34: Geriatric Assessment and Management

1. Describe the following basics of patient assessment for the geriatric patient:

• Scene size-up

• Initial assessment

• Focused history and physical exam

• Detailed physical exam

• Ongoing assessment

2. Discuss common chief complaints of older patients.

Cognitive Objectives (1 of 3)

Cognitive Objectives (2 of 3)

3. Describe trauma assessment in older patients for the following injuries:

• Injuries to the spine• Head injuries• Injuries to the pelvis• Hip fractures

Cognitive Objectives (3 of 3)

4. Describe acute illnesses in older people, including:

• Cardiovascular emergencies• Dyspnea• Syncope and altered mental status• Acute abdomen• Septicemia and infectious disease

5. Discuss response to older patients in nursing and skilled care facilities.

Psychomotor Objectives

6. Demonstrate the patient assessment skills that should be used to care for an older patient.

• There are no affective objectives for this chapter.• All objectives in this chapter are noncurriculum

objectives.

Geriatric Assessment

• Geriatric assessment has unique challenges.• The GEMS diamond can be a helpful tool.• Preexisting conditions may affect findings.

Scene Size-up (1 of 2)

• Be keenly aware of the environment and why you were called.

• Scene safety should include looking for unsafe conditions.

• Look for hazards.

– Steep stairs, missing handrails, poor lighting, other fall hazards

Scene Size-up (2 of 2)

• The general condition of the home will provide clues.

– Cleanliness, heat, lighting, food

• Look for signs of activities of daily living.

– Personal hygiene, getting dressed, food preparation

• Scene size-up continues throughout call.

Initial Assessment

• Never assume altered mental status is normal.

• May have to rely on family or caregiver to establish patient’s baseline LOC

• Assess the patient’s chief complaint and ABCs.

Focused History and Physical Exam (1 of 2)

• History is usually the key in helping to assess a patient’s problem.

• Patience and good communication skills are essential.

• Treat the patient with respect.

• Face the patient and speak in a normal tone.

Focused History and Physical Exam (2 of 2)

• Medication history– Often have multiple medication– Obtain a list of medications and doses.– Ask about medications recently started or

stopped.– Determine if the patient has taken other

medications.

Medication Use

The average geriatric patient takes four or more medications.

Detailed and Ongoing Exams

• Normal aging may affect physical findings.– Increased BP, respiratory changes

• Chronic changes can mask acute problems. • Ongoing assessments will help determine changes.

– Geriatric patients have decreased ability to compensate.

Common Complaints

• Dyspnea • Chest pain• Altered mental

status• Dizziness or

weakness

• Fever • Trauma• Falls• Generalized pain• Nausea, vomiting, and

diarrhea

Trauma Assessment (1 of 2)

• Common mechanisms of injury– Falls– Motor vehicle trauma– Pedestrian accidents– Burns

Trauma Assessment (2 of 2)

• Priorities in rapid trauma are the same.• Confounding factors:

– Medical conditions or previous injuries – Dentures or other dental implants– Decreased ability to compensate – Changes associated with aging

Injuries to the Spine

• Classified as stable or unstable

• Osteoporosis is a contributing factor to spinal injuries.

• Prompt spinal immobilization can reduce further damage and pain.– Pad void spaces.

Head Injuries

• Assume a significant injury in older patients who have signs and symptoms of head injury.

• Suspect brain injury in patients who take blood thinners and who suffer head injury.

• Maintain oxygen delivery to brain.

Injuries to Pelvis and Hip Fractures

• Often present as hip or buttock pain • Pelvic ring disruption can lead to hemorrhage or

internal organ injury. • Hip fractures:

– Common debilitating injury– Maintain leg in static position to prevent further

injury.

Hip Fracture

Blanket rolls maintain the leg in a static position so that further injury does not occur.

Medical Emergencies

• Determining chief complaint is challenging.– Multiple conditions and complaints – Ask what bothers them most today.

• Sensation of pain may be diminished. • Fear of hospitalization • Conditions may present differently.

Cardiovascular Emergencies

• Classic symptoms are often not present. • Many have “silent” heart attacks. • Common signs and symptoms

– Difficulty breathing– Toothache– Arm pain– Back pain

Dyspnea

• Related to many causes– Asthma– COPD– Congestive heart failure– Pneumonia

• Provide oxygen for all patients experiencing dyspnea.

Syncope

• Can occur for many reasons in geriatric patients– Standing up too fast– Straining to have bowel

movement– Myocardial infarction – Diabetic shock

Altered Mental Status

• Acute onset is not normal in any patient. • Most sudden changes are caused by a reversible

condition. • Evaluate and treat for hypoxia or hypoglycemia if

present.

Acute Abdomen

• Complaints of abdominal pain in older patients usually indicate a serious event.

• Nervous system response to pain is lessened. • Consider gastrointestinal problems or abdominal

aortic aneurysm.

Septicemia

• Results from presence of microorganisms or their toxic products in bloodstream

• Patients may present with: – Hot, flushed appearance– Tachycardia and tachypnea– Hypotension– Chills, cough

Response to Nursing andSkilled Care Facilities

• Important information to know from staff:– What is the patient’s chief complaint today?– What initial problem caused the patient to be

admitted to the facility?• Ask the staff about the patient’s overall condition.• Obtain any type of transfer papers.

Review

1. You arrive at the home of an 89-year-old woman with an altered mental status. Her son and daughter are both present, and tell you that she has diabetes, hypertension, heart problems, and hypothyroidism. Which of the following statements regarding this scenario is NOT correct?

A. Determine the patient’s mental status the day beforeB. An altered mental status is probably normal for her

ageC. An altered mental status indicates some brain

dysfunctionD. You should ask the family how the patient normally

behaves

Review

Answer: B

Rationale: Never assume that an altered mental status is “normal” simply because of a person’s age. Any alteration in mentation indicates some degree of brain dysfunction and should be evaluated by a physician. If family members are present, try to determine if the patient’s current mental status is typical for him or her, or if it has changed. If it has changed, you must try to determine when.

Review1. You arrive at the home of an 89-year-old woman with an altered

mental status. Her son and daughter are both present, and tell you that she has diabetes, hypertension, heart problems, and hypothyroidism. Which of the following statements regarding this scenario is NOT correct?

A. Determine the patient’s mental status the day beforeRationale: This is part of the assessment.B. An altered mental status is probably normal for her ageRationale: Correct answerC. An altered mental status indicates some brain dysfunctionRationale: This is part of the assessment.D. You should ask the family how the patient normally behavesRationale: This is part of the assessment.

Review

2. When immobilizing the spine of a patient with kyphosis, you should:

A. avoid the use of a long backboard.

B. use a vest-style device or short board.

C. use a scoop stretcher instead of a backboard.

D. place padding underneath the head as needed.

Review

Answer: D

Rationale: Kyphosis—a condition characterized by flexion of the neck and an outward curvature of the upper back—gives the patient a “hunchback” appearance, and can make spinal immobilization challenging. The outward curvature of the back makes it more protuberant than the back of the head; therefore, you should place padding underneath the patient’s head to fill this void.

Review2. When immobilizing the spine of a patient with kyphosis, you

should:

A. avoid the use of a long backboard.Rationale: You should use some type of approved device long

enough to extend from the top of the head to the bottom of the feet.

B. use a vest-style device or short board.Rationale: This will not immobilize the lower spinal area.C. use a scoop stretcher instead of a backboard. Rationale: This is used to lift a patient to place the patient on a

long backboard.D. place padding underneath the head as needed. Rationale: Correct answer

Review

3. Because of the presence of arthritis, relatively small hyperextension injuries of the neck can cause the spinal cord to be squeezed, resulting in weak or absent motor function that is more pronounced in the upper extremities. This condition is called:

A. a stable spinal injury.

B. an unstable spinal injury.

C. central cord syndrome.

D. a compression fracture.

Review

Answer: C

Rationale: In patients with arthritis, a relatively small amount of neck hyperextension can squeeze the spinal cord, resulting in a condition called central cord syndrome. Central cord syndrome is characterized by weak or absent motor function that is more pronounced in the upper extremities.

Review3. Because of the presence of arthritis, relatively small hyperextension

injuries of the neck can cause the spinal cord to be squeezed, resulting in weak or absent motor function that is more pronounced in the upper extremities. This condition is called:

A. a stable spinal injury.Rationale: This injury has a low risk for leading to permanent

neurologic deficit.B. an unstable spinal injury.Rationale: This injury has a high risk of permanent neurologic deficit.C. central cord syndrome.Rationale: Correct answerD. a compression fracture. Rationale: This is a stable injury that often results from minimal

trauma.

Review

4. During your assessment of a 74-year-old woman who experienced a syncopal episode, you take her blood pressure while she is lying supine. After sitting her up, you note a 15 mm Hg drop in her systolic blood pressure. This MOST likely indicates:

A. a stroke.

B. dehydration.

C. a heart attack.

D. a normal finding.

Review

Answer: B

Rationale: Dehydration is common in geriatric patients; it is often secondary to, among other factors, a decreased thirst mechanism. Orthostasis is a condition in which the systolic BP drops more than 10 mm Hg when going from a lying position to a sitting or standing position; it is highly suggestive of dehydration.

Review4. During your assessment of a 74-year-old woman who

experienced a syncopal episode, you take her blood pressure while she is lying supine. After sitting her up, you note a 15 mm Hg drop in her systolic blood pressure. This MOST likely indicates:

A. a stroke. Rationale: A stroke is an interruption of blood flow to the brain that

results in a loss of brain function.B. dehydration.Rationale: Correct answerC. a heart attack.Rationale: A heart attack occurs when a blood clot prevents blood

flow to an area of the heart.D. a normal finding. Rationale: This is not normal when associated with syncope.

Review

5. You respond to the home of a 90-year-old man who complains of generalized weakness. When assessing the patient, you should:

A. stand at or above his eye level.

B. turn on the lights and turn off the TV.

C. turn the patient’s hearing aids off if he wears them.

D. significantly elevate your speech when talking to him.

Review

Answer: B

Rationale: When speaking to an older patient, as with any other patient, you should stand at or below his or her eye level; this position is less intimidating. Turning on the lights and turning off the TV and/or radio will help the patient see and hear you better; it will also remove any distractions, which will allow the patient to focus on answering your questions. Hearing impairment is not automatic with aging. If the patient is hearing impaired, speak near his or her ear with normal or slightly elevated speech. Hearing-impaired patients are usually unable to hear high-pitched sounds; thus, significant elevation of your voice only distorts what they hear.

Review5. You respond to the home of a 90-year-old man who

complains of generalized weakness. When assessing the patient, you should:

A. stand at or above his eye level.Rationale: You should stand at or below the patient’s eye level.B. turn on the lights and turn off the TV.Rationale: Correct answerC. turn the patient’s hearing aids off if he wears them.Rationale: Have the patient put in his hearing aid, if he has one,

and turn it on.D. significantly elevate your speech when talking to him.Rationale: The elevation of your voice only distorts what the

patient hears.

Review

6. You are caring for a 76-year-old man with a possible head injury. After assessing the patient and applying spinal precautions, how should you position the backboard on the stretcher?

A. Tilted to the left

B. Tilted to the right

C. Head slightly lower than the body

D. Head slightly higher than the body

Review

Answer: D

Rationale: Slightly elevating the head of the backboard off the stretcher with a towel or blanket can help reduce intracranial pressure following a head injury. It may also make breathing easier by preventing the diaphragm from elevating into the thoracic cavity.

Review6. You are caring for a 76-year-old man with a possible head

injury. After assessing the patient and applying spinal precautions, how should you position the backboard on the stretcher?

A. Tilted to the leftRationale: There is no indication that the patient is vomiting or

has a potential airway problem.B. Tilted to the rightRationale: There is no indication that the patient is vomiting or

has a potential airway problem.C. Head slightly lower than the bodyRationale: This will increase the pressure in the head.D. Head slightly higher than the bodyRationale: Correct answer

Review

7. A 70-year-old woman was involved in a motor-vehicle accident and was removed from her vehicle prior to your arrival. After opening her airway, you note that she is not breathing. When ventilating her, you are unable to achieve adequate chest rise. Which of the following would be the LEAST likely cause of this?

A. Congestive heart failure with pulmonary edemaB. Loose-fitting dentures that are obstructing the airwayC. Brittle ribs, which increases the risk of a pneumothoraxD. Larger lung capacity, which requires higher ventilatory

volume

Review

Answer: D

Rationale: Lung capacity decreases with age; therefore, it typically requires lesser amounts of volume to achieve adequate chest rise when ventilating. In elderly patients, difficulty providing rescue breathing could be caused by loose-fitting dentures, which causes partial or complete obstruction of the airway; pneumothorax due to brittle ribs, which are more prone to fracture and perforate a lung; and congestive heart failure with pulmonary edema.

Review7. A 70-year-old woman was involved in a motor-vehicle accident

and was removed from her vehicle prior to your arrival. After opening her airway, you note that she is not breathing. When ventilating her, you are unable to achieve adequate chest rise. Which of the following would be the LEAST likely cause of this?

A. Congestive heart failure with pulmonary edemaRationale: This could be a cause of the inadequate chest rise.B. Loose-fitting dentures that are obstructing the airwayRationale: This could be a cause of possible airway obstruction and

inadequate chest rise.C. Brittle ribs, which increases the risk of a pneumothoraxRationale: This could be a possibility of the inadequate chest rise.D. Larger lung capacity, which requires higher ventilatory volumeRationale: Correct answer

Review

8. When assessing and treating an elderly patient who experienced a traumatic injury, it is important to remember that:

A. the patient should be treated as a younger adult.

B. an underlying medical condition may have lead to the injury.

C. padding behind the head should be avoided, even in the presence of kyphosis.

D. older patients have a better chance for survival because of the slow speeds they drive.

Review

Answer: B

Rationale: An underlying medical condition (ie, hypoglycemia, heart attack, fainting, stroke) often leads to a traumatic injury, such as a fall or motor-vehicle crash, in elderly patients. When assessing the patient, keep this in mind so you can properly treat both the medical condition and traumatic injury. Older patients have an increased mortality rate following a motor-vehicle crash; their bones are more brittle and prone to fracture and they are less able to effectively compensate for blood loss.

Review8. When assessing and treating an elderly patient who experienced

a traumatic injury, it is important to remember that:

A. the patient should be treated as a younger adult. Rationale: The patient is older and you must be aware of the

changes that occur in the geriatric patient.B. an underlying medical condition may have lead to the injury.Rationale: Correct answerC. padding behind the head should be avoided, even in the

presence of kyphosis. Rationale: Padding may be necessary to immobilize the patient

appropriately.D. older patients have a better chance for survival because of the

slow speeds they drive.Rationale: This question does not indicate if the traumatic injury was

the result of driving.

Review

9. When preparing an 84-year-old woman with a suspected hip fracture for transport, you should:

A. use a scoop stretcher if possible.

B. logroll the patient on the injured side.

C. pick the patient up using the shoulders and the feet.

D. sit the patient up and slide a backboard under her buttocks.

Review

Answer: A

Rationale: The scoop (orthopedic) stretcher allows you to move a patient without the need to logroll him or her. It is especially useful when moving a patient with a suspected hip fracture. Never logroll the patient onto the injured side; this would cause unnecessary pain and could potentially worsen the injury.

Review

9. When preparing an 84-year-old woman with a suspected hip fracture for transport, you should:

A. use a scoop stretcher if possible.

Rationale: Correct answer

B. logroll the patient on the injured side.

Rationale: Never logroll a patient onto his or her injured side.

C. pick the patient up using the shoulders and the feet.

Rationale: You should try to keep the patient’s legs as straight and still as possible to prevent additional injury.

D. sit the patient up and slide a backboard under her buttocks.

Rationale: The patient should remain in the supine position to prevent additional pain and injury.

Review

10. When assessing an elderly patient with possible cardiac compromise, it is important to recall that:

A. elderly patients are more likely to present with asystole as the initial cardiac rhythm.

B. chest pain or pressure is present in greater than 95% of elderly patients with cardiac compromise.

C. elderly patients often present with atypical signs and symptoms of cardiac compromise.

D. lethal cardiac dysrhythmias, such as ventricular fibrillation, are more common in elderly patients.

Review

Answer: C

Rationale: Because of decreased pain sensitivity and other factors associated with aging, elderly patient often present with atypical signs and symptoms of cardiac compromise. For example, the patient may only present with nonspecific symptoms such as nausea or weakness. Chest pain or pressure—although present in approximately 80% of patients with cardiac compromise—is less commonly observed in elderly patients. Elderly patients are neither less no more prone to lethal cardiac dysrhythmias as younger adults.

Review (1 of 2)

10. When assessing an elderly patient with possible cardiac compromise, it is important to recall that:

A. elderly patients are more likely to present with asystole as the initial cardiac rhythm.

Rationale: There are no significant differences in the types of lethal dysrhythmias.

B. chest pain or pressure is present in greater than 95% of elderly patients with cardiac compromise.

Rationale: Elderly patients often present with atypical signs and symptoms — this includes a lack of chest pain or pressure.

Review (2 of 2)

10. When assessing an elderly patient with possible cardiac compromise, it is important to recall that:

C. elderly patients often present with atypical signs and symptoms of cardiac compromise.

Rationale: Correct answer

D. lethal cardiac dysrhythmias, such as ventricular fibrillation, are more common in elderly patients.

Rationale: There are no significant differences in the types of lethal dysrhythmias.