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Geriatric Care: Assessment and Management of Age-Related Diseases, Study Guides, Projects, Research of Nursing

Johns Hopkins University (JHU)Nursing

This overview covers aging-related changes, psychosocial aspects, and tailored assessment/treatment for geriatric diseases and emergencies. It addresses cardiovascular, respiratory, neurologic, and endocrine conditions, including Alzheimer's and dementia. Special considerations include trauma, abuse, neglect, homelessness, and other geriatric challenges. Emphasizing the unique needs of elderly patients, it covers respiratory, musculoskeletal, and sensory changes. Medication management, adverse reactions, and comprehensive, tailored treatment plans are highlighted. Useful for medical students and healthcare professionals, it provides a foundation for understanding aging's impact on health. Topics include pressure sores, spinal cord injuries, and hospice care for terminally ill patients, serving as a valuable resource for improving elderly patient care.

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2024/2025

Available from 06/11/2025

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Chapter 44 Geriatric Emergencies
Unit Summary
As the number of individuals over the age of 65 continues to increase, EMS providers will be called upon
to assist with the complications of chronic and acute health issues. This chapter will provide the student
with a foundational understanding of the various issues that are associated with the aging process,
including physiological, psychological, and social changes that accompany advanced age.
National EMS Education Standard Competencies
Special Patient Populations
Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs
to formulate a field impression and implement a comprehensive treatment/disposition plan for patients
with special needs.
Geriatrics
Impact of age-related changes on assessment and care (pp 2088-2092)
Changes associated with aging, psychosocial aspects of aging, and age-related assessment and treatment
modifications for the major or common geriatric diseases and/or emergencies
• Cardiovascular diseases (pp 2082-2083)
• Respiratory diseases (p 2082)
• Neurologic diseases (pp 2083-2084)
• Endocrine diseases (p 2085)
• Alzheimer disease (pp 2097-2098)
• Dementia (p 2097)
• Fluid resuscitation in the elderly (pp 2085, 2103)
Normal and abnormal changes associated with aging, pharmacokinetic changes, psychosocial and
economic aspects of aging, polypharmacy, and age-related assessment and treatment modifications for the
major or common geriatric diseases and/or emergencies
• Cardiovascular diseases (pp 2093-2096)
• Respiratory diseases (pp 2092-2093)
• Neurologic diseases (pp 2096-2098)
• Endocrine diseases (pp 2102-2103)
• Alzheimer disease (pp 2097-2098)
• Dementia (p 2097)
• Acute confusional state (pp 2096-2097)
• Fluid resuscitation in the elderly (pp 2085, 2103)
• Herpes zoster (p 2107)
• Inflammatory arthritis (p 2108)
Patients With Special Challenges
• Recognizing and reporting abuse and neglect (pp 2112-2113 and see chapter, Pediatric Emergencies)
Health care implications of
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Chapter 4 4 Geriatric Emergencies

Unit Summary

As the number of individuals over the age of 65 continues to increase, EMS providers will be called upon to assist with the complications of chronic and acute health issues. This chapter will provide the student with a foundational understanding of the various issues that are associated with the aging process, including physiological, psychological, and social changes that accompany advanced age.

National EMS Education Standard Competencies

Special Patient Populations

Integrates assessment findings with principles of pathophysiology and knowledge of psychosocial needs to formulate a field impression and implement a comprehensive treatment/disposition plan for patients with special needs.

Geriatrics

Impact of age-related changes on assessment and care (pp 2088-2092) Changes associated with aging, psychosocial aspects of aging, and age-related assessment and treatment modifications for the major or common geriatric diseases and/or emergencies

  • Cardiovascular diseases (pp 2082-2083)
  • Respiratory diseases (p 2082)
  • Neurologic diseases (pp 2083-2084)
  • Endocrine diseases (p 2085)
  • Alzheimer disease (pp 2097-2098)
  • Dementia (p 2097)
  • Fluid resuscitation in the elderly (pp 2085, 2103) Normal and abnormal changes associated with aging, pharmacokinetic changes, psychosocial and economic aspects of aging, polypharmacy, and age-related assessment and treatment modifications for the major or common geriatric diseases and/or emergencies
  • Cardiovascular diseases (pp 2093-2096)
  • Respiratory diseases (pp 2092-2093)
  • Neurologic diseases (pp 2096-2098)
  • Endocrine diseases (pp 2102-2103)
  • Alzheimer disease (pp 2097-2098)
  • Dementia (p 2097)
  • Acute confusional state (pp 2096-2097)
  • Fluid resuscitation in the elderly (pp 2085, 2103)
  • Herpes zoster (p 2107)
  • Inflammatory arthritis (p 2108)

Patients With Special Challenges

  • Recognizing and reporting abuse and neglect (pp 2112-2113 and see chapter, Pediatric Emergencies) Health care implications of
  • Abuse (pp 2112-2113 and see chapter, Pediatric Emergencies )
  • Neglect (pp 2112-2113 and see chapter, Pediatric Emergencies )
  • Homelessness (see chapter, Patients With Special Challenges )
  • Poverty (see chapter, Patients With Special Challenges )
  • Bariatrics (see chapter, Patients With Special Challenges )
  • Technology dependent (see chapter, Patients With Special Challenges )
  • Hospice/terminally ill (see chapter, Patients With Special Challenges )
  • Tracheostomy care/dysfunction (see chapter, Patients With Special Challenges )
  • Home care (see chapter, Patients With Special Challenges )
  • Sensory deficit/loss (see chapter, Patients With Special Challenges )
  • Developmental disability (see chapter, Patients With Special Challenges )

Trauma

Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression to implement a comprehensive treatment/disposition plan for an acutely injured patient.

Special Considerations in Trauma

Recognition and management of trauma in

  • Pregnant patient (see chapter, Obstetrics )
  • Pediatric patient (see chapter, Pediatric Emergencies )
  • Geriatric patient (pp 2108, 2110-2112) Pathophysiology, assessment, and management of trauma in the
  • Pregnant patient (see chapter, Obstetrics )
  • Pediatric patient (see chapter, Pediatric Emergencies )
  • Geriatric patient (pp 2108, 2110-2112)
  • Cognitively impaired patient (see chapter, Patients with Special Challenges )

Knowledge Objectives

  1. Describe the old-age dependency ratio. (p 2080)
  2. Describe the phenomenon “the greying of America.” (p 2080)
  3. Discuss the social, economic, and psychosocial factors affecting the older population. (pp 2080-
  4. Discuss the physiologic changes that occur in the various body systems as people age. (pp 2081-
  5. Describe the steps in the primary assessment for providing emergency care to a geriatric patient, including the elements of the GEMS diamond. (pp 2088-2089)
  6. Discuss special considerations when performing the patient assessment process on a geriatric patient. (pp 2087-2088)
  7. Describe the pathophysiology of geriatric respiratory conditions, the signs and symptoms, and the emergency medical care strategies used in the management of each condition. (pp 2092-2093)
  8. Describe the pathophysiology of geriatric cardiovascular conditions, the signs and symptoms, and the emergency medical care strategies used in the management of each condition. (pp 2093-2096)
  • The Geriatric Mental Health Foundation web site highlights the needs and responses of older adults in disasters: http://www.gmhfonline.org/gmhf/consumer/disaster_prprdns.html.

Enhancements

  • Direct students to visit the companion website to Nancy Caroline’s Emergency Care in the Streets , Seventh Edition, at http://www.paramedic.emszone.com for online activities.
  • Schedule a visit to a local nursing home or assisted living facility. This can provide perspectives on the various disease processes, the psychological effects of aging and retirement, and allow the students to assess and interact with the patients and family members.
  • Arrange a visit to a senior center and have the students interact with the members.
  • Invite a staff member from the local hospice agency to speak with the students on the various aspects of death and dying.
  • Invite an attorney who specializes in EMS and ask him or her to discuss the legal challenges of advanced directives and do-not-resuscitate orders. Content connections: Chapter 44 of Nancy Caroline’s Emergency Care in the Streets , Seventh Edition, and all related presentation support materials, provide a detailed presentation of physical, psychological, and social issues associated with aging. Cultural considerations: Different cultures regard older family members in ways that may not be familiar to the students. Some cultures cherish their elders more than other cultures do, valuing their wisdom and deferring to them for all decisions regarding personal health issues. Other cultures may have rituals that are carried out when elder family members are dying or die in their presence. It is important for EMS providers to understand how different cultures view older people, as well as how these cultures deal with death and dying.

Teaching Tips

  • Invite students to bring an elderly family member or friend to spend a class period with them. Have the students and visitors work through scenarios incorporating the various challenges that can be experienced in the prehospital setting. For example, the elderly visitor could simulate loss of vision or hearing, confusion, polypharmacy, and loss of mobility, giving the student an opportunity to use their skills. Make sure that the students complete a full assessment and practice transferring the patient to the stretcher.
  • Look up your location’s legislation regarding the reporting of elderly abuse. Be familiar with whether or not it is mandatory to report suspected abuse, and how to properly report abuse whether mandatory or not.

Unit Activities

Writing activities: Assign each student to complete a report on a different common medical complication encountered in the elderly population, including symptoms, side effects, and treatment options. Student presentations: Have the students present the findings of their written report. Group activities: Divide the class into groups, and have them work through scenarios focusing on how to effectively communicate with family members who have just had a loved one die. Visual thinking: Add video segments of patient assessments performed on the elderly. Ask the class to critique each case and generate a run report.

Pre-Lecture

You are the Medic “You are the Medic” is a progressive case study that encourages critical-thinking skills.

Instructor Directions

Direct students to read the “You are the Medic” scenario found throughout Chapter 44.

  • You may wish to assign students to a partner or a group. Direct them to review the discussion questions at the end of the scenario and prepare a response to each question. Facilitate a class dialogue centered on the discussion questions and the Patient Care Report.
  • You may also use this as an individual activity and ask students to turn in their comments on a separate piece of paper.

Lecture

I. Introduction

A. Geriatrics is the assessment and treatment of disease in those 65 years or older.

  1. According to the 2010 census, 40,267,984 Americans are age 65 and older. a. A 15.1% increase from the 2000 census
  2. The elderly are four times more likely to use EMS for transport to the ED.

B. People 65 years and older account for 36% of all hospital stays in the United States.

  1. Receive more of their care outside of hospitals—a growing trend a. Insurance and public health assistance programs reduce costs. b. Potential changes from health care legislation
  2. Have more contact with physicians than younger patients
  3. As the number of older Americans grows, the need for physicians will increase. a. 80% of seniors have at least one chronic medical condition. b. 50% have two or more.

C. The old-age dependency ratio—the number of older people for every 100 adults

(potential caregivers) between the ages of 18 and 64 years

  1. Compares differences in age structure between time periods in a single society
  2. Compares age structures between two different societies a. Can be used as an indicator of the aging of the population

D. The “graying of America”—a term used by many social scientists to describe the

increasing number of older Americans

  1. 1990—20 older people for every 100 working-age caregivers
  2. 2025—projected 32 older people for every 100 working-age caregivers
  3. Supply of people providing resources for the older population not keeping pace with growth of older population a. Need for caregivers will increase b. Society will have difficulty keeping up with demand for services as population ages.
  4. EMS personnel will need to offer cost-effective and efficient services.
  5. Cost will also be a continuing concern due to: a. Insurance regulations b. Costs associated with providing care c. Facility issues

d. Stocks

  1. Many have delayed retirement
  2. More likely to have health insurance coverage
  3. Not all retired people live in comfort, however. a. More than 10% of seniors have been uncertain about having enough food each day, and this “food insecurity” may lead to: i. Poor nutrition ii. Poor self-reported health iii. Limited ability to care for self b. Older people who live in poverty may make lifestyle choices that pose serious risks to their health: i. May skip medication doses to save money ii. May use kerosene heaters rather than central heating

I. Psychosocial factors influence aging.

  1. Feel useless or unproductive in society—low self-esteem
  2. Feel frustrated due to inability to do things as easily as before
  3. Mourn the loss of activities they can no longer participate in
  4. Conversely, feel freedom or accomplishment during retirement
  5. Crisis of integrity versus despair: a. Integrity—they feel pride in life’s accomplishments b. Despair—they may not have time to accomplish all of their goals i. If despair, more likely to feel depressed, useless, or that they are a burden
  6. Older people will likely feel bereavement over the loss of friends and loved ones. a. Likelihood of death increases during the year following the death of a spouse. b. As friends and family die, elderly persons tend to feel more lonely and isolated. c. Death of spouse may increase financial concerns, especially in lower-income families without adequate retirement funds or life insurance coverage. d. Those who were reliant on their spouse for daily assistance may not be able to meet their basic needs and require help from their children or other resources.

II. Geriatric Anatomy and Physiology

A. Aging process begins in the late 20s and early 30s.

  1. A linear process—the rate at which a person loses function does not increase with age. a. Example: A 35-year-old person ages just as fast as an 85-year-old, but the older person exhibits cumulative results of aging. b. Organ and tissue aging may be accelerated by a variety of factors: i. Genetic qualities ii. Preexisting disease iii. Diet iv. Exposure to toxins v. Activity levels vi. Psychosocial characteristics
  2. Aging varies widely from person to person.

a. Example: A 60-year-old may look frail while an 80-year-old person may be healthy enough to run a marathon.

  1. Aging process is accompanied by physiologic function changes (eg, a decline in liver and kidney function) a. All body tissues undergo aging, but not at the same rate. b. Decrease in various organ systems’ functional capacity is normal, but affects the way a person’s body reacts to illness i. Signs and symptoms may be different than those of a younger person with the same disease or disorder. ii. Diseases may last longer with more detrimental effects in an older person.
  2. The aging process and its changes can affect the way health professionals react to an older patient’s illness. a. Important to differentiate between normal physiologic changes and acute changes indicating a pathologic process. i. If a health care provider does not understand the normal changes of aging, he or she might mistake them for illness and provide treatment that is not necessary. ii. A health care provider may attribute signs and symptoms to “just getting old” and fail to provide the needed treatment. b. Important to determine the patient’s baseline level of function when caring for older patients

B. Changes in the respiratory system

  1. Respiratory capacity undergoes a large reduction with age: a. Decrease in lung elasticity b. Decrease in size and strength of respiratory muscles c. Calcification of costochondral cartilage—chest walls stiffen
  2. Vital capacity decreases and residual volume increases. a. Total amount of air in the lungs does not change with age. b. Proportion of air used in gas exchange progressively declines c. Air flow deteriorates somewhat.
  3. Changes in blood flow distribution in the lungs results in declining partial pressure of oxygen (PaO 2 ). a. At 30 years, breathing ambient air—usually around 90 mm Hg b. At 80 years—around 75 mm Hg c. PaO 2 = 100 - age/
  4. Respiratory drive becomes dulled because of decreased sensitivity to arterial blood gases changes or decreased CNS response to these changes. a. Alveoli number also decreases.
  5. Consequence of these changes—older people have a slower reaction to hypoxia and hypercarbia.
  6. Musculoskeletal changes, such as kyphosis, may limit lung volume and maximal inspiratory pressure. a. Chest expansion is limited by decreased muscle strength and mass, requiring more energy to perform ventilation.
  7. These changes physically limit the respiratory system in the ability to modify tidal volume or respiratory rate to compensate. a. The lungs’ defense mechanisms are less effective due to aging. b. Cough and gag reflexes decrease with age, making aspiration easier. c. Ciliary mechanisms that help remove bronchial secretions are slowed.

a. Aging heart is less efficient at baseline b. The effects of any acute circulatory change much worse than in younger populations c. All potential cardiac compromises should be recognized and treated quickly.

D. Changes in the nervous system

  1. A neurologic examination will reflect aging-related changes in the nervous system. a. Most common normal neurological findings in the elderly are changes in: i. Thinking (cognitive) speed ii. Memory iii. Postural stability b. Studies have shown age-associated declines in mental function, especially: i. Slower central processing of sensory stimuli and language ii. Longer retrieval times for short- and long-term memory c. Changes affect mental status performance in a neurologic examination, with common findings including: i. Slow responses to questioning ii. Requests to repeat a question
  2. The brain decreases in weight and volume in aging. a. Functional significance not clear b. Human brain has reserve capacity, so smaller and lighter brain does not necessarily interfere with mental capabilities
  3. The brain is responsible for coordinating other body systems. a. As mental function declines, regulation of specific body system functions may also decline, such as: i. Respiratory rate and depth ii. Pulse rate iii. Blood pressure iv. Hunger and thirst b. Reflexes may slow, leading to slow response to pain. i. Example: Might take longer to move hand away from a hot surface, causing more extensive burns c. Temperature regulation and perception change in aging: i. Less capable of recovering from extreme temperature exposure ii. Less likely to recognize the exposures
  4. Sensory changes a. Most of the sensory organs’ performance declines with increasing age. i. Most common sensory impairments among the elderly include: (a) Decreased ability to see and hear (b) Decreased ability to taste (c) Decreased tactile sensation b. Do not assume elderly patients are blind or deaf. i. Use the same communication techniques as you would with others ii. If communication is ineffective, gradually modify communication techniques to fit the patient. c. As many as 50% of older patients have vision problems. i. May begin as early as 40 years ii. Tear production decreases, leading to:

(a) Sensations of dry or itchy eyes (b) Increased chances of mild eye injury and infection d. Causes of visual impairment in the elderly include: i. Diabetes ii. Age-related macular degeneration iii. Retinal detachment (may also be associated with diabetes) e. Most common visual disturbances in the elderly: i. Cataracts—result of hardening of lenses over time (a) Lenses eventually become opaque, preventing images from being transmitted to the rear of the eye. (b) Patients may report blurred vision, double vision, spots, and ghost images. (c) Surgical treatment may be needed. ii. Glaucoma—intraocular pressure damages the optic nerve (a) Potential of permanent peripheral and central vision loss (b) Treatment includes oral medications and eye drops. f. Visual acuity decreases, even without disease processes, are common in older people: i. Difficulty seeing at night ii. Inability to adjust to rapid changes in lighting, depth, and color perception iii. Development of presbyopia (far-sightedness) caused by loss of eye lens elasticity iv. Difficulty differentiating between colors g. Vision changes can affect: i. Level of independence ii. Ability to read—may lead to unintentional overdose iii. Ability to drive a vehicle—may lead to more accidents

  1. Some gradual hearing loss is common as people age. a. Presbycusis—progressive hearing loss with a lessened ability to discriminate between background noise and a particular sound. b. Some lose the ability to interpret most speech, decreasing their ability to communicate. i. Leads to feelings of isolation c. Even if hearing loss is not severe enough to interfere with communication, certain activities may be less enjoyable. d. Hearing loss may threaten safety because many warning systems are auditory.
  2. Hearing aids are one of the most common assistive devices in the United States, especially by older people. a. Consist of microphone and amplifier b. Some models fit entirely in the ear canal and will likely need to be removed if ear canal inspection is necessary. i. If patient is conscious and able, ask him or her to remove it. c. Almost always battery operated. d. Devices are expensive and not always covered by insurance—be careful not to lose them during transport.
  3. Meniere disease is a hearing-related impairment often found in older populations. a. Two out of 1,000 people b. Onset in middle age c. Symptoms present in cycles lasting several months at a time, and include: i. Vertigo ii. Hearing loss iii. Tinnitus

i. Symptoms could possibly indicate cardiac compromise. c. Gastric motility changes lead to slower gastric emptying. i. Important when assessing aspiration risk ii. Contributes to heartburn and acid reflux

  1. Small and large bowel function changes little from aging, but certain diseases increase (diverticulosis) a. Rectal sphincter may decrease in size and strength, causing fecal incontinence. b. Slowing peristalsis can lead to constipation. i. Constipation also caused or worsened by: (a) Some medications (b) Diet changes (c) Decreased physical activity ii. Can cause difficult, straining bowel movements that can cause hemorrhoids iii. Forceful straining or retching may lead to syncope or bradycardia. iv. Patient may try to treat constipation with diet and medications that may or may not be intended to treat constipation. (a) If treated too aggressively, may cause diarrhea, which may lead to dehydration v. If constipation cannot be resolved, a physician or nurse may need to remove the stool manually.
  2. The hepatic enzyme systems in the liver change with age, with some systems’ activity declining and others’ activity increasing. a. Enzyme systems that detoxify drugs decline. i. Complicates drug absorption and results in drug toxicity ii. If numerous medications are prescribed, risk for hepatic damage or drug toxicity increases.

F. Changes in the renal system

  1. Kidneys are responsible for: a. Maintaining body’s fluid and electrolyte balance b. Helping maintain body’s long-term acid-base balance c. Eliminating drugs from the body
  2. Kidneys weigh between 250 and 270 g in a young adult, but only 180 to 200 g in a healthy 70- year old. a. Weight decline from loss of functioning nephron units b. Causes a smaller effective filtering surface c. Renal blood flow also decreases by as much as 50%.
  3. Acute illness often causes fluid and electrolyte imbalances. a. Aging kidneys respond slowly to sodium deficiency—elderly patients lose a large amount of sodium before kidneys stop excreting urinary sodium. i. Problem exacerbated by a decreased thirst mechanism ii. Results in severe dehydration b. Elderly population at risk of overhydration with large sodium loads because of an aging kidney’s lower glomerular filtration rate i. IV saline solutions ii. Heavily salted foods c. Same factors apply when considering an older person’s ability to handle potassium. i. Prone to serious or lethal hyperkalemia if the patient becomes acidotic or the potassium load is increased

G. Changes in the endocrine system

  1. In 2010, 26.9% of US residents (10.9 million people) aged 65 years and older had diabetes. a. Does not include the approximate 50% of this population who were classified in the prediabetic category b. The elderly are at greater risk for developing type 2 diabetes because: i. Carbohydrate metabolism becomes more difficult. ii. Comorbid disorders have medications that may affect glucose metabolism.
  2. An increase in antidiuretic hormone (ADH) can occur as people age. a. Can cause electrolyte imbalances and fluid balance issues b. May present with signs of pedal or other peripheral edema i. Determine baseline for edema—worsening of edema more significant than its presence
  3. Menopause causes decreased hormone secretion, especially estrogen. a. Important role in bone mass preservation, so decreased levels may lead to decreased bone density and osteoporosis b. Estrogen and progesterone level changes also cause menopausal symptoms.

H. Changes in the immunologic system

  1. Every immune system function is affected by aging. a. Older persons are more prone to infection and secondary complications. b. Chronic conditions place the elderly at greater risk of serious infection, and include: i. Diabetes ii. Dementia iii. Malnutrition iv. Cardiovascular disease
  2. Infections manifest differently in older people. a. Fever usually indicates a severe infection. b. 30% of older people with severe infection may have no fever because of the aging immune system’s inability to initiate a fever. c. Leading cause of death from infection in patients older than 65 years is pneumonia.

I. Changes in the integumentary system

  1. The most visible signs of aging—wrinkling and resiliency loss in the skin a. Wrinkling is caused by the skin becoming thinner, drier, less elastic, and more fragile. b. Subcutaneous fat, which normally cushions blood vessels, becomes thinner, so bruising becomes more common. c. Elastin and collagen decrease. i. Thinner skin tears more easily. ii. More bleeding occurs before hemostasis takes over due to loss of elasticity. d. Skin is more prone to tenting when skin turgor is checked, even if there is no dehydration.
  2. Sebaceous glands produce less oil, so skin is drier. a. Sweat gland activity decreases, which hinders the ability to regulate heat. b. Hair follicles produce thinner hair or stop producing hair at all. i. Follicles produce less melanin, making the hair gray or white. c. Melanocytes in the epidermis decrease: i. Skin appears paler. ii. Increased sensitivity to sun exposure

b. Patients may have difficulty caring for themselves, especially for tasks requiring fine motor coordination and hand and finger strength: i. Taking medication ii. Caring for wounds

  1. Bone density and muscle mass loss may be slowed by physical activity. a. Older patients who started with larger muscles and history of physical labor are least susceptible to musculoskeletal decline. b. Less arthritic pain when patients consistently and gently use arthritic joints

III. Geriatric Patient Assessment

A. Illness is not an inevitable part of aging.

  1. Complaints from elderly patients should not be ascribed to “getting old.” a. Aging is a continuous and normal development process, and does not produce symptoms of disease by itself. b. Biologic effects of aging from: i. Normal wear and tear ii. Genetic makeup
  2. Widespread misconception that the elderly are hypochondriacs a. Hypochondria far less common in the elderly b. Older patients tend to not complain, even with real symptoms. c. If an older person calls for prehospital care, there is usually a real problem.
  3. Important to understand what is and is not part of the aging process a. Regular signs and symptoms may be altered as a consequence of aging. i. Myocardial infarction may not include chest pain. ii. Pneumonia may not include fever. iii. Uncontrolled diabetes is more likely to present as hyperosmolar nonketotic coma/hyperosmolar hyperglycemic nonketotic coma [HONK/HNCC] than as diabetic ketoacidosis. iv. A variety of acute illnesses may present with just delirium. b. Likely to be multiple problems with an older patient, including medical, psychological, and social i. While proportion of elderly with a disability has decreased, the total number with chronic disability has increased because there is a greater number of older people. c. Debilitating health conditions in this population include: i. Hypertension ii. Arthritic symptoms iii. Heart disease iv. Cancer v. Diabetes vi. Stroke vii. COPD d. 15% to 20% of people older than 85 years have some form of depression.
  4. Co-occurrence of multiple pathologic conditions creates problems for both patients and health care providers: a. Symptoms of one disease may hide or alter symptoms of another condition.

i. Example: Patient with severe pain from arthritis may not realize some of the pain is being caused by thrombophlebitis. b. A function disturbance in one body system may have repercussions throughout the body, causing a domino effect of multiple organ failure. c. May be difficult to determine which condition is causing which symptom d. Chronic comorbidities make it more difficult to treat an acute problem because of medicine contraindications and needed dosage modifications.

B. Scene size-up

  1. Ensure scene safety, and take standard precautions.
  2. Check for clues to help determine mechanism of injury or nature of illness.
  3. Determine number of patients, and consider any needed additional or specialized resources.
  4. Be aware of factors affecting the assessment process in geriatric patients, and be ready to accommodate them: a. Sensory alterations b. Verbal communication skills c. Mental and physical capabilities

C. Primary assessment

  1. Use the GEMS diamond. a. Form a relevant general impression. b. Check for potential clues such as: i. General living conditions ii. Social and family support iii. Activity level iv. Medications v. Overall appearance with respect to: (a) Nutrition (b) General health (c) Cleanliness (d) Personal hygiene (e) Attitude and mental well-being c. The GEMS diamond acronym is one way to remember assessment and treatment steps. i. Created to help providers recall key themes when caring for geriatric patients d. G—Recognize that the patient is a geriatric patient. i. Assessment should be geared to possible problems of this population. (a) May present atypically e. E—Environmental assessment for clues to patient’s condition or emergency i. Home too hot or cold; well-kept; secure? ii. Hazardous conditions? (a) It is important to find risks to prevent future accidents. f. M—Medical assessment i. Older patients may have numerous health problems and take many prescription, over-the- counter, and herbal medications. ii. Obtain a thorough history. g. S—Social assessment to determine if a social network exists i. May need assistance with activities of daily living (ADL) ii. Social agencies are available that can give patients a listing of services provided. h. GEMS can help providers remember important issues and make appropriate referrals.

vi. Uncontrolled hemorrhage c. Older people will easily decompensate. i. A general complaint of weakness and dizziness can be a sign of a serious heart problem. d. Consider early if advanced life support and immediate transport are appropriate. e. If possible, transport to a facility where the patient has been treated before.

D. History taking

  1. Use good communication skills to gather information. a. First words should focus on gaining trust. i. Introduce yourself. ii. Use respect when addressing the patient. (a) Use their name, not “buddy,” “honey,” “grandma,” or “dear” iii. Speak slowly, distinctly, and respectfully. iv. Do not raise your voice. v. Attempt to get the patient history from the patient whenever possible. vi. Getting a thorough history reflects education and experience: (a) Knowledge of prescription medications helps to understand patient’s diagnosis and medication compliance.
  2. Listen to the patient, and wait for their answers. a. Older people may need time to process questions and may speak slowly. b. Pay attention to tone, listening for fear and confusion.
  3. Nonverbal communication is important. a. Be aware of your eye contact, gestures, body position, expressions, and touch. b. Get face to face with patients, and ensure good lighting. c. Have patients use any hearing aids or wear glasses for better communication. i. Take these aids along to the hospital for better communication as well.
  4. Explain the plan, especially if the patient is confused. a. Determine if the confused state is normal, a new sign of a preexisting condition, or a lack of understanding. i. Family members can help outline changes. b. Preserve the patient’s dignity while discussing the history.
  5. A comprehensive history includes: a. Chief complaint b. Present illness or injury c. Pertinent medical history d. Current health care status and needs
  6. Pertinent medical history includes: a. Current cardiovascular health b. Exercise tolerance c. Diet history d. Medications e. Smoking and drinking habits f. Sleep patterns g. Other intrinsic and extrinsic factors
  7. Determining the chief complaint may be difficult with some elderly patients.

a. May believe their symptoms are just part of getting old b. May not mention legitimate symptoms because they don’t want to be labeled a hypochondriac c. May believe diagnosis will take away their independence

  1. May underreport serious symptoms, but report vague and seemingly unimportant symptoms. a. May not want to give symptoms in front of spouse b. May have several chief complaints from different sources
  2. If the chief complaint seems trivial, use a standard list of screening questions to ensure that all needed information is available. a. Questions designed to evaluate major organ systems functions include: i. Cardiovascular (a) Have you had any pain or discomfort in your chest? When? (b) Have you had any pain in your left arm or jaw? (c) Have you noticed any fluttering in your chest or fast heartbeats? ii. Respiratory (a) Do you ever get short of breath? When? (b) Have you had a cough lately? Is it painful? iii. Neurologic (a) Can you explain the reason for calling 9-1-1? (b) Have you had any dizzy spells? Have you fainted? (c) Have you had any trouble speaking? (d) Have you had headaches recently? (e) Have you noted any unusual weakness or odd sensations in your arms or legs? iv. Gastrointestinal (a) Have there been any changes in your appetite lately? (b) Have you gained or lost any weight? (c) Have there been any changes in your bowel movements? (d) Have you had any nausea or vomiting? v. Genitourinary (a) Do you have any pain or difficulty urinating? (b) Have you noticed any change in the color of your urine? (c) Have you noticed any changes in the frequency of urination? b. If any positive answers, follow up.
  3. Once the chief complaint is found, conduct a history of the present illness. a. May be complicated by chronic problems affecting the acute problem i. To determine which symptoms are acute and which are chronic, ask: (a) How does this differ from last week? (b) What happened today that made you decide to get help? b. Not generally feasible to do a complete medical history in the field i. Obtain a SAMPLE history to determine recent hospitalizations and allergies.
  4. Do a detailed history of the patient’s medications. a. Include all medications—prescription, over-the-counter, and herbal medicines. b. Ask the patient to list medications by name along with dosing and frequency. Include: i. Prescribed medications that are not taken ii. Medications provided by other sources c. Ask permission to take medications to the hospital, and then collect them all.
  5. Obtaining a history from an elderly patient takes patience. a. Be prepared to listen for an extended period.

E. Secondary assessment