4.7 Geriatric Considerations

The geriatric population (generally defined as age 65 and older) represents a growing proportion of EMS patients. Age-related physiological changes, multiple chronic conditions, and polypharmacy create unique assessment and treatment challenges. EMTs who understand these differences provide significantly better care to their elderly patients.

Age-Related Physiological Changes

Polypharmacy

Polypharmacy is defined as taking 5 or more medications simultaneously. It is extremely common in elderly patients.

Risks of Polypharmacy

• Drug-drug interactions -- medications may interact in harmful ways
• Increased fall risk -- sedatives, antihypertensives, and diuretics contribute
• Adverse drug effects -- more medications means more potential side effects
• Medication errors -- confusion about dosing, timing, or purpose
• Masking symptoms -- beta-blockers prevent tachycardia in shock, anti-inflammatories mask fever

EMT Considerations

• Always gather all medications (put them in a bag and bring to the hospital)
• Ask about recent medication changes
• Consider medications as a potential cause of the patient's complaint
• Note any over-the-counter medications and supplements

Falls

Falls are the leading cause of injury-related death in adults over 65 and the most common cause of traumatic brain injury in the elderly.

Risk Factors

• Medications (especially sedatives, antihypertensives, anticoagulants)
• Environmental hazards (rugs, poor lighting, clutter)
• Vision and hearing impairment
• Weakness and deconditioning
• Orthostatic hypotension
• Cognitive impairment

Assessment Priorities

• What caused the fall? (Did they trip, or did they become dizzy/weak first?)
• A fall caused by dizziness or syncope suggests a medical cause (cardiac, stroke, hypoglycemia)
• Assess for head injury -- even minor falls can cause subdural hematoma, especially in patients on anticoagulants (warfarin, eliquis, etc.)
• Elderly patients on blood thinners who fall and hit their head should be transported for CT evaluation even if asymptomatic

Atypical Presentations of Common Emergencies

One of the greatest challenges in geriatric care is that common emergencies often present differently in the elderly:

Myocardial Infarction

• Up to 30% of elderly MI patients have no chest pain
• May present with: weakness, shortness of breath, syncope, confusion, nausea, or just "not feeling right"
• Maintain a high index of suspicion

Infection / Sepsis

• May present without fever (immune system cannot mount febrile response)
• Altered mental status may be the ONLY sign of a urinary tract infection
• Subtle signs: new-onset confusion, weakness, decreased oral intake, tachycardia

Abdominal Emergencies

• Decreased pain perception may minimize complaints
• Rigid abdomen may be absent even with peritonitis
• Aortic aneurysm rupture: sudden back/abdominal pain, hypotension, pulsatile mass

Trauma

• Osteoporosis means fractures from minimal force
• Hip fractures are extremely common -- shortened, externally rotated leg
• Head injuries may present with delayed symptoms (subdural hematoma can expand slowly)

Elder Abuse

EMTs are mandatory reporters of suspected elder abuse in all 50 states.

Types of Elder Abuse

• Physical abuse: Unexplained bruises, burns, fractures, restraint marks
• Emotional/Psychological abuse: Withdrawal, fearfulness, depression, verbal threats by caregiver
• Sexual abuse: Unexplained genital injuries, STIs
• Financial exploitation: Missing belongings, sudden changes in financial status
• Neglect: Malnutrition, dehydration, poor hygiene, untreated medical conditions, bedsores (pressure ulcers)
• Self-neglect: Patient unable to care for themselves and has no support system

Red Flags

• Injuries inconsistent with explanation
• Caregiver prevents patient from speaking privately with EMT
• Patient appears fearful of caregiver
• Poor living conditions despite adequate financial resources
• Frequent unexplained injuries or hospital visits
• Pressure ulcers (decubitus ulcers) indicating neglect

EMT Responsibilities

• Document observations objectively
• Report to Adult Protective Services or law enforcement per local protocol
• Do NOT confront the suspected abuser
• Ensure patient safety -- transport to the hospital if possible

Communication Challenges

Effective communication with geriatric patients requires patience and adaptation:

Hearing Impairment

• Speak clearly and at a normal volume (shouting distorts sound)
• Face the patient so they can read lips
• Reduce background noise
• Ask if they have hearing aids and help them put them in

Vision Impairment

• Identify yourself clearly when approaching
• Describe what you are doing before you do it
• Ensure the environment is well-lit
• Offer to bring their glasses

Cognitive Impairment

• Speak slowly and use simple, direct sentences
• Ask one question at a time
• Allow extra time for responses
• Involve family/caregivers for history but still address the patient directly
• Treat all patients with dignity and respect regardless of cognitive status
• Distinguish between baseline cognitive impairment (dementia) and acute changes (possible stroke, infection, medication issue)

Advance Directives

DNR (Do Not Resuscitate)

• Legal document stating the patient does not want CPR if they go into cardiac arrest
• Must be a valid, signed document -- verbal reports from family are generally NOT sufficient
• If no valid DNR can be produced, begin resuscitation
• A DNR only applies to cardiac arrest -- continue to treat all other conditions

POLST (Physician Orders for Life-Sustaining Treatment)

• Also known as MOLST (Medical Orders for Life-Sustaining Treatment) in some states
• Signed by both patient and physician
• More detailed than DNR -- may specify wishes regarding:
  • CPR
  • Intubation and mechanical ventilation
  • Antibiotics
  • IV fluids
  • Hospital transfer
• Brightly colored form (often pink or yellow) for easy identification

EMT Responsibilities

• Ask about advance directives on every call with elderly patients
• Request to see the actual document
• Follow the directives as written
• When in doubt, err on the side of treatment -- you can always stop treatment, but you cannot undo a failure to act
• Contact medical control if uncertain about the validity or interpretation of a directive