Geriatrics is aged 65 and older. There may be some fear of losing independence. Always treat with respect and avoid ageism. Can stay fit and be active even though they are not able to perform at the same level as they did in their youth. When communicating with a geriatric patient, use name or sir or ma’am. Identify yourself, be aware of how you present yourself, look directly at the patient’s eye level, and ensure good lighting. Speak slowly and distinctly and have one person talk to the patient and ask only one question at a time. Do not assume that all older patients are hard of hearing and give the patient time to talk and respond unless the conditions appear urgent. Listen to the answer the patient gives and explain anything you are going to do before you do it. Do not talk about the patient in front of them as if they were not there.
Some common conditions are hypertension, arthritis, heart disease, cancer, diabetes mellitus, asthma, chronic bronchitis or emphysema, and stroke. Leading causes of death are heart disease, cancer, injury, chronic lower respiratory disease, stroke, Alzheimer disease, diabetes mellitus, injury, and influenza.
The aging process can vary dramatically from one person to another. The aging process is inevitably accompanied by changes in physiologic functions, such as a decline in the function of the liver and kidneys. All tissues in the body undergo aging, albeit not at the same rate. There are changes in vision and the inability to see up close, also known as presbyopia. They are more at risk for glaucoma, macular degeneration, and retinal detachment. There is a decrease in the number of taste buds. There is also a decreased sense of touch and pain perception from the loss of the end nerve fibers. So they may be injured and not know it. Hearing is another issue, an age-related condition of the ear that produces progressive bilateral hearing loss that is most noted at higher frequencies, which is known as presbycusis. Osteoporosis also develops.
There are changes to the respiratory system. Weakening of the airway musculature that can cause decreased breathing capacity. Less help from muscles in the chest wall when they have trouble breathing. The body’s chemoreceptors that monitor changes in oxygen and carbon dioxide levels in the blood become less sensitive with age. This makes the body respond more slowly to hypoxia, a dangerous condition in which the body tissues and cells do not have enough oxygen. Pneumonia is the leading cause of death from infection in Americans older than 65 years. The process of aging causes some degree of immune suppression and increases the risk of contracting infections such as pneumonia. Increased mucus production, pulmonary secretions, and the inflammatory effects of infection all interfere with the ability of the alveoli to oxygenate the blood. Pulmonary embolism is a condition that causes a sudden blockage of an artery in the lung by a venous clot. Clots develop in the legs or pelvis and then break off and embolize (move) through the heart to a pulmonary artery or one of its branches where they lodge. Some risk factors are sedentary behavior. A patient with a pulmonary embolism will present with shortness of breath and sometimes chest pain; thus, a cardiac, lung, or musculoskeletal condition. Patients present with tachycardia, sudden onset of dyspnea or shortness of breath, which differentiates this from an infection such as pneumonia, shoulder, back, or chest pain, cough, syncope, anxiety, apprehension, low-grade fever, hemoptysis (coughing up blood). Also look for leg pain, redness, and swelling in just one ankle and foot for the source of the clot. Place the patient in a comfortable position and apply high-flow oxygen via a nonrebreather mask.
There are also changes in the cardiovascular system. Arteriosclerosis is a disease that causes the arteries to thicken, harden, and calcify. The result is a widening pulse pressure, decreased coronary artery perfusion, and changes in cardiac ejection efficiency. Increased risk for formation of an aneurysm. With aging, the left ventricle, which pushes blood out into the body, becomes thicker and eventually loses elasticity, resulting in decreased filling of the left ventricle, which in turn causes decreased cardiac output. Something else to note is that the sinoatrial node is the normal pacemaker of the heart, but by age 75 the number of cells in the sinoatrial node will decrease by 90%. This event, combined with fibrosis and fatty deposits attaching to the electrical pathway, makes it likely that the patient will have some kind of heart rhythm disturbance, aka dysrhythmia. Orthostatic hypotension, which is a decrease in blood pressure caused by a change in position when a person moves from sitting to standing. Venous stasis means the motionless state and, in this context, refers to loss of proper function of the veins in the legs that would normally carry blood back to the heart. This creates issues known as deep venous thrombosis. Eventually causes a red-brown discoloration on the skin and, in some cases, skin ulcers.
Heart failure is the signs and symptoms of heart failure will differ depending on the extent to which the right or left side of the heart is not functioning correctly. Right-side heart failure occurs when fluid in the blood backs up in the body. There is jugular vein distention, ascites or fluid in the abdomen, abnormal accumulation of excess fluid in the peritoneal cavity, and peripheral edema in the body tissues. You may also see a large liver when palpating. Left-side heart failure occurs when fluid backs up into the lungs. Pulmonary edema is a result. The patient will have severe shortness of breath and hypoxia with crackles in the lungs. Paroxysmal nocturnal dyspnea is the sudden respiratory distress that awakens the person at night when the patient is in a reclining position. Not being able to breathe while lying down is called orthopnea. An aneurysm is the swelling or enlargement of the wall of a blood vessel that results from weakening of the vessel wall.
Stroke is the leading cause in older people. Preventable risk factors include smoking, hypertension, diabetes, atrial fibrillation, obesity, and a sedentary lifestyle. Signs of stroke include altered level of consciousness, numbness, weakness, or paralysis on one side of the body, slurred speech, difficulty speaking or understanding speech (aphasia), visual disturbances, headache and dizziness, incontinence, and, in the worst case, seizures. Hemorrhagic stroke is where a broken blood vessel causes bleeding in the brain. Ischemic stroke occurs when a blood clot blocks the flow of blood to a portion of the brain. If the symptoms occurred within the past few hours, the patient may be a candidate for stroke center therapy and has a high chance of recovery.
Studies have documented age-associated declines in mental function, especially slower central processing of sensory stimuli and language and longer retrieval times for short- and long-term memory. The brain decreases in weight (10% to 20%) and volume as a person ages. This increases the space in the cranium, making brain injury (coup-contrecoup) more likely. In addition, there is a 5% to 50% loss of neurons in older people. Neurons are responsible for transmission of impulses, so the motor and sensory neural network slow down, which affects control of breathing, heart rate, blood pressure, hunger, thirst, and body temperature. The brain has enormous reserve capacity, and having a smaller, lighter brain does not necessarily interfere with the mental capabilities of all older people.
The senses can deteriorate with age, which can be detrimental to the patient’s overall health. About 50% of patients older than 65 have vision problems. Cataracts, the clouding of the lens or surrounding membranes, interfere with vision and make it difficult to distinguish colors and see clearly. There are also many other diseases that affect vision, including glaucoma, macular degeneration, and retinal detachment. Increased intraocular pressure is a risk factor for glaucoma, which can damage the optic nerve. In retinal detachment, the retina is pulled away from the choroid, a thin layer of blood vessels that supply nutrients. Hearing is a sensory change that affects most older people. There are problems with the inner ear that make high-frequency sounds difficult to detect. Changes in the ear can also cause problems with balance. Presbycusis is an age-related hearing loss. Taste can be diminished because of a decreasing number of taste buds. An older person may have a decreased sense of touch and pain perception from the loss of nerve endings. There is also a slowing of the peripheral nervous system, which can create situations where a person may be injured but not able to feel.
Dementia is the gradual onset of progressive disorientation, shortened attention span, and loss of cognitive functions. Dementia develops slowly over a period of years rather than a few days. Dementia is the result of many neurologic diseases. Alzheimer disease, Parkinson disease, cerebrovascular accidents, and genetic factors may cause dementia. To help determine the patient’s normal mental status, question family members or friends if present at the scene. Sometimes patients are not only confused but are angry as well. They may be poor historians and have impaired judgment. They can be unable to vocalize areas of pain and current symptoms, or they may be unable to follow commands. There is inattention, memory loss, disorientation, hallucination, delusion, and a reduced level of consciousness.
Delirium is a sudden change in mental status, consciousness, or cognitive processes and is marked by the inability to focus, think logically, and maintain attention. Some things to look for are intoxication or withdrawal from alcohol, withdrawal from sedatives; medical conditions such as a UTI, bowel obstruction, dehydration, fever, cardiovascular disease, and hyperglycemia or hypoglycemia; psychiatric disorders such as depression; malnutrition or vitamin deficiencies; and environmental emergencies. Assess the patient for the following specific conditions that can be managed at the prehospital level: hypoxia, hypovolemia (hypotension), hypoglycemia, and hypothermia. They may not understand why they need to go to the hospital. You should always assume that syncope, or fainting, in an older patient is caused by a life-threatening problem.
Your patient could be experiencing a neuropathy, a disorder of the nerves of the peripheral nervous system in which function and structure of the peripheral motor, sensory, or autonomic nerves are affected. Motor nerves: muscle weakness, cramps, spasms, loss of balance, and loss of coordination. Sensory nerves: tingling, numbness, itching and pain; burning, freezing, or extreme sensitivity to touch. Autonomic nerves affect involuntary functions that could include changes in blood pressure and heart rate, sensation of hunger, and the fight-or-flight reflex.
There are changes to the mouth, including a reduction in the volume of saliva, with a resulting dryness of the mouth. Dental loss is not a normal result of the aging process, but rather the result of disease of the teeth and gums; nevertheless, dental loss is widespread in the geriatric population and can contribute to nutritional and digestive problems. These both increase the risk of choking. There is slower gastric emptying, a factor of some importance when assessing the risk of aspiration. Risk of diverticulosis increases as a person grows older. A person with diverticulitis generally presents with left lower quadrant pain and fever; fever suggests a condition that requires immediate attention. Blood flow to the liver declines, there are notable changes in hepatic enzyme systems, and there is a decrease in the liver’s ability to detoxify and remove drugs from the bloodstream.
Poor muscle tone of the smooth muscle sphincter between the esophagus and stomach can cause regurgitation and lead to heartburn and acid reflux. There is a decrease in hydrochloric acid in the stomach and alterations in absorption of nutrients and slowing peristalsis, which can cause constipation. The rectal sphincter may also become weak, resulting in fecal incontinence, or lack of bowel control. There can be gastrointestinal bleeding, which can include hematemesis or melena (black, tarry stools). Red blood typically means a local source of bleeding such as hemorrhoids. Extreme blood loss can lead to shock, which is life-threatening. Upper gastrointestinal bleeding occurs in the esophagus, stomach, or duodenum. It is seen in people who are long-term users of nonsteroidal anti-inflammatory drugs (NSAIDs), celecoxib, ibuprofen, and naproxen, and in long-term alcohol users. Irritation of the lining of the stomach or ulcers can cause forceful vomiting that tears the esophagus. Hepatitis and cancer can also cause bleeding problems. Peptic ulcer disease is an abrasion of the stomach or small intestine, which is more common in older adults, especially people who use NSAIDs. The patient will report a gnawing, burning pain in the upper abdomen that improves after eating but returns later. Older patients are at higher risk of gallstones; the risk of death from surgery to remove the gallbladder increases with age. Inflammation of the gallbladder, or cholecystitis, will present with fever and right upper quadrant pain that may radiate to the shoulder and potential jaundice. This condition is dangerous because the infection can spread to the blood, causing sepsis and shock. When a patient strains to have a bowel movement, they can stimulate the vagus nerve, which can cause a vasovagal response, where the heart rate drops and the patient becomes dizzy or passes out.
When assessing patients with gastrointestinal problems, ask about NSAID and alcohol use. Presentation can include pale or yellow, thin skin, frail musculoskeletal system, peripheral, sacral, and periorbital edema, hypertension, fever, tachycardia, and dyspnea. Orthostatic vital signs can help determine if a patient is hypovolemic; blood pressure and pulse rates are taken with the patient lying down and again after standing for 2 minutes. The most serious threat from abdominal complaints is blood loss, which can lead to shock and death, such as with an abdominal aortic aneurysm. This is a condition in which the wall of the aorta in the abdomen weakens and blood leaks into the layers of the vessel, causing it to bulge. When found early, there is a chance to repair the vessel before rupture. It typically develops in people who have a history of hypertension and atherosclerosis. Patients commonly report abdominal pain radiating through to the back. It can also be felt as a pulsating mass just above and slightly to the left of the navel during your physical examination, though this is rare. Occasionally, AAA causes a decrease in blood flow to one of the legs, and the patient reports some discomfort in the affected extremity.
There are also changes in the renal system. There is a reduction in blood flow to the kidneys. There is decreased bladder capacity, decline in sphincter muscle control, decline in voiding sensation, increase in nocturnal voiding (waking up in the middle of the night to urinate), and in men, benign prostatic hypertrophy (enlarged prostate). The kidneys are responsible for maintaining the body’s fluid and electrolyte balance and have important roles in maintaining the body’s long-term acid-base balance and eliminating drugs from the body. There is also a reduction in weight from 8–9 oz to 6–7 oz. Acute illness in older patients is often accompanied by derangements in fluid and electrolyte balance. There may be sodium deficiency. There is a decreased thirst mechanism in older people, which may lead to rapid development of severe dehydration. Urinary incontinence (loss of control), which many people do not seek help for due to embarrassment; however, it is not a normal part of aging and can lead to skin irritation, skin breakdown, and UTIs. Two types of incontinence are stress and urge. Stress incontinence occurs during activities such as coughing, laughing, sneezing, lifting, and exercise. Urge incontinence occurs when there is a sudden urge to urinate. Treatments include medication, physical therapy, and possibly surgery. There is also urinary retention. In men, enlargement of the prostate can place pressure on the urethra, making voiding difficult. In severe cases of urinary retention, patients may experience renal failure.
Changes in the endocrine system: a significant change that occurs in an older person is decreased metabolism of thyroxine. This is a thyroid hormone that affects the body’s metabolism, temperature, growth, and heart rate. This can lead to hypothyroidism. Most signs people experience are attributed to the process of aging and include slower heart rate, fatigue, drier skin and hair, cold intolerance, and weight gain. There can also be an increase in the secretion of antidiuretic hormones, causing fluid imbalance, hyperglycemia, and an increase in the levels of norepinephrine, possibly having a harmful effect on the cardiovascular system. Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is a diabetic complication in older people and occurs more often in people with type 2 diabetes than in those with type 1 diabetes. It does not cause ketosis; it leads to osmotic diuresis and a shift of fluid to the intravascular space that results in dehydration. Associated signs and symptoms include hyperglycemia, polydipsia (thirst), polyuria (urination), and polyphagia (hunger), as well as dizziness, confusion, altered mental status, and possibly seizures. Differences between DKA and HHNS include blood glucose level: HHNS is typically 600 mg/dL or higher. DKA will present with Kussmaul respirations (deep and labored), and patients with HHNS will not. Treatment should include airway, ventilatory, and circulatory support.
Treatment should include airway, ventilatory, and circulatory support. Increased risk of infection. Anorexia, fatigue, weight loss, falls, or changes in mental status may be the primary symptom of infection in these patients. Pneumonia and UTI are common in patients who are bedridden. Bones also become brittle and tend to break more easily. The disks between the vertebrae of the spine begin to narrow and decrease in height by between 2 and 3 inches, leading to changes in posture. One half of all older people have some form of arthritis. Less muscle mass often results in less strength. Older patients will show some degree of kyphosis (a forward curling of the spine, humpback). Osteoporosis is a decrease in bone mass leading to reduction in bone strength and greater susceptibility to fracture. The most rapid loss of bone occurs in women during the years following menopause, and many postmenopausal women use hormone replacement therapy to reduce bone loss. Calcium and vitamin D supplements and other medications like diphosphonates improve bone strength. There are also changes in the skin. The proteins that make the skin pliable fall with age. Bruising becomes more common because the skin can tear more easily. Exocrine (sweat) glands do not respond as well. Pressure ulcers, known as bedsores or decubitus ulcers, occur when a patient is lying or sitting for a long time. To help prevent them, take special care to pad under any bony prominences and in the voids under a patient. Placing a geriatric patient on a backboard can cause significant injury to the skin. They appear in various stages: Stage I – nonblanching redness with damage under the skin; Stage II – blister or ulcer that can affect the dermis and epidermis; Stage III – invasion of the fat layer through to the fascia; Stage IV – invasion to muscle or bone (osteomyelitis).
Older people are more susceptible to toxicity due to decreased kidney function, altered gastrointestinal absorption, and decreased vascular flow in the liver that alters metabolism and excretion. Medication interactions can be dangerous. Polypharmacy refers to the use of multiple prescription medications by one patient. If a patient receives all of their care within an integrated health system that maintains an electronic medical record that includes information from multiple providers, some states have developed health information exchanges to facilitate exchange of information between providers and pharmacies and decrease risk to the patient. Medication noncompliance is an issue in older patients and may occur because of financial challenges, inability to open containers, or impaired cognitive, vision, and hearing ability.
When assessing and caring for the elderly, it is important to remember GEMS.
G – Geriatric patients: present atypically, deserve respect, experience changes with age.
E – Environmental assessment: questions like is the home too hot or cold, is there odor, are liquor bottles present, is bedding soiled or dirty, does the patient have access to a telephone, are medications prescribed, expired, unmarked, or from multiple physicians.
M – Medical assessment: older patients tend to have a variety of medical problems; a trauma patient may have an underlying medical condition related to the traumatic event; obtaining medical history, primary assessment, and reassessment.
S – Social assessment: assess the activities of daily living (ADLs): eating, dressing, bathing, toileting; are there delays in obtaining food, medication, or hygiene; does the patient have regular visits from family members; is the patient able to feed themselves; does the patient have a social network.
There are environmental emergencies to consider with aging. Older people are more likely to experience burns due to altered mental status, inattention, and compromise. Falls are the leading cause of fatal and nonfatal injuries in older adults. Nearly one-half of fatal falls in geriatric patients are associated with traumatic brain injury. Older people with osteoporosis are at higher risk and are prone to hip fractures. Because the brain shrinks, older people are more likely to sustain certain types of traumatic brain injuries such as subdural hematomas. Acute subdural hematomas are among the deadliest of all head injuries. Blood fills the skull rapidly, compressing brain tissue, which often results in brain injury. It can go unnoticed initially because the blood has a lot of space to fill before it can produce pressure in the skull. Serious head injuries are often missed in older patients because the mechanism may seem relatively minor or health care providers consider the altered mental status as part of aging.
Special considerations at nursing and skilled care facilities include the following: Methicillin-resistant Staphylococcus aureus (MRSA) infections are common among people who live in close quarters. Vancomycin-resistant enterococci (VRE) are bacteria that are normally present in the human intestines and the female reproductive tract. Respiratory syncytial virus (RSV) causes an infection of the upper and lower respiratory tract. Clostridium difficile (C. diff) is a bacterium responsible for most infectious diarrhea. COVID-19 and influenza are factors as well. Make sure to wash hands and wear N95, gloves, and eyewear when the situation calls for it.
Remember to use TALK in situations where an elder may have an altered consciousness as a result of Alzheimer’s.
T
ake it slow.
A
sk simple questions.
L
imit reality checks.
K
eep eye contact.
Alzheimer’s Association 24/7 Helpline and Safety Center
800.272.3900
alz.org/safety
The Alzheimer’s Association offers information and support all day, every day through our 24/7 Helpline and our online Safety Center.
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