CBT 701 EMT 11 Geriatric Medicine 2010 Seattle

CBT 701 -EMT 11 – Geriatric Medicine © 2010 Seattle / King County EMS

Introduction • With advancing age various organ systems in body begin to fail or show decreased function • Elderly have less reserve in their organ systems • Loss of function (for example renal, cardiac, endocrine or respiratory function) makes person more vulnerable to injury or illness • It is estimated organ systems lose approximately 1% of capacity per year starting at about 30 years of age • Consider the following: – – Increasing cholesterol will lead to more heart attacks Decrease in cardiac output will lead to more falls and syncopy Decrease in lung elasticity lead to more respiratory infections Decrease in bone and muscle mass leads to more falls and fractures – Multiple medical conditions leads to increased medication interactions © 2011 Seattle / King County EMS

Introduction • Good way to approach elderly patients – assume they are more vulnerable to injury or illness • Examples: – Pneumonia in someone 80 years of age is likely to be far more serious than in someone age 25 – Fall in someone 85 may be very serious whereas in a younger person the fall may lead to no harm © 2011 Seattle / King County EMS

Course Objectives 1. 2. 3. 4. 5. 6. 7. Identify unique characteristics of the elderly patients. Identify examples of diminishing stroke volume in the elderly patient. Identify factors that affect outcome of the elderly patient in trauma. Identify signs and symptoms of dementia and or the pathophysiology. Identify signs and symptoms of cardiovascular emergencies. Identify emergency care for a traumatized elderly patient. Identify emergency care for the medical elderly patient. © 2011 Seattle / King County EMS

Terms Diuretic - A drug such as Lasix (furosemide) and HCTZ (hyrdrochlorothiazide) used primarily to treat hypertension and congestive heart failure. Diuretics may cause dehydration, making the patient more susceptible to syncope or heat stress. Dysrhythmia - Irregular or abnormal heart rate, also sometimes referred to as cardiac arrhythmia. Elderly - There is no general agreement when a person becomes “old”. The common use of a calendar age to mark the threshold of old age assumes that everyone ages at the same rate which is not true. Metabolism - The process by which cells take in energy (food and oxygen) so they can function. All bodily functions such as digestion, muscle contractions, and breathing require energy. Heat is a by-product of these processes. © 2011 Seattle / King County EMS

New Terms Bradypnea - Slow breathing. It is defined as a respiratory rate of less than 10 breaths per minute. Things to consider are ingestion of central nervous system (CNS) depressants (eg, narcotics, benzodiazepines), stroke, or per terminal conditions. Dementia - (meaning "deprived of mind") is a serious loss of brain function that lead to problems in memory, thinking, language, behavior, and judgment. Dementia may be progressive or stable. The incidence of dementia increases with advancing age. Elder Abuse - Harmful treatment toward an elderly person, includes physical, sexual, or emotional abuse, financial exploitation, and neglect. © 2011 Seattle / King County EMS

New Terms continued Hematemesis - Vomiting blood. The source is generally the upper gastrointestinal (GI) tract. This can be confused with hemoptysis (coughing up blood). The spectrum of upper GI bleeding varies from occult (meaning not readily seen) bleeding that presents as anemia to acute, life-threatening hemorrhage resulting in hypotension and shock. Sources of life-threatening upper GI bleeding include peptic ulcer disease, esophageal varices, and Mallory-Weiss tears. Huntington's disease, chorea, or disorder (HD) - Progressive neurological genetic disorder, which lead to loss of muscle coordination and some cognitive problems. Its onset is typically in middle age. It is the most common genetic cause of abnormal involuntary writhing movements called chorea and is much more common in people of Western European descent. © 2011 Seattle / King County EMS

New Terms continued Hyperosmolar nonketotic state (HKS) - An uncommon type of diabetic coma. It has a high mortality. Other commonly used names are hyperosmolar hyperglycemic nonketotic coma (HHNKC) or hyperosmotic non-ketotic coma (HONKC). Patients with this condition have very high sodium caused by severe dehydration. Neglect - Failure of a caretaker to provide goods or services necessary to avoid physical harm or mental anguish, such as abandonment, denial of food or health related services. It can be intentional of unintentional through ignorance or lack of training. Vulnerable Adult - adults age 60 and older who cannot care for themselves. Also, includes adults age 18 and older who, have a legal guardian, are developmentally delayed, live in a DSHS licensed facility, receive in home care services, or have a personal care aide who is paid for their services. © 2011 Seattle / King County EMS

CARDIOVASCULAR AGING © 2011 Seattle / King County EMS

Heart Disease • Almost all cardiac diseases more common in elderly • Includes higher incidence of coronary heart disease, congestive heart failure, cardiomyopathy & heart dysrhythmias © 2011 Seattle / King County EMS

Valves in the Heart • Valvular heart disease leads to heart failure by causing impaired cardiac filling and then chronic volume overload, which results in secondary heart failure • Infection cause endocarditis (infection of the heart valves) – More likely to occur in older persons – Increase is due to number of factors including higher number of prosthetic valves & increased hospitalizations with associated hospital-acquired infections in the elderly © 2011 Seattle / King County EMS

Degeneration of the Cardiac Conductive System • Heart contraction – initiated by signal coming from SA node in atria – Signal then travels to AV node by special conducting cells – Signal then conducted through bundle of His to bundle branches in ventricular walls which in turn signal muscle fibers in walls to contract © 2011 Seattle / King County EMS

Degeneration of the Cardiac Conductive System • Block occurs when signal cannot progress or its progress delayed • Three degrees of block – 1 st degree (slow conduction in the atria) – 2 nd degree (Mobitz 1 and 2) (partial block in the AV node) – 3 rd degree (complete block in the AV node) • Stokes Adams Syndrome: slowing of heart & often leads to syncope • Patient may become pale before fainting – Normally syncope short lived • Seizures may occur with associated fall in blood pressure – Often less than 30 seconds in duration © 2011 Seattle / King County EMS

Stroke Volume • Stroke volume (SV) – volume of blood ejected with each contraction • Ejection fraction (EF) – blood ejected by left ventricle during contraction divided by total volume of left ventricle • Normal EF is approximately 60 -65% Video explanation available at EMS Online: http: //www. emsonline. net/geriatric 2011/ strokevol. asp © 2011 Seattle / King County EMS

Congestive Heart Failure • In heart failure, heart cannot pump enough blood through body • Can affect right, left, or more commonly both sides of heart • Can be chronic or acute • Common symptoms of heart failure include: – Shortness of breath or difficulty breathing – Feeling tired – Swelling of the lower legs – Elevated jugular venous pressure © 2011 Seattle / King County EMS

Coronary Implications • Aging heart has diminished stroke volume, increased atherosclerosis, increased calcification in the valves & less effective conduction • Results may present as angina, myocardial infarction, heart failure, atrial fibrillation, aortic stenosis • Elderly patients often do not present with typical symptoms of acute myocardial infarction – May be due to loss of sensory fibers though exact reasons are not known © 2011 Seattle / King County EMS

Coronary Implications • Acute myocardial infarction in elderly may include any combination of following symptoms: – – Fatigue Shortness or breath Syncope Hypotension Be especially alert to atypical symptoms of MI in elderly patients © 2011 Seattle / King County EMS

RESPIRATORY SYSTEM © 2011 Seattle / King County EMS

Emergencies • Older patients more likely to have conditions like emphysema & heart failure (pulmonary edema) and/or combination of these diseases – Less ability to compensate compared to younger patients • Acute pulmonary edema often a result of acute myocardial infarction (MI) © 2011 Seattle / King County EMS

Pneumonia • Common & significant health problems for elderly • Fourth leading cause of death in this age group • Nosocomial (hospital acquired) pneumonia fairly common among older patients – Especially for thoracic or abdominal surgery, on a respirator, or undergoing tube feeding • Serious underlying illness – major risk factor for developing pneumonia in elderly © 2011 Seattle / King County EMS

X-ray of lungs with pneumonia © 2011 Seattle / King County EMS

Pulmonary Embolism • Pulmonary embolism (PE) – obstruction of pulmonary artery caused by blood clot – Travels to pulmonary artery from another location (atria or lower leg) • Incidence of PE increases with age © 2011 Seattle / King County EMS Risk factors: • Prolonged bed rest • Underlying cancer • Recent surgery Video DVT & PE: http: //www. emsonline. net/geriatric 2011/ pulmonary. asp

Asthma • Typically chronic disease caused by episodic bronchospasm (constriction) of lung’s small airways • Treated with two kinds of medicines: Nebulizers often prescribed © 2011 Seattle / King County EMS –Quick-relief medicines to stop bronchospasm & reduce inflammation –Long-term control medicines to prevent recurrence

NEUROVASCULAR SYSTEM © 2011 Seattle / King County EMS

Disorders • Disorders & conditions of neurovascular system include: • Blood vessel aneurysms in brain • Stroke syndromes • Vascular malformations of brain & spinal cord • Dementia (Alzheimer’s type dementia is most common) typically associated with atrophy of brain cells – Exact causes of dementia largely unknown © 2011 Seattle / King County EMS

Delirium • State of confusion that can last days, weeks or even months • Associated with hospitalization & may last from hours to days • Onset of delirium usually fairly sudden • Can be treated & often temporary, even in people with advanced illness © 2011 Seattle / King County EMS Precipitating cause of delirium include: • Drug side effects • Dehydration • Pain • Urinary or other infections • Poor vision or hearing • Strokes • Bleeding • Heart problems • Breathing problems

Dementia • Show signs of disorientation – May not know what day of week, day of month, or even what year it is – May not know where they are – May not know relatives or people around them • Often loss of memory especially short term memory • Progressive & largely untreatable © 2011 Seattle / King County EMS

Alzheimer’s Disease • Caused by series of small strokes • Two most common types of dementia – Vascular dementia – Alzheimer’s Disease • People with advanced Parkinson's disease may also develop dementia © 2011 Seattle / King County EMS

Alzheimer’s Disease • Alzheimer’s type dementia has no cure • Most common type of dementia & accounts for up to 70 percent of cases • As many as 5. 3 million Americans living with Alzheimer’s type dementia • Sixth-leading cause of death in United States © 2011 Seattle / King County EMS Video Information re: brain changes: http: //www. emsonline. net/geriatric 2011/ delirium. asp

Strokes • Stroke (also known as a cerebral vascular accident – CVA) is a medical emergency • Occurs when blood flow to portion of brain stops • Two major types of strokes – Ischemic strokes –blood clot in vessel or artery in brain (80%) – Hemorrhagic strokes – blood vessel bursts & bleeds into brain (20%) • Blood supply to brain is interrupted, cells begin to die due to lack of oxygen, glucose & other nutrients © 2011 Seattle / King County EMS

TIAs • Transient ischemic attacks (TIAs) – blood supply to brain temporarily interrupted • Symptoms of TIA resolve within 24 hours • While person is having stroke symptoms – impossible to distinguish stroke from TIA © 2011 Seattle / King County EMS

Thrombolytic Therapy & CVA • Selected patients with CVA can benefit from rapid thrombolytic therapy designed to dissolve clot causing CVA • Effective thrombolytic therapy – should be given within 4. 5 hours of onset of stroke – Hospital requires one hour for evaluation & CT this means symptoms onset to arrival at hospital should generally be <3. 5 hours • Most hospitals in King County designated as stroke centers & equipped & staffed to rapidly make diagnosis & treat acute CVA © 2011 Seattle / King County EMS

Thrombolytic Therapy & CVA FAST Narrative to rapidly determine if patient has experienced a stroke A short telephone report to the hospital should include items 1 — 4 © 2011 Seattle / King County EMS Signs/Symptoms Record 1. Face: Is it symmetrical? YES/NO Speech: Is it slurred or abnormal? YES/NO Time: What time was patient last known to be normal? Note Time 2. Is the patient on Coumadin (Warfarin)? YES/NO 3. Glucometry. Glucose should be over 60. Severe hypoglycemia can present like a stroke. Check/Note reading 4. Glasgow Coma Scale Score Note Score 5. Time of hospital notification Note time 6. Time you left the scene enroute to hospital Note time

Glasgow Coma Scale Score • Means of measuring & monitoring level of consciousness • Calculate score based on best eye, verbal, & motor response – Lowest score possible is 3, highest is 15 – GCS part of Code CVA © 2011 Seattle / King County EMS

Glasgow Coma Scale Score Glasgow Coma Scale Eye Response Best Verbal Response Best Motor Response Spontaneously opens - 4 Oriented and talking - 5 Obeys commands - 6 Opens to voice - 3 Disoriented and confused -4 Locates pain - 5 Opens to pain - 2 Inappropriate words - 3 Withdraws from pain - 4 No response - 1 Incomprehensible - 2 Flexes to pain - 3 No response - 1 Extends to pain - 2 No response - 1 © 2011 Seattle / King County EMS

Parkinson's Disease • Disorder affects part of brain that controls muscle movement • Symptoms may include: – – Trembling of hands, arms, legs, jaw & face Stiffness of the arms, legs & trunk Slowness of movement Poor balance & coordination • People may have trouble walking, talking or doing simple tasks • Disease slowly progresses © 2011 Seattle / King County EMS

Huntington's Disease • Huntington's disease (also known as Huntington’s Chorea) – progressive disease causes brain cell damage leading to uncontrolled movements & mental deterioration • Inherited disease • Signs & symptoms typically develop in middle age • Disease usually progresses slowly though it can progress rapidly in younger patients © 2011 Seattle / King County EMS

GENITOURINARY SYSTEM © 2011 Seattle / King County EMS

Disorders • Geriatric patients experience general decline in renal function • Renal filtration falls average of 50% between ages of 20 & 90 • Kidney mass decreases by 20% • Many drugs eliminated through renal filtration – Underlying renal dysfunction often cause of decreased drug efficacy & other medicationrelated problems in older patients © 2011 Seattle / King County EMS

Disorders • Urinary incontinence, inability to maintain bladder control, more common in older patients • Some causes of incontinence in the elderly are: – – – – Decrease in bladder capacity Involuntary bladder contractions Decreased ability to delay voiding Medications that affect bladder control Decline in sphincter muscle control Prostate cancer Severe dementia © 2011 Seattle / King County EMS

ENDOCRINE SYSTEM © 2011 Seattle / King County EMS

Diabetic Issues • Incidence of type 2 diabetes increases with age • Complications of diabetes include: – Kidney failure – Blindness – Heart disease – Stroke – Lower extremity amputations © 2011 Seattle / King County EMS

Type 2 Diabetes • Type 2 diabetes associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity & race or ethnicity • More children have been diagnosed with type 2 diabetes • Believed obesity & insulin resistance are to blame • Unknown if resistance is due to obesity itself or a combination of inactivity & increased consumption of refined sugars © 2011 Seattle / King County EMS

Hypothyroid Issues • Approximately 0. 5% to 5% of older adults have hypothyroidism • 5% to 10% have subclinical hypothyroidism • Most cases in elderly people due to chronic autoimmune inflammation of thyroid © 2011 Seattle / King County EMS

Hypothyroid Issues • Symptoms of hypothyroidism often nonspecific in older adults & may include: – – – Dry skin Slowed thinking Weakness Constipation Anemia © 2011 Seattle / King County EMS • Symptoms usually have insidious onset & slow rate of progression – Result, diagnosis of hypothyroidism often missed • Elderly patients with mild hypothyroidism may become severely hypothyroid if they experience serious illness

MUSCULOSKELETAL SYSTEM © 2011 Seattle / King County EMS

Disorders • Osteoporosis common in geriatric patients (especially women) • Often loss of total muscle mass • Falls common & often result in fractured hips or collapsed vertebrae • Hip fracture – 10 th leading cause of hospital admission in elderly – Most result from falls at home © 2011 Seattle / King County EMS Osteoporosis bone resembles Swiss cheese

OTHER GERIATRIC ISSUES © 2011 Seattle / King County EMS

Trauma • Trauma more serious in elderly compared to younger patient • Falls leading cause of trauma – Falls can lead to moderate to severe injuries, such as hip fractures & head trauma • Elderly patients on Coumadin (anticouagulant) – Fall or experience trauma (such as a motor vehicle accident with a head strike) – Very high risk of internal bleeding – Must be evaluated in hospital © 2011 Seattle / King County EMS

Polypharmacology • Use of three or four medications – important risk factor falls in geriatric patients • Use of multiple medications also lead to mental confusion or other undesirable side effects © 2011 Seattle / King County EMS

Elder Abuse/Vulnerable Adult • As an EMT, under Washington State law (RCW 74. 34. 035) mandated reporter of suspected elder abuse • Who is a vulnerable adult? – – – 60 years or older Functional, mental or physical inability to care for self Found incapacitated Has developmental disability Receiving services from home health, hospice, or licensed home care agency – Receiving services from an individual provider © 2011 Seattle / King County EMS

Elder Abuse/Vulnerable Adult • • Signs of abuse and neglect include: Unexplained injuries or behavior Reports of physical, mental, or sexual abuse Reports of being abandoned or deserted without basic necessities • Failing to provide basic life necessities, not taking action to prevent harm or pain • • – Lack of food, hydration, clothing, proper housing (heat), or hygiene – Lack of physical aids like hearing aids, dentures, or eyeglasses, wheelchairs, canes Failure to provide safe living conditions Untreated injuries or health problems Intentionally taking advantage of a vulnerable adult either financially, or personally Undue influence or coercion © 2011 Seattle / King County EMS

Elder Abuse/Vulnerable Adult • Injuries can result from following behaviors & actions: – Pushing, striking, slapping, burning, biting, or pinching to severe beatings – Restraints with ropes or chains – Force-feeding – Incorrect positioning - creating pressure sores – Improper use of restraints or medications If you encounter any of these environments or injuries & you suspect abuse, call Department of Social and Health Services (DSHS) at 1 -800562 -6078, your local police, or Adult Protective Services © 2011 Seattle / King County EMS

Case Studies Video Case Study #1 http: //www. emsonline. net/geriatric 2011/case 1. asp Video Case Study #2 http: //www. emsonline. net/geriatric 2011/case 2. asp © 2011 Seattle / King County EMS

Summary Diminishing stroke volume in the elderly patient • Stroke volume (SV) is volume of blood ejected with each contraction • Ejection fraction (EF) is blood ejected by left ventricle during contraction divided by total volume of left ventricle • Normal EF is approximately 60 -65% Pneumonia • Most common & significant health problems for the elderly • Fourth leading cause of death in this age group • Serious underlying illness is major risk factor for developing pneumonia in the elderly © 2011 Seattle / King County EMS

Summary Signs and symptoms of dementia • Disorientation – may not know timeframes, where they are, who their relatives are • Memory loss, mostly short-term Strokes • A stroke (also known as a cerebral vascular accident – CVA) is a medical emergency • Strokes occur when blood flow to a portion of the brain stops • Require rapid evaluation & rapid transport © 2011 Seattle / King County EMS

Summary Polypharmacology • Use of multiple medications • Can lead to mental confusion Elder Abuse/Vulnerable Adult • Mandated reporter of elder abuse • Signs of abuse & neglect include: – Unexplained injuries or behavior – Reports of physical, mental, or sexual abuse – Lack of food, hydration, clothing, proper housing (heat), or hygiene – Lack of physical aids like hearing aids, dentures, or eyeglasses, wheelchairs, canes – Failure to provide safe living conditions – Untreated injuries or health problems – Undue influence or coercion © 2011 Seattle / King County EMS

Questions EMS Online Guidelines and Standing Orders http: //www. emsonline. net/downloads. asp Susan Kolwitz Program Manager Email support: help@emsonline. net Dr. Mickey Eisenberg Medical Director Ask the Doc: http: //www. emsonline. net/doc. asp © 2011 Seattle / King County EMS