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As people age, they may experience various changes in their senses and cognitive abilities. Hearing loss can be caused by long-term exposure to loud noises. Taste buds can decrease in number over time, impacting the ability to taste. Anosmia, the inability to smell, can occur, such as after COVID-19. Decreased sense of touch and pain perception can lead to injuries. Dementia is a progressive loss of cognitive function and can have different types, including Alzheimer's. Dementia patients may regress in memory and struggle with daily tasks. It is important to assess and support these individuals in their daily living activities. The gradual hearing loss that is caused by loud noises. So back, you know, you're talking about your 70 or 80 years old, 10-year-olds now, that they were working in the 50s and 60s when OSHA was just a, not even an OSHA yet. So they were subjected to all loud noises and so that would cause hearing loss. So you think you guys with OSHA today, noise pollution protections, you guys would be all set? No? Well, you don't have any. Put your headphones in. There you go. You put headphones in. You turn them up high and loud. There you go. You can put them on. Well, they have noise blocks now. They don't need to go too loud to ignore the water. They have noise blocks and they don't need to go too loud. Right. So it's going to block out the outsides. Actually, the Apple ones now, you've got to put the hearing aids. Really? Yeah. Oh, there you go. By the FDA. No kidding. A lot of radiation. Very much. Sure. Yeah. Right. And you can just hear. There's no one else hearing. You don't hear back from your arms. Oh, they're not cancellation? No. You just literally put it open and it doesn't go through. So heredity and long-term exposure to loud noises are the main factors. It's the main reason why people lose their hearing anyway. Taste. A decrease in the number of taste buds. So this can have a negative result. It can have a positive result. It can have a negative result. It can have a positive result. It can have a negative result. It can have a positive result. It can have a negative result. It can have a negative result. It can have a positive result. It can have a negative result. It can have a negative result. It can have a negative result. First of all, if you take my 11-year-old son and me, we put our tongue out, he'd have 10,000 more taste buds than I do. What happens is, over time, those taste buds kind of wear away. You wear them away. So that's one of the reasons why older people can eat pretty much anything and it's okay. Whereas young people, young people can't eat anything. They can't eat anything. They can't eat anything. They can't eat anything. They can't eat anything. They can't eat anything. They can't eat anything. They can't eat anything. They can't eat anything. They can't eat anything. They can't eat anything. 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They still smell like dog poop. Really? Yeah. Oh, that sounds like real green peppers. Yeah. It's been like two, three years and it still smells like dog poop. It throws it off. It throws off the chemical connections. Decreased sense of touch and pain perception from the lungs to the hands to the nerve fibers. This is one of the reasons why you can have an elderly patient put their hand on a hot stove and not realize until they smoke a smoke. Oh, my hand is burning. Obviously, diabetes can add to it because the sugar destroys nerve fibers. If my nerve fibers are naturally degrading over time and then I get diabetes as well, it can be twice as bad. Dementia is the slow onset of progressive disorientation, shortness of attention span and loss of cognitive function. Dementia is kind of a blanket term. You can have different types of dementia. You can have Lewy body dementia, which affects what they call these Lewy bodies that cause miscommunication within the cerebral cortex and the cerebral medulla. You can have Parkinsonian dementia, which is dementia with Parkinson's tendencies. You can have vascular dementia, which is what they call cortical dementia. My stepmother had that. It's a narrowing of the blood vessels in the cervical lobes. And the most common one is Alzheimer's dementia, which is a buildup of these plaques within the brain, these proteins. Chronic, generally irreversible condition that causes progressive loss of cognitive ability, psychomotor skills and social skills. Now, we say the elderly because most commonly the elderly have dementia. But especially with Alzheimer's, you can see this in younger people. The youngest age, a gentleman in China, 19 years old, was diagnosed with dementia. Can you imagine that? At 19 years old, he had to drop out of school because he just didn't. There are treatments for it. There are medications you can treat. But it's generally degenerative chronic. It does not get better, so to speak. They still don't know. They still don't have a full understanding of how Alzheimer's develops. Something about these proteins and plaques, but they don't know. Alzheimer's? I mean, we don't know. It was diagnosed back in the 60s, I believe. But it probably has been with us since the beginning. It could be chemicals that we eat. Maybe we didn't have it in the 1800s, so we didn't know it was chemicals. You heard that they're doing a study that is doing statins to see if that is a correlation between using statins and reducing Alzheimer's because it reduces the plaque in the brain. I don't know what the result of the study is. I know that they are doing a study, though. So, dementia. Again, there are different types of dementia. Dementia is interesting because when you're dealing with patients, it's like a degenerative People go backwards in time. So, we have had nursing home contracts where we take patients to dialysis. And they've been at the nursing home for years. And they go to dialysis for years, so we would take them. And I would see patients digress. And patients would, you know, they kind of just forget the name of their children. And then they digress to the point where they think you're their husband. And then you digress to the point where you think you're a boyfriend in high school. And then they think you're their father. And that's how they quickly, that's how much they go back. These patients, some of these patients can tell you the words from every song while they were in high school, when they were in their 80s. But they don't remember their children's names. They don't remember their own names. My stepmother, toward the end, when I would go visit her, she was always talking about how my father was going to pick her up and they were going to go shopping and this and that. But she kept calling him Jim. My father's name is Ray. The reason she kept calling him Jim because that was her first, that's her ex-husband, which she divorced some 50 years ago. So she was remembering Jim, but she was correlating it to my father. And so you can see that progression of how people go backwards over time. This is the one Bruce Willis has. He's got, he's got, what is it? He's got frontal lobe, frontal lobe, frontal lobe dementia. It's more of a communication than anything. He's got an issue with communication. So on assessment, patients may have short and long-term memory loss, have a decreased attention span, unable to perform daily routines. And what happens is the patient basically degrades to the point where they can no longer take care of themselves. They can't handle activities of daily living. We call it ADLs, activities of daily living. And eventually the brain shuts down. You'll see these patients and they kind of just lay there and they'll just hum or they'll make noises and they're just non-functioning. And that's kind of the late or last stages, which unfortunately makes these patients who end up in memory units and Alzheimer's units in nursing homes, especially if the nursing homes are not so great, they end up being the ones that are mostly amused because they can't speak. They can't fight back. So decreased ability to communicate, appear confused or angry. Sometimes your dementia, especially with Alzheimer's patients, toward the later stages will actually become violent because people come up to them and say, Hey, honey, how you doing? Hey, dad. I don't know you. You call me dad. I don't know this house. You tell me this is my house. You call me a name. And they get violent. They get angry. This is usually where most people put these patients in a nursing home or some kind of memory unit because they can't keep them at home anymore. They're either violent or they're walking away or they're always getting hurt and so they have to put them in. They need 24-hour care. Yeah, that happened to my great-grandma. My grandma was taking care of her. She had to bring me over because she didn't recognize me as me, as her great-grandma. She thought I was one of her dads, her child. So she'd be like, Maria. She called all of us Maria because all her children are Maria. And then I would call her now and my grandma could be taking care of her. Right. Exactly. They have impaired judgment and unable to vocalize pain. And a lot of times we'll find these patients, these are the patients who get a call for the confused elderly patient and you show up and they don't know where they are, they don't know what they're doing. I remember my stepmother a couple of times, she ended up in like McDooan or Revere. She was just driving to the store. And then she'd be like gone for like four hours and then a police would call from McDooan. They'd be like, yeah, we have Maria Lambert here. She says this is her phone number. Who are you? I said, how come you're doing away out there? You have to go get her. And situations like that. And that kind of leads you down that road. Delirium. Delirium is different. This is sudden. Alzheimer's, dementia, Parkinson's, whatever it is, those are all chronic. They're long-term. The patient will have it and they'll have a history of it. Delirium is a sudden change in mental status, consciousness, or cognitive process. Marks an inability to focus, think logically, or maintain attention. The number one cause of delirium in the elderly patient is anybody remember? UTI. Urinary tract infection. Affects about 15 to 50% of hospitalized people aged 70 years or older. My stepmother, before she got diagnosed, she had degenerative disc syndrome and had to have significant surgery to respond to it, including getting rotted. So she ended up spending about a month at the Whittier in rehab. She would get up in the middle of the night at the Whittier and go and try and find the kitchens to cook food for her parents who had been dead for years because she developed this delirium. They call it institutional delirium. Acute anxiety may be present. Generally, it results in a reversible physical ailment, a cause. Again, it could be infection. It could be fever with infection. It could be medication, changes in medication, hypoxia, things like that. Metabolic causes, dehydration or malnutrition. In history, look for withdrawal from alcohol or sedatives. Very common. Medical conditions, depression, malnutrition or vitamin deficiencies, and environmental emergencies, hot and cold, things like that. Wernicke's encephalopathy is very common in alcoholics. It is a form of... It causes a form of... It can be permanent, but it's a thiamine deficiency. It's from malnutrition. Assess advantage of the patient for hypoxia. We can do that by putting them on pulse oxygen to make sure they have oxygen. Hypovolemia by checking their blood pressure. Hypoglycemia by checking their blood sugar. And hypothermia by assessing their temperature and keeping them warm. If you can reverse all of those, if you can assess all of those and they're good and the patient is still altered, there's something else, more metabolic or internal. You may see changes in circulation, breath sounds, motor function, and pupillary response. So, encephalopathy. This is passing out. Assume this is a life-threatening problem until otherwise proven. We assume in Massachusetts, if you have a patient that's a cyclical episode and you have no known etiology why, you call it in as a stroke. Because it's potentially a stroke or cardiac event. It's often caused by interruption of blood flow to the brain. It could be dysrhythmias or a heart attack. It could be vascular and volume changes. Maybe it's a drop in blood pressure due to rapid, like somebody who's bent over and they stand up and their body, especially if they're hypovolemic, their body can't compensate for that rapid change in position and they get what they call postural hypertension and they pass out. And then neurological causes. It could be a stroke, it could be a heart attack, it could be an aneurysm. So, thinkable episodes, especially elderly, we don't just say, ah, you just passed out, you'll be fine. Even if the patient is fine now, we still treat it and assess it as such. Neuropathy. Disorder of nerves of the peripheral nervous system. They call it peripheral neuropathy. You can have autonomic neuropathy and many times this is caused by diabetes. Most common cause of it is diabetes. What happens is the sugar destroys the nerve endings. If I have what they call diabetic neuropathy, peripheral neuropathy, my hands and my feet, they'll be numb and tingling and I won't be able to feel anything. I can take a hammer, break every bone in my hand and I won't feel it. I'll only feel the numbness and tingling. That's it. You can have autonomic neuropathy which can affect digestion. It can affect that peristaltic action. It can affect your kidneys and how they function or your liver and how it filters blood. So, the symptoms depend upon the nerves affected and where they are located. This is one of the reasons why diabetics end up with having amputations. Because they walk and stub their toe, right? And they don't notice it and they develop a sore. And sugar, bacteria love sugar. So, they get this sore. Bacteria starts growing in it because of all the extra sugar in their blood system and it starts growing and growing and it causes necrosis. And then they end up having their toe cut off and then, you know, all the toes cut off and then transmitted tarsal and then below the ankle and above the ankle and below the knee and above the knee and they just have it because the tissue doesn't heal. GI changes. Reduction in the amount of saliva which means that we don't have as much saliva. It means that the food we eat is not going to be as well digested which can lead to constipation and that can lead to bowel obstructions and basal-vagal reactions bearing down and passing out on the toilet. Dental loss. Loss of teeth. It happens over time. Teeth get worn, they break down over time. It doesn't matter how... And it all depends on your teeth. I know some people that have lost their teeth in their mid-thirties. And I know people that have reached 100 and still have their teeth. My grandmother died at 101. She still has her teeth. God bless her. Right? So it all depends on how hard your teeth are and how healthy they are and how well you take care of them. Gastric secretions are reduced. Your body doesn't produce as much gastric secretions so not only do you not digest food as well you don't get as much nutrients from them and you're more likely to develop those bowel obstructions. Changes in GI motility. Incidence of certain diseases of the bowel increase. Things like diverticulitis. Remember diverticulosis? Is that what that is? It was just in my head. I wanted to ask you if people have diverticulitis. If they eat more fiber is it more likely to be better for them? No, because fiber doesn't affect diverticulitis. Diverticulitis are those pockets of ulcerations. Fiber will help you kind of pass through faster but you'll still get those pockets of irritation. They get inflamed by a different thing. Fiber will help with digestion. Water will help with digestion. But if you have diverticulosis you're more likely to get diverticulitis from an irritation of those diverticulitis. And then blood flow to the liver decreases over time which means we're less likely to detoxify the blood which means we're more likely to have a toxic dose of a medication. That's why elderly patients generally have a different dose of medication than you would have. Age-related changes in the GI system include issues with dental problems decreased saliva and taste of sensitive taste which may lead me to not eat as well or to over-salt my food. Poor muscle control of the center between the esophagus and stomach can lead to GERD, gastroesophageal reflux disease. That's where the acid from the stomach heats back up in the esophagus and causes irritation and burning. You treat that with a medication called omeprazole or PEPCID. That is a proton pump inhibitor. It stops the proton pumps from reducing and from acting. I saw that they put a device right at the end of the esophagus that blocks that from coming out of the stomach. Yeah. It's a mechanical spacer. It's like a ring. Yeah. It enhances the sphincter action of the esophagus. The cardiac sphincter. Absolutely. To create hydrochloric acid means you're not breaking down the food as much. We talked about that. Alterations in the azole serum nutrients and weakening of the rectum. You can develop weakening of the rectal and urethral sphincter which can lead to bowel and bladder leakage. That in and of itself can be bad. That's why people wear adult undergarments, adult briefs. What happens is over time that moisture and that bacteria can break down the tissues and can lead to things like urinary tract infections or women can develop yeast infections. As a matter of fact, that's one of the most common causes of UTIs in nursing homes is patients with bowel and bladder leakage and they don't have, they wear the adult briefs and they don't get changed regularly. You might be lucky if a nurse can change you twice a day if you can. But you're going to have leakage a lot more than that so that bacteria is going to build up. GI bleeding can be caused by inflammation, infection or obstruction of the upper or lower GI. Usually heralded by hematemesis which is that vomiting of coffee ground blood. But it could also travel down and end up in the lower digestive tract which can lead to melanoma, that dark, fiery stool. Right? That folliculitis stool. Some patients can have just what they call a co-bleeding or minor bleeding. It's not really, it doesn't develop hematemesis or melanoma. It's just a little bit of bleeding. And this is why many patients on blood thinners in nursing homes will get a GLIAC test weekly and they'll swab the rectum with this test strip and it can detect blood in the fecal matter. Red blood usually means a local source of bleeding such as hemorrhoids. We talked about that. A hemorrhoid is really just a varicose vein in the rectum. A patient with GI bleeding may experience weakness, dizziness or syncope. And this would be weakness, dizziness or syncope without an external cause. Like they're not sick. They're eating okay. But there's something, their blood pressure is still low. They're still having these syncopal episodes. And then they'll do a blood test and they'll see they're anemic. And they'll be like, wait a minute. Why are you anemic? And then they'll realize that there's a GI bleed. Specific problems in older patients include diverticulitis. That's the descending colon. Those little pockets develop diverticuli or ulcerations that can become irritating. Diverticulosis is the condition. Diverticulitis is the acute exacerbation. Bleeding in the upper and lower GI system. Peptic ulcers. An ulceration. Anywhere on the digestive tract is just a sore, a burn in the mucosal lining of the intestines. And sometimes it can burn right through. Gallbladder disease which can lead to cholecystitis or inflammation of the gallbladder. And bowel obstructions. And so I've seen bowel obstructions so bad that patients were vomiting up fecal matter. Usually that's kind of like a terminal sign at that point. If you're backing up to the point where you're bringing up fecal matter, that's a hell of a backup. When assessing patients asked about NSAIDs and alcohol use, what is an NSAID? It's a non-steroidal anti-inflammatory. Advil. Acetaminophen. Aspirin. Those are all non-steroidal anti-inflammatories. What's that? Non-steroidal anti-inflammatory drug. But what happens is, if you use NSAIDs like ibuprofen. What do you call that? Marine candy. You give it out like you do in the army. You give it out all the time. The problem was it's not good for your kidneys over the long term and it also causes increased bleeding. Which I never understood. It works great for cramping during menstruation but it increases bleeding. So women who take a lot of Midol, yeah their cramps feel better but they bleed like stuck pigs. They can't figure out why. Well that's why. But now you take an NSAID and add alcohol to it which also causes increased bleeding. So a patient who's taking NSAIDs and alcohol not only can have increased bleeding but they can also have kidney problems and that can cause bleeding in the GI system as well. Orthostatic vital signs can help determine if a patient is hyperbolemic. What are orthostatic vitals? Three sets of vitals, usually standing, sitting and lying down. Well lying down first. Then sit up, wait about three to five minutes, take a blood pressure and a pulse. If the pulse goes up by more than 10 pints and the blood pressure goes down by more than 10 points that's positive for orthostatic hypotension. That's positive hyperbolemia. Usually if I see that, I won't have them stand because they'll probably pass out when they stand. Treatment includes, treatment consists of airway, ventilatory and circulatory support. You want to support, you want to treat for basically shock. Futune abdomen, non-gaso-intestinal complaints. Extremely difficult to assess in pre-hospital. Patient's gonna have a distended, rigid abdomen. Maybe nausea and vomiting, that kind of thing. Well a serious threat to the abdominal complaint is blood loss. Not uncommon to see patients with a triple A. Remember we talked about triple A? That rapid onset of, oh my god, what the hell is this? Use an epigastric plant. It feels like I'm being stabbed with a knife. We have those different, these pulse pressures. The right side my blood pressure is 160 over 90, on the left it's 90 over 40. You're like, what? Strong pulse, weak pulse. Why? Triple A, it's a classic triple A. These are one of the most rapidly fatal conditions because once that thing starts to dissect, especially if it ruptures, you're done. AIDS brings changes in the kidneys. Reduction of renal flow, reduction of renal function, blood flow, and tubule degradation. Remember the loop of Henle, those are called the tubules, the loop of Henle. That's where the urine is actually produced and excreted. When they break down, we don't excrete as much urine, so what happens is we retain fluid. That fluid retention actually can lead to hypertension. Remember the kidneys not only filter blood, but they also control blood pressure by either releasing or retaining fluid. They also control, they're the secondary acid-base bumper system because they excrete or retain bicarbonate. They control acid-base, they control blood pressure, and urinary production. When your kidneys start to function, you can develop acidosis, you can develop hypertension, and you can develop a buildup of metabolic wastes in your blood.