Geriatrics

Anatomy and Physiology Review

• Life span development

Pathophysiology

• Many physiological changes occur in the body systems with the aging process. Although all are relative to age and none is guaranteed to occur, some of these changes commonly lead to certain complications:
  • RESPIRATORY: Loss of elasticity in the lungs, decreased total lung volume and functional residual capacity → Decreased ability to compensate for respiratory challenges
  • CARDIOVASCULAR: Decreased strength of cardiac contraction, increasing rates of cardiac and vascular disease, increasing rate of cardiac dysrhythmias including atrial fibrillation → Higher rates of acute coronary syndrome and cardiac arrest, decreased ability to compensate for shock
  • DIGESTIVE: Decreased digestive function → Common bowel related disorders
  • MUSCULAR: Decreased muscle mass and increased rates of degenerative bone diseases such as osteoporosis → Increased risk for fractures
  • ENDOCRINE: Increased rate of endocrine disorders → Diabetes and thyroid problems
  • URINARY and DIGESTIVE: Decreased kidney and liver function → Slowed elimination of drugs
  • INTEGUMENTARY: Decreased fat stores and thinning of the skin → Higher risk for soft tissue injuries and environmental injuries
  • NERVOUS: Diminished nervous system function → Decreased pain perception, memory failure, higher risk for dementia
• Geriatric patients frequently manage multiple diseases and disorders simultaneously. Underlying problems may complicate acute problems such as trauma.
• Medication-related issues may also occur:
  • Commonly prescribed medications may complicate acute problems. For example, beta blockers may hamper a patient’s ability to compensate for shock.
  • Polypharmacy, or the prescription of many—often conflicting—medications, may be a problem in and of itself.
  • Difficulty managing daily medications can lead to medication noncompliance and even toxicological emergencies in extremes.
• Because some geriatric patients have difficulty living independently, risk for elder abuse and maltreatment can be high. There is also evidence in some geriatric populations of an increased risk for depression and suicide.

Geriatric Assessment

• Although geriatric patients can pose unique assessment challenges, it is most important to remember to conduct assessment in the same manner as with any other patient:
  • Be comprehensive.
  • Emphasize a strong primary assessment.
  • Use scene clues, history and physical examination to make appropriate management decisions.
• Cognitive and communication problems are common among geriatric patients, but never assume that these challenges are present. Some guidelines:
  • Address each challenge specifically.
  • Maximize communication by assuring that all aids (glasses, hearing aids, and the like) are present before you attempt to communicate.
  • If cognitive issues are present, use caregivers to establish a baseline and to help you communicate.
• Consider aging-associated changes when conducting a patient assessment. Tachycardias, tachypneas and altered mental status may represent a baseline status for a particular patient—however, be careful not to assume that such conditions are present.
• Remember that certain daily medications can mask acute problems—for example, medications designed to manage heart rate, such as calcium channel blockers, can prevent tachycardia in shock.
• Always keep in mind that underlying conditions and diseases will complicate new, acute problems.
• When considering mechanism of injury, always take into account factors such as degenerative bone disease and anticoagulant medication use. In certain situations, an unremarkable mechanism can pose a serious risk.

Treatment

• Treat geriatric patients as you would any other patient. Life-threatening conditions do not discriminate on the basis of age. Be respectful and preserve dignity in all patients.
• Consider the higher risk that some disorders pose with age. For example, a 65-year-old male is far more likely to be experiencing acute coronary syndrome than is a 5-year-old male.
• Consider the risk of environmental exposure. Take steps to manage body temperature (especially in suspected shock patients).
• Beware of decreased ability to compensate in the geriatric population. Decompensation may occur quickly.
• In patients with degenerative bone disease, consider the need for spinal precautions even with low risk mechanisms.
• Have a high index of suspicion and transport any trauma patient who is taking anticoagulant medications. These patients have a high risk for internal bleeding.

Important Concepts

• Not all geriatric patients will be affected by the changes of aging at the same rate. NEVER ASSUME that cognitive or communication difficulties exist.
• Advocate for your patient when maltreatment is suspected. Remember, many states have mandated reporting laws for suspected elder abuse.
• Caregivers are an important part of any assessment or treatment plan. Family members often can help you overcome communication issues and provide valuable history when the patient cannot do so.