16.2 Geriatric Syndromes, Polypharmacy, Elder Vulnerability & Falls

16.2 Geriatric Syndromes, Polypharmacy, Elder Vulnerability & Falls

Anatomical and Physiological Changes of Aging

Geriatric patients represent an escalating demographic in Canadian emergency medical services. Aging produces progressive, multisystem physiological declines that diminish functional organ reserve (homeostenosis) and alter typical disease manifestations. Primary care paramedics under the Canadian Paramedic Competence Framework (CPCF Appendix A #13, Area F1) must distinguish normal physiological senescence from acute pathological crises.

Cardiovascular System

• Vascular Stiffening: Arteriosclerosis, elastin fragmentation, and collagen cross-linking decrease arterial compliance, resulting in elevated systemic vascular resistance (SVR) and isolated systolic hypertension with a widened pulse pressure.
• Blunted Baroreceptors: Age-related desensitization of carotid sinus and aortic arch baroreceptors diminishes reflex sympathetic vasoconstriction and heart rate acceleration during postural transitions or acute hypovolemia, causing orthostatic hypotension and a blunted compensatory tachycardia during occult hemorrhage.
• Conduction System Degeneration: Fibrotic degeneration of the sinoatrial node, AV junction, and bundle branches increases the incidence of sick sinus syndrome, first- or second-degree AV blocks, bundle branch blocks, and atrial fibrillation.

Respiratory System

• Chest Wall & Lung Mechanics: Costochondral calcification and thoracic kyphosis stiffen the thoracic cage. Loss of pulmonary parenchymal elastin increases lung compliance while diminishing alveolar tethering, leading to premature airway closure during tidal breathing and increased dead space ventilation.
• Decreased Functional Reserve: Vital capacity declines by up to 50% by age 80, while residual volume increases. Ventilatory drive responses to arterial hypoxemia and hypercapnia decline by 40% to 50%, predisposing elderly patients to sudden, silent hypoventilation and respiratory failure during systemic infection or opioid administration.

Renal & Hepatic Elimination

• Renal Atrophy: Cortical nephron mass declines by 30% to 40% between ages 30 and 80. Glomerular filtration rate (GFR) falls by roughly 1 mL/min/year after age 40. Serum creatinine remains paradoxically "normal" due to concomitant skeletal muscle wasting (sarcopenia), masking significant renal insufficiency.
• Hepatic Clearance: Hepatic mass and splanchnic blood flow decrease by 20% to 40%. Phase I cytochrome P450 microsomal enzymatic oxidation diminishes, markedly prolonging the serum half-lives of lipophilic sedatives, analgesics, and antiarrhythmics.

Musculoskeletal & Integumentary Systems

• Skin & Thermoregulation: Loss of subcutaneous adipose tissue, atrophy of dermal capillaries, and thinning of the stratum corneum compromise thermal insulation and skin turgor. Skin turgor over the clavicle or forearm is an unreliable indicator of dehydration in older adults; paramedics must evaluate oral mucous membranes, axillary moisture, and orthostatic vital signs. Slower basal metabolic rates and impaired shivering predispose geriatric patients to hypothermia even in mild indoor environments.
• Spinal Deformity: Kyphosis, osteopenia, and degenerative disc disease produce fixed spinal curvatures. Paramedics must never force a kyphotic geriatric patient flat onto a rigid backboard; customized padding (towels, blankets, or vacuum mattresses) must support the anatomical curvature beneath the head, neck, and shoulders to prevent airway occlusion and iatrogenic fractures.

Neurological Atrophy & Subdural Hematoma Mechanics

Between ages 30 and 80, total brain weight decreases by 10% to 15%, producing progressive cerebral cortical atrophy and ventricular enlargement. This cerebral shrinkage creates a significantly widened subdural space between the cortical surface and the dura mater. Consequently, the parasagittal bridging veins that traverse this space from the cerebral cortex to the superior sagittal sinus are stretched, taut, and fragile.

  [Normal Brain]                    [Atrophied Geriatric Brain]
┌─────────────────────┐            ┌─────────────────────┐
│ Dura Mater          │            │ Dura Mater          │
├─────────────────────┤            ├─────────────────────┤
│ Narrow Subdural Sp. │            │ WIDENED SUBDURAL SP │ <─ Extended Distance
│ Bridging Veins Int. │            │ STRETCHED BRIDGING  │ <─ Taut, Fragile Veins
├─────────────────────┤            │ VEINS (High Risk)   │
│ Cerebral Cortex     │            ├─────────────────────┤
└─────────────────────┘            │ Atrophied Cortex    │
                                   └─────────────────────┘

• Mechanism of Injury: Even a minor ground-level fall (GLF) or trivial head impact (e.g., bumping the head on a car door or kitchen cabinet) generates angular acceleration that tears these taut bridging veins.
• Insidious Venous Bleeding: Because bleeding originates from low-pressure venous structures into an expanded intracranial space, symptoms may not manifest for days, weeks, or even months. The expanding hematoma produces chronic subdural hematomas (cSDH), presenting insidiously with subtle cognitive decline, new-onset confusion, persistent dull headache, unsteady gait, personality changes, or fluctuating focal deficits that are frequently misattributed to "worsening dementia."

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Polypharmacy, Drug Interactions & Hemodynamic Masking

Polypharmacy is conventionally defined as the concurrent use of five or more distinct prescription medications. In Canada, more than 30% of seniors over age 65 take five or more medications, and 10% take ten or more.

The Beers Criteria

The American Geriatrics Society (AGS) Beers Criteria catalogs potentially inappropriate medications in older adults due to adverse drug events, anticholinergic toxicity, and heightened fall risks:

• Benzodiazepines & Sedative-Hypnotics (e.g., Lorazepam, Diazepam, Zopiclone): Prolonged clearance; produce excessive daytime sedation, severe motor ataxia, cognitive impairment, and a four-fold increase in fall and fracture risks.
• Anticholinergic Agents (e.g., Dimenhydrinate, Diphenhydramine, Amitriptyline): Block muscarinic receptors centrally and peripherally, inducing acute delirium, severe dry mouth, blurred vision, acute urinary retention, and severe constipation.
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs: e.g., Ibuprofen, Naproxen, Ketorolac): Inhibit renal prostaglandins, precipitating acute kidney injury (AKI), fluid retention, worsening heart failure, and severe gastrointestinal hemorrhage.
• Long-Acting Sulfonylureas (e.g., Glyburide): Cause profound, recurrent, and prolonged hypoglycemia lasting 24 to 72 hours due to renal metabolite accumulation.

Hemodynamic Masking in Occult Trauma and Sepsis

One of the most dangerous prehospital pitfalls is the failure to recognize occult shock in patients prescribed cardiovascular medications:

• Beta-Adrenergic Blockers (e.g., Metoprolol, Bisoprolol, Atenolol) & Non-Dihydropyridine Calcium Channel Blockers (e.g., Diltiazem, Verapamil): Inhibit chronotropic and inotropic cardiac responses. When a geriatric trauma patient suffers internal hemorrhage (such as a retroperitoneal hematoma from a pelvic fracture or ruptured spleen), beta-blockers block compensatory sinus tachycardia. A heart rate of 75 to 85 bpm in an anticoagulated elder who has fallen does not indicate hemodynamic stability; it may represent maximal pharmacological tachycardia in profound hypovolemic shock.
• Anticoagulants & Antiplatelets: Direct Oral Anticoagulants (DOACs: apixaban, rivaroxaban, dabigatran), warfarin, and antiplatelet drugs (clopidogrel, ASA) prevent physiological hemostasis. Any elderly patient taking an anticoagulant who sustains a head strike must undergo mandatory emergency department transport for non-contrast head CT, regardless of a normal Glasgow Coma Scale (GCS 15) score on scene.

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Differentiating the 3 Ds: Delirium, Dementia & Depression

Acute cognitive alteration in elderly patients represents a medical diagnostic challenge. Paramedics must differentiate between Delirium, Dementia, and Depression:

Prehospital Mnemonic for Reversible Delirium Causes: DELIRIUMS

• D - Drugs (polypharmacy, sedatives, anticholinergics, toxic levels, withdrawal)
• E - Electrolyte imbalance / Endocrine (hyponatremia, hypercalcemia, hypoglycemia, DKA/HHS)
• L - Low oxygen (hypoxia, PE, severe anemia, acute pulmonary edema, COPD exacerbation)
• I - Infection (urinary tract infection [UTI], pneumonia, sepsis, cellulitis, meningitis)
• R - Retention (acute urinary retention, severe fecal impaction)
• I - Intracranial (subdural hematoma, acute stroke, TIA, subarachnoid hemorrhage)
• U - Underhydration / Uremia (dehydration, acute kidney injury)
• M - Metabolic / Myocardial (hypothermia, hyperthermia, silent myocardial infarction)
• S - Subdural / Sensory deprivation (acute or chronic SDH, loss of hearing aids/glasses)

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Elder Abuse, Neglect & Mandatory Provincial Reporting Duties

Elder mistreatment is an insidious violation of human rights affecting an estimated 8% to 10% of older Canadians. It occurs across all socioeconomic spectra and is categorized into distinct forms:

• Physical Abuse: Non-accidental bodily injury, rough handling, sexual assault, or unlawful physical/chemical restraint.
• Psychological / Emotional Abuse: Verbal assaults, humiliation, intimidation, threats of institutionalization, social isolation, or infantilization.
• Financial / Material Exploitation: Unauthorized misappropriation of pension funds, forging signatures, coercion regarding property or wills, or theft of valuables.
• Active Caregiver Neglect: Intentional refusal or failure by a designated caregiver to fulfill caretaking obligations (withholding food, water, hygiene, heating, or vital prescription medications).
• Passive Caregiver Neglect: Unintentional failure to provide adequate care resulting from caregiver illness, ignorance, cognitive impairment, or burnout.
• Self-Neglect: Failure of an older adult to provide for their own basic survival needs due to physical infirmity or neurocognitive decline.

Clinical Red Flags for Paramedics

• Injury Patterns Inconsistent with History: Bruising on protected anatomical areas (inner thighs, upper arms from grabbing, chest, posterior trunk, genitals), bilateral symmetric wrist or ankle contusions from restraints, or burns with clear immersion lines.
• Multi-Stage Injuries: Multiple contusions, lacerations, or fractures in varying stages of biological healing, suggesting recurrent trauma.
• Severe Neglect Indicators: Unstageable, foul-smelling sacral, ischial, or heel decubitus ulcers; untreated contractures; severe malnutrition, cachexia, or dehydration; insect infestation or soiled, soaked clothing and bed linens.
• Medication Discrepancies: Unfilled prescriptions, empty medication vials, or toxic hoarding.
• Caregiver Behaviors: Caregiver displays hostility, indifference, or evasiveness; refuses to permit the paramedic to interview the patient alone; insists on answering for the patient; or displays a delay in contacting EMS following acute trauma.

Canadian Provincial Reporting Duties & Documentation Standards

In Canada, paramedics are bound by provincial and territorial adult protection statutes (e.g., Ontario Long-Term Care Homes Act and Fixing Long-Term Care Act, British Columbia Adult Guardianship Act, Alberta Protection for Persons in Care Act, Nova Scotia Adult Protection Act). Paramedics have an unambiguous legal and professional obligation to report suspected abuse, neglect, or exploitation of vulnerable adults to designated authorities (Adult Protection, provincial health authority crisis teams, or police).

[!IMPORTANT] Documentation Standards for Suspected Elder Mistreatment: Paramedics must document physical findings and scene dynamics with meticulous, objective precision. Record exact physical dimensions, biological colors, and anatomical locations of all injuries. Never record subjective speculations, accusatory assumptions, or legal labels (e.g., do not write "patient was abused by son"). Instead, record direct verbatim statements in quotation marks (e.g., "Caregiver stated: 'I didn't give him his pills because he made me angry'"). Photographing injuries is subject to provincial service privacy protocols.

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Prehospital Fall Risk Assessment & Home Safety Pathways

Ground-level falls (GLF) account for over 85% of all injury-related hospitalizations among Canadian seniors. Falls are rarely isolated mechanical events; they represent a complex convergence of intrinsic host vulnerabilities and extrinsic environmental hazards.

The "Long Lie" and Its Pathophysiology

When an older adult falls and cannot get up without assistance, remaining on the floor for extended periods (defined as >1 hour on the floor) precipitates life-threatening systemic cascades:

1. Rhabdomyolysis: Prolonged mechanical pressure on dependent muscle tissue produces ischemic skeletal muscle necrosis, releasing toxic quantities of myoglobin, creatine kinase (CK), and potassium into the systemic circulation. Myoglobin obstructs renal tubules, triggering acute tubular necrosis and myoglobinuric renal failure.
2. Severe Hypothermia: Conductive heat loss to cold flooring causes core hypothermia, triggering cardiac arrhythmias, coagulopathy, and metabolic acidosis.
3. Dehydration & Electrolyte Derangements: Inability to access fluids produces acute hypovolemic hypernatremia.
4. Pressure Injury: Continuous capillary occlusion causes irreversible deep tissue ischemia and decubitus ulceration within 2 to 4 hours.

Paramedic Home Safety Assessment & Specialized Referral Pathways

Rather than merely treating the acute trauma and executing transport, paramedics evaluate the domestic environment to interrupt the fall cycle:

• Environmental Hazards: Loose throw rugs, lack of hallway illumination, absence of bathroom grab bars, cluttered pathways, and footwear lacking non-skid soles.
• Referral Pathways: When an older adult declines hospital transport or sustains minor injuries, paramedics in many Canadian jurisdictions initiate direct referrals to Community Paramedicine, specialized Falls Prevention Programs, Home Care Nursing, Physical Therapy, and Geriatric Assessment Clinics, transforming a routine 911 dispatch into a proactive healthcare intervention.

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Clinical Scenario: The Anticoagulated Elder with Ground-Level Fall

Paramedics respond to a private residence for an 81-year-old female who fell out of bed.

1. Primary Assessment: The patient is found sitting on the bedroom carpet. She is conscious, alert, and oriented to person and year, but disoriented to month and situation (GCS 14: E4, V4, M6). Vital signs: HR 64 bpm regular, BP 138/82 mmHg, RR 16 breaths/min, SpO2 97% on room air, blood glucose 5.8 mmol/L. Physical exam reveals a 3-cm boggy hematoma over the right parietal scalp.
2. History & Medication Review: The patient's spouse states she tripped getting up to use the bathroom 3 hours ago. Medical history includes non-valvular atrial fibrillation and hypertension. Medication list reveals apixaban (Eliquis) 5 mg BID and metoprolol tartrate 50 mg BID.
3. Clinical Integration: Although her heart rate (64 bpm) and blood pressure appear stable, the paramedic recognizes that metoprolol masks compensatory tachycardia. Furthermore, age-related cerebral atrophy and therapeutic factor Xa inhibition (apixaban) place her at extreme risk for a slow-bleeding subdural hematoma. The GCS score of 14 represents an acute neurocognitive change from her baseline normal function.
4. Transport Decision: The patient and husband initially resist transport, stating, "It's just a bump on the head." The paramedic clearly explains the physiology of bridging vein tearing, the impact of blood thinners, and the delayed presentation of subdural hematomas. The patient agrees to transport. Paramedics package the patient with generous head and neck padding on the stretcher, initiate gentle transport, and provide an alert to the trauma team. Subsequent hospital non-contrast CT reveals an acute 8-mm right subdural hematoma with midline shift requiring immediate neurosurgical intervention.

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Exam Pitfalls & High-Yield Geriatric Pearls

• Misinterpreting "Normal" Heart Rates: A heart rate of 70 to 80 bpm in an elderly trauma or septic patient taking a beta-blocker or calcium channel blocker may represent maximal compensatory cardiovascular effort; never assume normocardia equals stability.
• Relying on Skin Turgor for Dehydration: Skin loses elasticity with age; check the tongue, oral mucosa, and axilla for dry membranes rather than pinching the back of the hand.
• Dismissing Low-Mechanism Head Trauma on Anticoagulants: Any elderly patient on anticoagulants (warfarin, apixaban, rivaroxaban) who sustains a ground-level fall with head impact requires urgent emergency department neuroimaging, regardless of GCS 15.
• Confusing Delirium with Normal Aging or Dementia: Acute confusion developing over hours or days with inattention is delirium until proven otherwise. Never dismiss acute disorientation as "old age."
• Subjective Accusations in Suspected Abuse: Never write personal suspicions or conclusions in the patient care report. Record meticulous anatomical descriptions of injuries and exact verbatim quotes from caregivers and patients.