with hydrocolloid or hydrogel dressings
Loosely pack severe ulcers with loosely woven, saline moistened gauze
![Page 97: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/97.jpg)
Musculoskeletal Disorders
![Page 98: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/98.jpg)
Osteoarthritis
Leading cause of disability in elderly Joint pain, worsened by movement Diminished mobility, joint deformity,
crepitus, tenderness Immobility can worsen condition Management includes physical therapy,
anti-inflammatory drugs, analgesics, surgery
![Page 99: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/99.jpg)
Osteoporosis
Affects ~20 million Americans Accounts for wrist, hip, spinal fractures
following falls
![Page 100: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/100.jpg)
Osteoporosis
Age >50 Female gender Early menopause
(<45) No estrogen
replacement Caucasian or Asian
Low body weight Family history Late menarche Nulliparity Use of alcohol,
caffeine, cigarettes
![Page 101: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/101.jpg)
Environmental Emergencies
Elderly tolerate temperature extremes poorly
![Page 102: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/102.jpg)
Environmental Emergencies
Poor cardiovascular function
Poor nutrition Endocrinopathies,
especially thyroid disease
Chronic illness, debilitation
Drug effects Diuretics Antipsychotics
Low, fixed incomes
Predisposing Factors
![Page 103: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/103.jpg)
Environmental Emergencies
High index of suspicion in any patient with altered LOC or
vague clinical presentation in hot or cool environment
![Page 104: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/104.jpg)
Toxicology/Pharmacology
25% of prescription drug use is by people >65
By 2030 this will increase to 40%
![Page 105: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/105.jpg)
Toxicology/Pharmacology
Generally more sensitive to drug effects Changes in body mass and fat alter drug
distribution Fat soluble drugs distribute more widely Water soluble drugs distribute less widely
Liver size, blood flow decrease Renal filtration rate, tubular function decrease
![Page 106: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/106.jpg)
Toxicology/Pharmacology
Causes of drug related illness Forgetful/confused/does not understand drug Compliant, but prescribed dose excessive Receives meds from more than one source Resumes use of old meds Uses meds intended for others
![Page 107: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/107.jpg)
Toxicology/Pharmacology
Causes of drug related illness Does not mention non-prescription drugs Drug abuse (signs/symptoms are from
withdrawal) Ran out of meds or reduced dose for
financial reasons Added a drug that impairs or exaggerates
effects of drugs already in use Changed smoking, alcohol, or dietary habits
![Page 108: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/108.jpg)
Lidocaine
Decreased hepatic metabolism causes toxicity
CNS-related signs, symptoms Numbness, tingling Drowsiness Depression Muscle twitching Seizures
![Page 109: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/109.jpg)
Beta-Blockers
Can produce depression, lethargy Can produce bronchospasm in patients
with asthma/COPD May cause decreased ventricular
contractility, worsening heart failure May mask early signs of hypovolemic
shock
![Page 110: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/110.jpg)
Diuretics
Volume depletion Postural hypotension Circulatory collapse
Hypokalemia Arrhythmias Enhanced digitalis effect
![Page 111: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/111.jpg)
ACE Inhibitors
Cause vasodilation, diuresis Can produce
Hypovolemia Hypotension Electrolyte imbalances Nausea, vomiting, headache, fatigue
![Page 112: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/112.jpg)
Digitalis
40-60% of patients become toxic Usually caused by decreased volume of
distribution and clearance Digitalis toxicity may result from diuretic-
induced hypokalemia
![Page 113: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/113.jpg)
Antidepressants
Sedation, confusion, lethargy, muscle weakness
Dry mouth, constipation, urinary retention, confusion
TCAs may cause orthostatic hypotension
![Page 114: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/114.jpg)
Lithium Carbonate
Excreted entirely by kidneys Decreased renal function can cause
toxicity Metallic taste in mouth, hand tremors,
nausea, muscle weakness, fatigue, blurred vision, lack of coordination, coma
![Page 115: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/115.jpg)
Antipsychotics
Sedation, anticholinergic effects Extrapyramidal reactions
![Page 116: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/116.jpg)
Sedative/Hypnotic Drugs
Increased sensitivity to sedation Increased risks of falls/hip fractures
![Page 117: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/117.jpg)
Anti-Parkinsonian Drugs
Sinemet, Parlodel, Cogentin, Symmetrel Dyskinesia, hallucinations, nightmares Orthostatic hypotension Tsmar in combination with Sinemet can
produce liver damage
![Page 118: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/118.jpg)
Anti-Seizure Medications
Side effects include sedation, GI distress, lack of coordination, dizziness, dermatologic reactions
![Page 119: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/119.jpg)
Aspirin, NSAIDS
Gastrointestinal bleeding Higher doses can cause renal/hepatic
toxicity Aspirin toxicity can cause confusion,
tinnitus
![Page 120: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/120.jpg)
Corticosteroids
Side effects include Hypertension Peptic ulcer Aggravation of diabetes mellitus Glaucoma Increased risk of infection Addison’s disease secondary to suppression
of endogenous corticosteroid production
![Page 121: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/121.jpg)
Theophylline
Smoking speeds theophylline metabolism Physicians compensate by increasing
maintenance doses Patients who stop smoking may become
toxic
![Page 122: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/122.jpg)
Drug/Disease Interactions
Glaucoma + Atropine Acute Glaucoma CHF + Beta blockers Decompensated
CHF COPD + Beta blockers Bronchospasm COPD + Opiates Respiratory failure
![Page 123: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/123.jpg)
Drug/Disease Interactions
Hypokalemia + DigitalisArrhythmias
Peptic Ulcer Disease + NSAIDS GI bleed Peptic Ulcer Disease + Anticoagulants GI Bleed
![Page 124: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/124.jpg)
Drug/Disease Interactions
Prostate Enlargement + Atropine Urinary retention Conduction disorders + Tricyclics AV Block
![Page 125: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/125.jpg)
Psychiatric Disorders
![Page 126: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/126.jpg)
Depression
Common in elderly May account for symptoms
attributed to “senility” Should be considered immediate
life threat Persons over 65 account for 25%
of all suicides
![Page 127: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/127.jpg)
Alcoholism
Much more common than generally suspected
Onset may be due to bereavement May account for deterioration in grooming,
unexplained falls, unexplained GI bleeds Withdrawal may account for seizures
![Page 128: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/128.jpg)
Neuropsychiatric Problems
Illness in elderly may precipitate acute episodes of dementia, confusion
Emotional disorders due to isolation, loneliness, loss of self-dependence, loss of strength, fear of the future may present as physical disorders
![Page 129: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/129.jpg)
Trauma
![Page 130: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/130.jpg)
Trauma
Increased risk of injury Slow reaction times Diminished vision, hearing Falls Criminal acts
![Page 131: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/131.jpg)
Head Injury
Common, even with minor trauma Increased ICP signs develop slowly Patient may have forgotten injury
![Page 132: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/132.jpg)
Cervical Injury
Osteoporosis Increased injury risk with trivial
accidents Arthritic changes
Narrow spinal canal Increased injury risk
![Page 133: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/133.jpg)
Cervical Injury
Sudden movement may cause cord injury without fracture
Decreased pain sensation may mask pain of fracture
![Page 134: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/134.jpg)
Chest Trauma
Aging decreases chest movement, vital capacity, respiratory reserve capacity
Organs have less anoxia tolerance Nitrous oxide may have greater
depressant effect
![Page 135: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/135.jpg)
Chest Trauma
COPD may be present Positive pressure ventilation may cause
pneumothorax Hypoperfusion may cause severe tissue
hypoxia
![Page 136: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/136.jpg)
Trauma
Cardiovascular System Decreased compensation for hypovolemia
Move to decompensated or irreversible shock very rapidly
Tolerate hypoperfusion poorly, even for short periods
Hypoperfusion may lead to CVA, MI, bowel infarcts, renal failure, adult respiratory distress syndrome
![Page 137: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/137.jpg)
Trauma
Cardiovascular System May be hypoperfused at “normotensive”
pressures Chronic beta blocker therapy may mask
signs of shock Decreased myocardial reserve may lead
to difficulty with fluid resuscitation
![Page 138: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/138.jpg)
Trauma
Renal System Decreased kidney function may result in
fluid overload
![Page 139: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/139.jpg)
Trauma
Orthopedics 33% of falls cause at least one fracture Most common are hip or pelvis Think about underlying medical causes Positioning/packaging may have to be
modified to accommodate physical deformities
![Page 140: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/140.jpg)
Trauma
Burns Higher mortality than any group except infants
Preexisting disease Thin skin Poor immune response Reduction in organ system reserve Inability to meet metabolic demands of burn injury
Increased risk of shock Fluid administration critical to prevent renal failure
![Page 141: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/141.jpg)
Geriatric Abuse/Neglect
Physical or psychological injury of older person by their children or care providers
Knows no socioeconomic bounds
![Page 142: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/142.jpg)
Geriatric Abuse/NeglectPatient
Older (average age mid-80s) Multiple chronic diseasesUnable to be totally independentOften has sleep pattern disruption leading to nocturnal shouting or wandering
![Page 143: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/143.jpg)
Geriatric Abuse/Neglect
Family has difficulty upholding commitment to care
Other causes of stress present Financial difficulties Marital discord Work related problems
![Page 144: Geriatric Emergencies](https://reader033.fdocuments.net/reader033/viewer/2022061203/547cf0bab4af9fcf338b4d1a/html5/thumbnails/144.jpg)
Geriatric Abuse/Neglect
Primary findings Trauma inconsistent with history History that changes with multiple tellings
Management Do NOT confront family Report suspicions to ER physician, law
enforcement Reporting is mandatory