seventeen

As people age, their kidneys slow down, reducing their ability to detoxify and eliminate substances like medications and alcohol. Over-the-counter medications can have negative effects when combined with other medications or herbal substances. Multiple prescriptions from multiple doctors at multiple pharmacies can lead to medication issues and interactions. Elderly patients may have difficulty taking medications regularly due to financial problems or trouble opening containers. Depression is not a normal part of aging but is treatable with medication and counseling. Elderly patients are at higher risk of suicide, especially if they have a history of depression, chronic disease, or experience significant loss. Chronic conditions, substance abuse, isolation, and prescription medication use also contribute to depression. It's important to assess patients for signs of suicide and ask about suicidal thoughts. Older patients have specific considerations in their assessment, including underst their kidneys slow down, which causes a decrease in the ability to detoxify and neutralize that agent. Kidneys undergo many changes with age to keep super function as well, talk about that, reduces the ability to eliminate things like medications and alcohol. Over-the-counter medications can have a negative effect when mixed with each other or herbal substances, alcohol and prescription medications. A lot of your cold medicines, you can't take with blood pressure meds because it reverses the blood pressure meds and gives you hypertension, things like Sudafed and polypharmacy refers to the use of multiple prescription medications by one patient. I'm going to go beyond that. I'm going to say multiple prescriptions by multiple doctors at multiple pharmacies. I go to my primary care physician on the east side of town and I go to CVS, but when I see my cardiologist, I go to the west side of town and then Walgreens. Now the doctors and the pharmacies don't communicate, so I could very well get a medication issue. I could have a medication interaction and medications can have a synergistic or even a potentiating effect. Synergistic effect means that two work together to enhance a reaction. A potentiating effect means I can take two medications and they can double or triple the effect that I would expect to get. Sometimes medication, and whenever you're dealing with a patient with medications, you always want to find out if they're compliant with their meds. So you have medications, this is your list, you take them every day, right? So they can have a lot of different reasons why. Financial problems, I'm on a fixed income. My rent costs so much, my food, my heat costs so much, so what goes by the wayside? Well, I'll take my medication every other day. That means I double my supply, it costs me half as much money. Well, what happens is every other day you don't have any medicine in you. So every other day you have the same problem, you're taking the medicine for, it doesn't work that way. Inability to open containers, it was a great thing, the number of poisonings went way down once they came up with the safety caps, but the problem is that sometimes I have problems opening the safety caps, imagine an 80-year-old person with weak fingers. And then impaired cognitive, vision, and hearing disabilities, the reason why a lot of elderly patients will have what they call home health aids, or CNAs, so they come to visit, they'll help them with medications. Depression, depression is not part of normal aging, but medical disease is a treatable condition. You can treat the patient with medication and counseling, right? Depression, if untreated, is one of the number one causes of suicide, especially in the geriatric population. Who has the highest rate of successful suicides? 55- to 65-year-old males, because they have more means and opportunities. Risk factors include depression, a history of depression, chronic disease, and loss. To include the loss of a significant other, you have a husband and wife that have been together since they were in high school, they're in their 80s, and one of the spouses dies. And the other spouse dies within six months of what they call a broken heart. That is actually a medical, a defined medical condition. It's called, what is it, Takotsubo, Takotsubo is cardiomyopathy. My mother had it, but it's caused by stress. My mother had it from stress at work, she stopped working and it went away. But it's a common condition where people, when they lose a loved one, they end up dying. I think that's it. It happens to dogs, too. Animals, yeah, it happens to animals. They die from broken hearts. Yeah. Chronic conditions contribute to the onset of significant depression. Substance abuse. You know, as we get older, you know, especially if patients have problems, money problems or housing problems, or they don't get along with their children, they turn to substance. Isolation. Some of the saddest patients I've ever gone to. I've gone to patients where, like, especially when you go to nursing homes and you'll have like a three-room nursing home room, and two of the family, two of the patients, they have active family members that visit them all the time, and you have the one in the middle that they get a phone call from their child on their birthday, and they never see their children again. Saddest thing you've ever seen. They kind of look longingly when the family is visiting other people. Prescription medication use and chronic medical conditions. Older men, again, age 55 to 65-year-old males have the highest rate of successful suicides. They have motive means and opportunity. They tend to choose more lethal means, and they have a weaker recuperative capacity. Suicide, chronic predisposition, predisposing events, things like death of a loved one. We talked about that. Physical illness. Physical illness that might lead to a terminal condition, or a patient not being fully active or being bedridden, unable to ambulate. Depression and hopelessness, alcohol abuse, alcohol dependency, and meaningful loss of life. I've heard of people, I've heard of elderly patients committing suicide after their family took their driver's license away. That's their last mode of freedom. Once my license is gone, I can't go anywhere. I can't do anything. I'm stuck in the house. When assessing a patient who's displaying signs of suicide, when you're talking to a patient who's displaying signs of depression, ask them if they've considered suicide. Things like, have you ever felt like you wanted to hurt yourself or somebody else? And that's important. Don't think you're going to put an idea in their head, I wasn't thinking about it, but now I've said that. If it's there or it's not. Now, if they do, ask a little bit. Do they say, yeah, I just don't want to be alive anymore. That's sad. That's serious. That needs to be addressed. But if they have a plan, yeah, I'm going to take some pills or I'm going to walk up a bridge or I'm going to stand in front of traffic. They've got a plan. They've thought about it. They've thought it through. That's far worse. It is a warning sign. Actually, anybody who, technically in Massachusetts, anybody who displays or verbalizes suicidal ideations, they get a section 12. Right? And you're supposed to report that. So if anybody, you're dealing with any patient and they report any feelings of self-harm or harmful of others, you have to report that. And they might be, they might be sectioned. The Gems Diamond. Oh, no, another mnemonic. Man. Brandon, help me remember what is different about older patients. This is not, we're going to talk about the P18, the Pediatric Assessment Triangle. That is a general impression when we do pediatrics. This is not a general impression. What this is, is just gives you an overview of things you want to assess when you're assessing your patients. Right? It's an acronym. And it stands for G for Geriatric Patients. Patients over 65 years of age. Be familiar with the normal changes of aging. Understand how patients change with age. And some things are expected. Environmental assessment. Assess the environment. Their home. You know, if you're going to a home, is the home properly lit? Is it a hoarding situation? Do you see carpets all torn up? Or is there, you know, dead animals under the couch, which I've seen. Is it trash lying around? Plates of food in various states of decay. Is there no banister on the stairway? Are there broken steps? All that stuff. Is it safe for the patient? If you look at a home and say, I wouldn't want my kids or my grandmother living here. Probably not safe for them. Right? And so we do what we call a 19A, which is an elder in need of services or elder abuse, elder, contact elder affairs and do a 19A. So that's their environment. Medical assessment. You're going to do a complete sample history. Remember, all the patients tend to have a variety of medical problems and numerous medications. So we want to make sure we get a good history as possible. When you go to a patient's home, easiest way is to ask the patient, do you have been to the hospital recently? And do you have your discharge summary? Discharge summary will have a history of medical allergies and what's the last time they went to the hospital. That saves you from asking them questions. And again, a thorough medical assessment. And then as to social, older people may have less of a social network. Right? As you get older, our friends and family members die off. And so we have less of a social structure. They need assistance with the ADLs, activity of daily living. Toileting, cleaning their house, bathing. And this is one of the reasons why you have home health aides. They come in, do shopping for patients, clean up the house, do laundry. Maybe toilet and bathe the patients. You know, take the patient to doctor's appointments. Consider obtaining the information pamphlets about some of the agencies in your area that help people. Elder services. Every city, town, or county has an elder affairs and elder service center. Get the phone number of the local one and you can give it out to people. You keep it in your phone. And you can write it down and say, here, this is the phone number for elder services. I recommend you call and you can get Neal's help. You can get your phone number. They have elder services will bring handymen out to do repairs in the home. Simple repairs. Like broken chairs, putting up banisters, and fixing lighting, and things like that. These are all important things that elder patients don't generally know that exist. That comes out of your tax money. Let them use it. They pay for it. Special considerations. Alterations. Assess an older patient can be challenging because of communication issues. And it's not necessarily that you're not on the same wavelength with the patient. You should be able to communicate with anybody. But maybe they don't understand. They don't have the same understanding as you do. Hearing and vision deficits. Again, hearing impaired. Maybe they have trouble hearing. Put the stethoscope in. Reverse. Put the stethoscope in their ears and talk into the bell. That can act like a hearing aid. Alterations in consciousness, complicated medical histories, and the effects of medication. Sometimes medications can alter the patient's perceptions. Keriatric patients are commonly found in their own homes, retirement homes, or skilled nursing facilities. But many patients live alone. And don't be surprised. There are Alzheimer's patients who live alone. And you can very well go to them. And if you find that they have diminished capacity, that's your responsibility to do a 19A and get them those services that they need. Maybe they can't go back home. Access may be hampered if the condition prevents them from getting to the door. I have kicked in doors because patients have been lying on the floor. Help! And I look in the window and I see them on the floor. They can't get to the locked door. You kick in the door. I have gone to homes where we had to force our way in because there's that much trash. And you have to climb over the trash. It's a hoarder house. And you have to climb through the trash. Some of them are huge. So you can kick in the doors. You don't have to call fire to have them do it. Well, I mean, I might call fire, but it depends on the situation. If I see a patient screaming to me, help, help, I'm going to go in the door. A lot of times the fire department is there, too. So they'll make access or make entry. But I've kicked in doors. Fire department wasn't there. The police weren't there. Kicked in the door. Go in and see the patient. The last thing I'm thinking about is the door. You're protected. They're not going to break anything or whatever. No, no, because you're going in. They called you. You have to access them. So no, you wouldn't do it because of fire consent. But by the same token, I probably want to make sure that the police or the fire department got there to secure the home afterwards because now the home is open. Or at least contact the family or something. Take note of any such unsafe or negative situations and make sure you report it. So mechanisms of injury and nature of illness may be difficult to determine on the patients with an ultimate mental status of dementia. They very well could have fallen and then called 911 and forgot why they called. They don't know what they have. They don't know what the problem is. You can't do a full head-to-toe assessment and push on everything until you find pain. Ask the family member, caregiver, or vice-caregiver why you were called. Why am I here? That's a chief complaint. Right? The patient may not be able to give it to you. Multiple or chronic disease causes may also complicate the determination of the nature of illness. Again, they could have, you know, man, why are we here today? Oh, I've got a headache and my butt hurts and I've got constipation and I don't sleep well. Okay, but man, why is the ambulance here? Oh, I have chest pain. Right? That's the chief complaint. Everything else may be associated symptoms, but that's the chief complaint. And it can change. Chest pain, shortness of breath, and often levels of consciousness should always be considered serious. Those are the big ones. Chest pain, shortness of breath, alterations in consciousness. Those are the serious ones. And don't assume alterations in consciousness is, ah, it's dementia. She's 90. Don't assume that. Address life threats. Determine the transport priority. You're never going to go wrong with high priority. Especially chest pain, shortness of breath, alterations in mental status, abdominal pain. I got it. Form your general impression. You should be able to tell if the patient is generally stable or unstable just by looking at them. And if they look stable, they may be potentially unstable anyway. Determine their level of consciousness. Anatomic changes that occur as a person ages predisposes them to airway problems. They might not be able to clear secretions, which means they've got more secretions in their airway. You're going to hear more raspy breathing. Ah, maybe, um, ah, maybe they're lying flat causes the lungs to fill up with fluid. Ensure that the patient's airway is open and not obstructed by dentures, barbiturates, blood, or fluid. Whenever you're going to an elderly patient with respiratory distress, abdominal pain, chest pain, bring suction in. Because nausea and vomiting and secretions can be very, can very rapidly cause an airway issue. And the worst thing you can do is have the patient stop vomiting. Move, walk, get the suction. You've got to have it. Anatomic changes affect the patient's ability to breathe effectively. And again, over time, that elasticity of the lungs wears out. So, the lungs do not expand and contract properly. They stay inflated, and we become chronic CO2 retainers. Loss of mechanisms that protect the upper airway have caused a decrease. You have these little hairs, microvilli, or calcillia, in your, ah, in your bronchioles. And they take the secretions of mucus that catches the detritus and bacteria and bring it up. And it brings it all the way up, and you get that frog in your throat, and you go, cough it up. That's what it's supposed to do. So, if I go like this, I'm not coughing it up, number one. And number two, maybe I smoked for 30 years, so all the cilia has been damaged. Or maybe just it's damaged because I'm older. Maybe I worked in the trades and I exposed it to chemical agents for all those years. But whatever it is, the cilia doesn't work, and so that mucus stays in my lungs. That's a pneumonia. That's a pneumonia. Oxygenation, be prepared to ventilate with suction. Core perfusion is a serious issue with the older adults. They get that peripheral vascular disease, that poor circulation, especially if it's related to diabetes. Physiological changes may negatively affect circulation just as we get older, right? We're more sedentary, so we're not getting that same circulation. Maybe my heart doesn't beat as well. I get that hypertrophy, and so therefore I have reduced heart squeeze. Vascular changes and circulatory compromise make it difficult to feel a pulse. We call it a vascular pulse. Especially with that arteriosclerosis, that hardening of the artery, they don't function as well. So any compliance to compromised ABCs should result in prompt transport. Airway, breathing, circulation, got a problem with it? High priority transport. Determine conditions that affect the lights that are light threatening and fix them right away. Don't wait. Provide prompt transport. Don't be afraid to call ALS. Find and account for all medications. Some patients with polypharmacy, when my father died, he was like, I don't know, I think like 17 or 18 or 20. Something like that. Put them all in a bag. Just throw them in a bag. If you have one of those pill things where they have the 7 days of pills or 30 days of pills, bring the whole thing with you. The hospital, the nurse will go through them. There are programs on your phone where you can actually take a picture of a pill and it will tell you what that medication is. Remember we talked about that in pharmacology. All pills have to be made with a certain marking, a certain color, and a certain size. And that depicts what they are. No two pills are exactly alike. So you can identify them without seeing the picture. Determine early whether there is an alteration in consciousness and whether it is acute or chronic. Chronic would be something like dementia or Alzheimer's. We have to find that from their patient's history. We won't be able to accept that. It has to be told to us. Multiple disease processes and multiple and ordained complaints can make assessments complicated. Collect a sample history on the patient. Collect a sample history on the patient. Signs, symptoms, allergies, medications. Passport, history, last order, KMS. You may have to rely on a relative or caregiver. The patient may not be able to give you that information. List the patient's medications or at least bring them with you to the hospital. You can always write them down for your PCR while you are at the hospital after you have transferred patient care to the nurse. The last meal is particularly important not only in diabetes but if you suspect the patient may need surgery. And transport the patient to where they are known. Unless it is a trauma patient, I would just assume take a patient to where they are known. They have been there like Memorial. A lot of elderly patients like to go to Memorial because they were born there. It is a hospital in their neighborhood. Take them there if it is not contraindicated. If you happen to be in the area and it is a cross between Haywood and Athol but the patient is seen at Athol all the time, go to Athol. Because the patient is known there. You want to take the patient to where they are known. The doctor is known. The nurse is known. They know their ins and outs. Their idiosyncrasies. They are more likely to be treated. I would not take a patient who goes to UMass to St. V's. Why? Now they are going to do everything all over again. They don't have access to the UMass system. It is like a brand-new patient. They are going to do a bunch of unneeded tests. If you brought them to UMass, they can punch up their history and say, oh, I know what the issue is. Without even having to do all those tests. Does that make sense? Bring the patient to where they are known. If you can. Older patients may not feel comfortable being exposed. I don't think anybody is. It is funny because you get some of those elderly patients like the elderly ladies in nursing homes. And you say, ma'am, I am going to have to put some stickers on your chest. I am going to just reach under your shirt just so we can put the stickers on. Oh, you mean like this? Thank you, ma'am. They don't care. It is to protect their modesty anyway. Consider the need. The more important thing, I am not so worried about modesty. I am worried about keeping the patient warm. Remember, they have a poor thermoregulatory system or reduced thermoregulatory system. I want to keep them warm. It is 20 degrees outside. My ambulance inside might be 60. I don't want to go ripping all their clothes off. I want to keep them warm. Get all your vital signs. Heart rate should be within the normal range, but may be compromised by medications such as beta blockers. Beta blockers block the beta 1 stimulation, which causes the heart to beat faster, which slows down the heartbeat and maintains blood pressure. Which is great if I have hypertension, but bad if I have trauma. Because my body cannot compensate. My heart rate won't increase in times of loss of blood. Recurrent irregular pulses are common, especially in patients with atrial fibrillation. Circulatory compromise may make it difficult to feel a radial pulse. Sometimes we have to go to other areas. If I can't get a radial pulse, maybe I can go to a femoral pulse, a brachial pulse, maybe I'll go to carotid. Do you mind if I just check your pulse? Well, you take a stethoscope and you put it right over the heart and you listen. It's called the apical pulse. Blood pressure tends to be higher, right? Because as we get older, our blood pressure, because of arterio and atherosclerosis, as well as retention of fluid, is generally higher. So, if a patient has, and this is important to remember, because if I have an elderly patient who had a motor vehicle crash, bleeding, stopped the bleeding, and his blood pressure is 120 over 80, ah, your blood pressure is better than mine, it's solid. No, he might be hypertensive that's untreated and his normal blood pressure is 180 over 100. Now he's 120 over 80. What does that mean? He's decompensating. He's dying. But his blood pressure looks great because he's normally hypertensive. So, make sure you have, that's why it's so important to get a history and find out what medications the patient takes. Maybe the patient will tell you, yeah, I'm hypertensive and I don't take medication for it. I can't afford it. So, you know he should be hypertensive. Reassess the geriatric patient. Often they can decline very rapidly. They can drop right off the cliff. Repeat your vital signs and achieve complaints. Chief complaint can change. Recheck your interventions and then identify and treat any changes in the patient's condition. Maybe you have to take up the oxygen more. Maybe you have to bandage the patient more. Turn off the heat in the ambulance and turn on the AC in the ambulance. Communicate all your findings and interventions to the hospital nurse. Document all your history, medications, assessments and interventions. Make sure you draw a complete picture for the nurse and the doctor. When you write your narrative, especially when you give your verbal report, make sure you draw a complete picture. To include the environmental assessment. How you found the patient. Where were they? How were they presented? Geriatric patient guidelines. When you enter the home, take note of issues that make it environmentally unsafe. We talked about that, right? How's the home presenting to you? Is it safe? If you wouldn't feel safe walking in it, they're not safe. Introduce yourself. Show respect. Use patience. Assess that all the patients can be complicated by multiple medical and traumatic conditions. Who knows? They could have fallen down the stairs and not realized it. Airway breathing and circulation conditions and vital signs are changed by the normal processes of aging. Well, everything stays pretty much the same. Your respiratory rate might go up a little bit. Your heart rate should stay the same. Your blood pressure is going to go up. And your body temperature may actually go down. But they should stay relatively the same. All the patients use both of the medications. We call that polypharmacy. We can go one step further. Multiple medications by multiple doctors at multiple pharmacies. And they can have interactions. Older person's body does not have the flexibility or reserves when facing illness or injury. So they're more likely to decompensate faster. They're more easily affected by poor nutrition. They don't thermoregulate as easy. So they tend to be more affected by hot and cold weather emergencies. Memory and cognition may be impaired. Even as we get older, it's just normal aging will make it worse. At 56 years old, I find I forget things more often than I used to. It's just the way it is. Skin of an older patient may be fragile and tear easy. You get that paper-thin skin. And it's like trying to literally stitch wet paper. That's what it is. That's how brittle that skin can be. See right through it. So trauma in a geriatric patient. Conditions that create risk in compensatory assessment. Slower homeostatic compensatory mechanism. They don't compensate well. Slower and less able to compensate. The compensatory mechanism is slower and less able to compensate. Limited physiological reserves, especially when you're thinking about things like malnutrition. Normal effects of aging on the body and in any existing medical condition. Cardiovascular disease. Diabetes. COPD. The mechanisms are much more minimal. Whereas in your age, a motor vehicle crashes 20 miles an hour and you hit the steering wheel. And you're like, oh, man, that hurts. An 80-year-old hits a steering wheel, it could crush their chest. So the mechanism is falling down. You fall down the stairs. You get up and go, what an idiot. An 80-year-old falls down the stairs, it could be life threatening. So remember, it takes a lot less. Elderly patients do not fare well with gunshots. Even minimal gunshots, they don't do well. Motor vehicle crash. Motor vehicle striking a pedestrian. Elderly people being struck by motor vehicles. They do not do well. Recuperations are longer and less successful. Healing takes longer. Many injuries are under-triaged and under-treated. Patients will hide them. And we talked about this. Older patients are more likely to experience burns because of altermental status, inattention, or compromised neurological status. They don't do well with burns. Over 55, a severe burn becomes a critical burn. A serious burn becomes, or a moderate burn becomes a severe burn. It goes up one level because of their age and their inability to compensate. Not only that, but because of the massive fluid loss, they need IV fluids. But you have to be careful because many have renal compromise. So that fluid, if I'm renally compromised because of age, or maybe kidney issues, and somebody dumps a bunch of IV fluid in me, where's it going to end up? What's that? It's going to end up in my lungs. CHF. Absolutely. High mortality from penetrating trauma in older adults, especially gunshot wounds. They do not do well. Falls are the leading cause of fatal and non-fatal injuries in elderly. You get a lot of time, you get the elderly patients who are on their own at home, and they climb up on the roof to clean out the gutters, or they're working in the yard, or they're trying to fix something on the house, and they fall. Very common, especially patients who are, especially elderly patients who are very, let's see, I was doing...