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Geriatrics is a specific field in medicine that focuses on the assessment and treatment of patients aged 55 and older. The geriatric population presents unique challenges to healthcare providers, as the number of older adults is increasing and they often have chronic conditions and take multiple medications. It is important to treat elderly patients with respect and avoid ageism. Effective communication skills are essential when interacting with older adults. The geriatric population is predisposed to certain health problems such as hip fractures, pneumonia, and chronic conditions like hypertension, arthritis, and heart disease. The leading causes of death among older adults are heart disease, cancer, and stroke. The aging process brings about physiological changes that can affect the body's response to illness and injury. Age-related changes can also make older adults more susceptible to respiratory illnesses. Geriatrics is the assessment and treatment of patients 55 years or older, and it's its own specific discipline in medicine because there are conditions and illnesses that are specific or happen mostly in the geriatric population. So you have pediatrics, you have cardiology, you have, they're specialized. So again, geriatrics. Geriatric patients present special challenges to healthcare providers. As by the year, I think, 2030, some 30, 35 to 40 percent of the population will be over the age of 55. So that's going to mean an increase in patients for us. We have increased the quantity of life, but not necessarily the quality. People are living longer, but especially in the United States, they're not necessarily healthier. We give them drugs to extend their life, but it does not necessarily make them healthier. Injuries and illnesses are affected by chronic conditions, multiple medications, and just the physiology of aging. Remember, from about age 30 on, every year, your body decreases about 1 percent, all of the body systems in general. That's why they say the maximum life expectancy for a healer is about 130. All right? So by the time I'm 65 years old, I'm running at 65 percent of what I was at 30, approximately. Now some people are healthier, and some are not. It's important to understand and appreciate how the life of an older person might differ from yours. Obviously, it's a big difference. And that's going to come into play a lot with how you present yourself and how you speak and how the patient perceives your treatment of them. It takes time and patience to interact with an older person. Always treat with respect. I treat everybody the same way, ma'am or sir, whether you're 18 or 18, right? And always treat them with respect. I have seen elderly patients withhold life-saving information from paramedics because the paramedics spit them off. You don't want to be in that position. You want to build a good rapport with the patient. Make every attempt to avoid ageism. What is ageism? Hey, pops, how you doing? Right? Oh, he must be deaf because he's old. Or he must be senile because he's old. Or he must be immobile. I know people in their 80s that run marathons. I know people in their 80s that are still practicing medicine. They're still fighting trials in court. So, don't assume because somebody is old that they are, you know, hard of hearing, have dementia. We always go up to every patient, whether they're 18 or 80 or anywhere above or below. We always approach them as if they're anal times four, they have perfect mentation. Now, if I come up to you and you say, Juan, it's acute, it's acute, it's a medical emergency. And then I start doing my assessment. Now, somebody walks up to me and says, oh, that's, you know, Obama Cass and she's got dementia. All right, fine. That's, I accept that. But until I find out for sure, I treat it like it's a treatable medical emergency. All right? So, just remember that. Don't assume because you know what happens when you assume? They can ask that of you and me. Effective communication skills are essential with everybody. We talk about this as being specific to geriatrics. This is everybody. Treat everybody the same. Again, I know people that work in EMS and they talk to the teenagers one way and the elderly another way. And they try and, you know, fit in. I'm not that good of an actor. I could never do it. So, guess what? Everybody gets treated the same. And then I will adapt to how my patient responds. So, communication techniques. Speak respectfully. Identify yourself. Always let them know, hello, ma'am, my name is Greg. I'm an EMT. What is your name? Right? Get the information. Identify and present yourself. Right? Remember we talked about this at the beginning of the course. What's going on? All I said was what's going on. But what did I convey with my presentation? I'm annoyed. You're bothering me. I could be doing better things. That's not the best foot you want to put forward when you're dealing with a sick patient. Look directly at the patient at eye level. Don't tower over them. Get down and look at their level. And speak slowly and distinctly. And remember, this might be just another call for you. I've been on 10 chest pain calls today. This is number 11. It's 2 o'clock in the morning. I can do this in my sleep. For the patient, they could feel like this is the end. I'm dying. My whole life is over. It's not about you. It's about your patient. That's where we come up with the term empathy. Have one person talk to the patient and only ask one question at a time. I was bad at this because as an educator, I always felt that I was in education mode. So when I'd be working with partners, especially newer people, I'd be like, they'd be talking to the patient, asking questions. And I'm like, this is a question I want to ask. And so I would ask it. That's not correct. What I should do is talk to my partner. Hey, maybe you want to ask this question. Let my partner do it. Or take over the question. But two people, you should not be tag teaming a patient with questions. Never assume this patient is hard of hearing. Give the patient time to respond. And I find as I get older, I think a little more before I give an answer. So that may not be that the patient's having a problem. They might just be thinking of an answer. But if it's going on for a minute or two, maybe you want to rephrase the question. And explain what you're going to do before you do it. Always keep the patient oriented. Let them know what you're doing, where you're going, why you're doing it. The geriatric population is predisposed to a host of problems not seen in the youth. Hip fractures are common, especially in the older elderly population. Hip fracture, pneumonia, death. Hip fracture, seizure, pneumonia, death. It's not an uncommon thing. Because patients become secondary. More likely to occur when bones are weakened by osteoporosis or infection. Especially post-menopausal women. Osteoporosis is a very common condition. It's treatable, but many patients don't treat it. Especially if you smoke, or you have a history of smoking, or if you drink or had a history of drinking. Secondary behavior can lead, again, to pneumonia and blood clots. Common conditions that lead and cause a death. These common conditions, most of these, I could take 100 patients and I could write this. Take 100 patients over 80 and write these as their history. And I'd be right about 90% of the time. Things like hypertension. Remember arterial and atherosclerosis causing a hardening and a constriction of the arteries. And it increases blood pressure. It's very common in the elderly. As a matter of fact, it's unusual not to have hypertension. Arthritis. The most common form of arthritis in the elderly is what we call osteoarthritis. It's the wearing. Wear and tear of the joints. Rheumatoid arthritis is more common in younger people. That's an autoimmune disorder where the body starts damaging and destroying the joint capsule. Because it sees it as an invading organism. Heart disease. Cardiovascular disease. Cancer. Diabetes mellitus. Type 2 diabetes is the most common. We talked about that. Asthma. COPD. And stroke. COPD, hypertension, arthritis. Those are probably the most common you're going to see. And then leading causes of death. The big three. Heart disease, cancer, and stroke. I know they have injury in there. And they have chronic low respiratory disease. Because of the advancement in treating, especially large vessel occlusions and things, more people are surviving from strokes. That's why they've kind of moved it down on the list. But heart disease, cancer, and stroke are kind of up in the top three. They've also got injury. You know, you fall down the stairs. You get up. You feel like an idiot. Hope nobody's looking. And you move on with your day. Elderly patients fall down the stairs and they don't get up. Diabetes mellitus, accidents, and then influenza and pneumonia. And I told you what happens. You get the flu. Or you get some form of a virus. And your body sends out an immune response. It's just a massive army. It just invades all those invading organisms. It counterattacks. And it doesn't distinguish between bad and good cells. It just destroys cells. And what happens is it destroys that protective lining that protects your inner tissues from infection. So you break that down and then you're susceptible to bacterial infections. That's why bacterial pneumonia is very common in patients with influenza. And that's what kills... I need to turn my volume down. What was that? Sounds like an elephant. And that's what kills elderly patients and children. The aging process is accompanied by changes in physiological function. All tissues of the body undergo age. Like I said, about 1% over all body systems every year after 30. A decrease in functional capacity of various organ systems is normal. But can affect the way the body responds to illness. The issue is patients are usually very good until they get injured or sick. Remember how I told you that children have a great compensatory mechanism, right? We compensate well. The elderly just walk up to a cliff and go... And they drop right off. They don't have the physiological reserves for the compensatory mechanism to respond to illness, especially severe illness and injury. Age-related changes can predispose an older adult to respiratory illnesses. The airway musculature becomes weakened. It never goes like... You file things, right? And then you go back five years later and you open up the elastic because you want to unfold something and the elastic just snaps, right? And that's what happens to your lungs. Your lungs are elastic tissue and they get used constantly. Over time, they wear down. The elasticity wears down. And so what happens is the lungs don't contract back down. They stay kind of inflated. And what happens is we become chronic air retainers as we get older. Well, the air that we retain, is it oxygen? It's carbon dioxide. It's waste product. So we become chronic CO2 retainers. The alveoli and the lung tissue become enlarged. Again, we talked about that. The body's chemoreceptors slow with age. So the body's chemoreceptors that read the amount of carbon dioxide slow. So therefore, my response to hypercapnia or increased carbon dioxide levels is reduced, which means I tend to retain carbon dioxide. Now, my body can do pretty well with that, even at advanced age, as long as I don't have any kind of lung issues. But if I have interstitial lung disease, COPD, what happens is those patients end up becoming chronic CO2 retainers to the point where their primary respiratory drive shuts off. And so now they live off their hypoxic drive. And those are the ones you put oxygen on and they stop breathing. And decreased cough and gag reflex. You ever see the 90-year-old trying to cough? What are you clearing up? What are you bringing up? Nothing. You're not clearing anything. You're not bringing up mucus. So the mucus stays in the lungs. Primary reason for pneumonia. Pneumonia is inflammation and infection of the lungs from bacterial, viral, and fungal causes. The most dangerous is the bacterial pneumonia. One of the number one causes of death in nursing homes and skilled nursing facilities is aspiration pneumonia. I vomit up something and I inhale it into my lungs to aspirate. That is a bacterial form of pneumonia because it's the bacteria from the stomach and the digestive tract. Leading cause of death. One of the leading causes of death in infections from Americans older than 65 years of age. Aging causes sub-immune suppression and increased risk of contracting infections like pneumonia, especially from other viral infections. You can get pneumonia from the flu. You can get pneumonia from norovirus. You can get pneumonia from any one of a dozen viruses that we deal with. Pneumonia, increased mucus production, pulmonary secretions, and infection all interfere with the ability of the body, the ability of the alveoli to process to get oxygen and remove the waste product, carbon dioxide. You end up with a consolidation. Right here. That's where the bacteria starts to grow and build a condominium complex. It spreads out. You're not able to exchange those gases in that area. Management of pneumonia is the same. Pneumonia is pneumonia is pneumonia. Whatever age you are, you treat it the same way. It's just that sometimes you have to treat it more aggressively, specifically in the alveoli. A lot of elderly patients, they have suppressed renal systems. I can't go give them high doses of fluid. It'll end up in their lungs because they don't urinate properly. They don't diurese properly. Pulmonary embolism, sudden blockage of an artery by a venous clot. The most common cause is a... DVT. DVT. Jesus, thank you. A deep vein thrombosis. Thank you very much. And that breaks free, travels up, and if it's large enough and enlarges in the pulmonary artery, it can cause instantaneous cardiac arrest. Many elderly patients do succumb to these more commonly because elderly patients are more commonly less active. The more sedentary you are, the more likely to develop what they call venous stasis, where the blood kind of pools in the capillary beds, and that's where clots develop. That's why you keep moving. When I walk, my valve, my muscles contract as I walk. It squeezes my veins. Helps with blood flow. And I have these valves that are open that make blood flow in one direction. The valves move more, and the muscles constrict the veins, and that's like a compression, right? And it helps with circulation. If I sit around all day, or if I'm bedridden, or if I'm in a wheelchair, or if I don't get that exercise, I'm more likely to develop these clots. This is one of the reasons why, after orthopedic surgery, they get you right up. Like, they had a hammer and chisel to your knee three hours ago, and you just woke up from anesthesia, and they're going to get you up walking. And that's the reason why. They want to get that natural circulation. Patients will present with shortness of breath and sometimes chest pain. It hurts right here. I can't breathe. It hurts right here. Shortness of breath, coughing up blood. But it'll be almost instantaneous. Like, it'll be 10 out of 10 chest pain, or all of a sudden rapid onset shortness of breath. There's very few things that cause rapid onset of shortness of breath in the human body. The reason why they say sometimes chest pain is because as we get older, all of our body functions slow down. One of them is our nerves. So the nerves that dictate pain, especially visceral or internal pain, they're no longer firing the same way. So you don't feel that pain. That's why elderly patients can end up with what we call the silent MI. They don't have chest pain. They have shortness of breath, cool, pale, clammy skin, nausea, vomiting, you know, a feeling of that impending doom. But they have no chest pain. And you're thinking, ah, maybe it's just got a, you know, a little flu. It lets you go to bed and sleep it off. And then they don't wake up. Because they have what they call a silent MI. Can be confused with cardiac, lung, or musculoskeletal problems. This is why, especially in the elderly, you have to pay attention to subjective changes. Subjective symptoms, very mild subjective symptoms. Maybe massive. I could be having a massive MI and I'm on the ground. And I have an 85-year-old diabetic woman who's having a massive MI and she goes, I'm just having a little trouble breathing. But she has silent MI. Her nerves are not firing like mine are. Pulmonary embolism risk factors. Living in a nursing home. Why? More likely to be what? Sick and less likely to be active. The best nursing homes are the ones that get the patient up and moving daily. Recent surgery. Because, again, with recent surgery you can develop embolisms like fat embolisms or clot embolisms from the surgery itself. But being immobile. A history of blood clots or heart failure in the past. Presence of a pacemaker or central venous catheter. Because you can get those release of clots from the heart itself. Obesity or sedentary behavior. Goes without saying. Recent long-distance travelers. One of the reasons why they say if you fly, especially as you get older, you should get up every hour, you shouldn't smoke, you shouldn't drink alcohol, and you should drink plenty of fluids. And trauma, cancer, or paralyzed extremities. Because, again, you are less likely to move and because with cancers you can end up with what they call coagulopathy or coagulation disorders. Tachycardia. Tachycardia, it's going to be almost instantaneous. Almost instantaneous. I'm going to feel something's wrong. Heart rate's going to go up. Respiratory rate's going to go up. I'm having shortness of breath. You may or may not have chest pain. If you have pain, it'll be in the shoulder, the chest, or the mid-back. You'll have a cough. Maybe syncope. The patient might pass out. Anxiety. Could even be cardiac arrest. Immediately. Apprehension. The patient's going to say, I feel like I'm really sick. A low-grade fever. That's a pyretic reaction and that's very common. Tomoxicis, coughing up blood. Leg pain, redness, and unilateral pedal edema. That's because the leg is where the DVT came from. Right? Where the clot came from. It became an embolism from a thrombus. So, you're going to see the sign of the blockage in the leg. You're going to have a cord-like femoral vein. You're going to have pedal edema. Poor circulation. The leg may be hot and flushed and swollen. You're going to have fatigue and possibly cardiac arrest. The heart hypertrophies with age. All organs of the body atrophy. They get swollen. The brain, the kidneys, the liver. The only organ that enlarges is the heart. And that's because the heart's a muscle. So, as we work it, it gets bigger. Over time, 80 years of beating, especially if you get hypertension, it's going to get larger. But that doesn't mean it gets stronger. It just gets larger. So, the heart will hypertrophy with age, but cardiac output will decline. That's that afterload, right? The blood that goes out and the blood left in the circulatory system. Arterial and atherosclerosis contribute to systolic hypertension. Systolic is the pumping hypertension, right? So, if you have blocked blood vessels due to atherosclerosis, or you have a hardening of the arteries due to arteriosclerosis, you're more likely to have that systolic hypertension. Although arteriosclerosis can lead to diastolic hypertension because the hardening of the arteries, they don't dilate like they're supposed to. Geriatric patients are at risk for atherosclerosis. Again, that fats and plaques that build up in the blood vessels. Major complications include heart attacks and strokes. And we've seen this. We saw this in cardiology. This is the outer layer. We call it the tunica adventitia. The middle layer, which is the muscular lumen, that's the tunica media. And then the inner lining, that is the lumen, is called the tunica intima. And then, as you can see, clots can develop and they kind of build up over time. And they can just acutely build up and you end up with a heart attack. Or, if this was in the brain, it would be a stroke. Older people are at increased risk for the formation of aneurysms. That's an abnormal, fluid, blood-filled dilation of the blood vessel wall. You get a bubble. Remember that tunica adventitia is puff and fibrous and it holds that in. But the two lower layers, the tunica media and the tunica intima, they just pop open and the blood travels out and makes a bubble. Severe blood loss can occur. It can also rupture, which can be rapidly fatal. Blood vessels and heart valves become stiff and degenerate. A lot of patients end up having to have valvular replacements. They can actually do that now by PTCA, percutaneous transluminal coronary angioplasty. They can put stents. But they can also, with the wire they do the stents with, they can clear out the clot, put in a stent, and then wire in a new valve and put a new valve and take the old one out. All through that wire. It's amazing. You never get a chance to watch it. Heart rate becomes too fast, too slow, or erratic and they may end up having things like pacemakers and defibrillators put in. Another blood vessel related problem is venous stasis. This causes DVTs, which will lead to pulmonary embolisms or heart attacks or strokes. Loss of proper function of the veins and the legs to carry blood back to the heart. Most common cause is inter-sedentary activity or lack of activity. DVTs can lead to pulmonary embolisms. The embolisms people will exhibit that edema of the legs and feet. We go plus one to plus four pitted edema. When I get to plus four pitted edema, I go to the, you've seen the tankles, right? Those ankles that just go to the calf that just go right to the ankle. You push on it and it leaves a dent and it stays there. That's plus four pitted edema. That's fluid. I have taken elderly patients with plus four pitted edema. I go to give them an IV and I put the needle in. You know what comes out? Water. Because that's all they have in their tissues is water. Once I hit the vein, it'll bleed. But when I stick the needle in, water comes pouring out of their skin. That's how much water they have in them. The classic symptoms of a heart attack are not often present in the geriatric patient. Especially women who handle internal or visceral pain better and diabetics. So you have the elderly diabetic female, she might not even know she's having a heart attack. She could be, you know, just shortness of breath. I just don't feel right. She's having a massive MI. That's why, again, those subjective subtle changes. So many having shortness of breath and a little nausea, vomiting. All right, we're gonna call ALS. We're gonna put you on the monitor just to be safe. And you put them on the monitor and showing up. Oh, they're having a massive widow-maker stent. So manifestations of acute cardiac disease. We call this that coronary, well, it's caused by coronary artery disease. We call it acute coronary syndrome, ACS. So you can develop things like dyspnea, which is shortness of breath. Epigastric or abdominal pain. In the elderly especially. Abdominal or epigastric pain. Nausea, vomiting. We automatically consider that cardiac and rule it out with a EKG. Loss of bowel or bladder control. Nausea, vomiting. Weakness, dizziness, lightheadedness, and syncope. Fatigue or confusion. Other signs and symptoms include issues with circulation. They're gonna have that peripheral edema, right? That plus four edema. They're gonna have ascites or fluid in the abdomen. They're gonna have sacral abdomen. Maybe they'll have pulmonary edema. They'll have that CHF. You can hear that fluid in their lungs as they breathe. Diaphoresis, which is a cold, wet sweat. That means blood is shunted to the core. Pale cyanotic or marbled skin. Abnormal or decreased breath sounds. And increased peripheral edema. The signs and symptoms will differ depending upon whether it's a right-sided or left-sided heart, which is not functioning properly. So we know the right side of the heart receives blood from the body and it goes to the lungs. We call this the pulmonary circulation. If the right side of the heart also calls poor core pulmonale or right heart hypertrophy. If the right heart fails, where are we gonna see fluid backing up? In the lungs or in the? In the body. Right, I'm gonna see, again, the peripheral edema, the excities, right? We're gonna see it's all building up there. If the left side of the heart fails, the left side is the systemic circulation that takes blood from the body, takes blood from the lungs and brings it to the body. If the left side fails, what are we gonna see? Pulmonary edema. We're gonna see a CHF, congestive heart failure. Whenever a pump fails, always think of where it comes from before the pump. That's where the problem happens. So if the right side of the heart takes blood from the body and it fails, it's gonna back up in the body. If the left side of the heart pumps blood from the lungs and it fails, it's gonna back up in the lungs. Left-sided heart failure causes CHF. Right-sided heart failure causes peripheral edema. And of course, right side leads to left side, left side leads to right side eventually. Right-sided heart failure occurs when fluid backs up in the body. You're gonna see JVD, jugular venous distension, ascites, which is free fluid in the abdomen, peripheral edema, added in a large liver. You're also gonna see a low blood pressure because if the right side's failing, blood backs up in the body. It doesn't travel through to... Remember the heart's an elastic. The more it stretches, the more it snaps back. The less blood that goes in, the lower the blood pressure because the less it speeds back. So right-sided heart failure causes a low blood pressure. These are patients we do not give nitro to. Their blood pressures will be low.