Curriculum Update: Culturally Diverse Patients Geriatric Population Medications for Home Use

1
Curriculum UpdateCulturally Diverse
PatientsGeriatric PopulationMedications for
Home Use

• Condell Medical Center EMS System
• March 2006
• Site Code 10-7200-E-1206
• Revised by Sharon Hopkins, RN, BSN
• EMS Educator

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Objectives

• Upon successful completion of this module, the
  EMS provider should be able to
• understand the sensitivity required when caring
  for a culturally diverse patient population.
• discuss the unique assessment and care necessary
  for the geriatric population
• discuss common medications taken by the
  population and potential impacts with clinical
  presentations

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Culturally Diverse Patients

• Differences of any kind race, class, religion,
  gender, sexual preference, personal habitat,
  physical ability
• Good healthcare depends on sensitivity toward
  these differences
• Every patient is unique
• Westernized medicine is not
  accepted by all

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Culturally Diverse Patients

• Key points
• Individual is the foreground, culture is the
  background
• All people share common problems/situations
• Not all people identify with their ethnic
  cultural background
• Every patient needs to be treated equally
• Do not force someone
  to have an intervention
  that is against their
  personal beliefs

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Culturally Diverse Patients

• Patients have the right to self-determination
• If the patient is of legal age (18 or older, not
  emancipated), the patient has the right to refuse
  any care or treatment offered
• Document what has been refused and why
• The patient, or person authorized to consent,
  must sign for themselves
• spouses, grandparents, older siblings, police
  officers cannot sign a refusal
• if telephone permission is taken, witness by 2
  persons, and EMS signs and adds the name of the
  person supplying permission

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Culturally Diverse Patients

• Respect the integrity of cultural beliefs
• Patients may not share your explanation of causes
  of ill health and not accept conventional
  treatments
• Recognize your personal cultural assumptions,
  prejudices and belief systems.
  
• Avoid letting your prejudices
  interfere with patient
  care

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Culturally Diverse Patients

• Language barriers
• your assessment and accuracy of interpretation
  will be hindered when a language barrier is
  present
• if an interpreter is used, document their name
  and relationship
• in some cultures, use of children is insulting to
  adults and seen as too much responsibility placed
  on the child
• language lines are available - know your own
  departments resources

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Culturally Diverse Patients

• Locale of practice
• get to know the predominate cultures of your area
• the more you understand the culture, the more
  effective a practitioner you can be
• know resources available in your community

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Culturally Diverse Patients And Body Language

• Very important especially when a language barrier
  exists
• Usually at a subconscious level
• Components of body language
• eye contact
• facial expressions
• proximity
• posture
• gestures

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Body Language - Eye Contact

• Can play a key role in establishing rapport
• Failure to make eye contact can be a sign of
  dishonesty
• Making eye contact can be a sign of disrespect in
  some cultures (Chinese)
• Asians may be reluctant to make eye contact with
  a figure of authority

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Body Language - Facial Expressions

• One of the most obvious forms of body language
• Can convey mood, attitude, understanding,
  confusion, other emotions
• Smiles are usually universally understood
• Smiling and winking can have different
  connotations

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Smiling and Winking

• Japanese - may smile when confused or angry
• Others Asians - smile in friendly greeting
• Latin Americans - winking is romantic, sexual
• Nigerians - parents wink at children to have them
  leave the room
• Chinese - winking is rude
• Hong Kong - blinking is sign of disrespect and
  boredom
• Filipinos - point to objects with eyes, not
  fingers
• Venezuelans - finger pointing is impolite

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Body Language - Proximity

• Acceptability varies widely culture to culture
• In the United States, twice the arm length is a
  comfortable social distance - 4-12 feet
• Personal space is 1.5 - 4 feet
• Different messages are interpreted when standing
  above, at, or below eye level
• above eye level shows authority, can be
  intimidating
• at eye level indicates equality
• below eye level shows willingness to let patient
  have some control over the situation

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Body Language - Posture

• Range of attitudes conveyed from interest,
  respect, subordination, disrespect
• Argentina - standing hands on hips suggests anger
  or a challenge
• Taiwan - good posture extremely important
• Some cultures impolite to show the bottom of the
  shoe because it is dirty will not sit with a
  foot resting on opposite knee

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Body Language - Gestures

• Can replace or accompany verbal communication
• Japan - rude to pass an item with one hand
• Middle Far Eastern cultures - left hand
  considered unclean - rude to pass items with left
  hand
• In Europe, waving goodbye is raising the hand
  palm facing out, wiggling fingers back and forth
• In Nigeria, this is an insult if the hand is too
  close to anothers face

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Gestures

• In Bulgaria Greece, head nodding means no
• In the USA, beckoning with 1 finger means come
  here. In some cultures it is insulting or
  obscene.
• Indonesia - pointing is done with a thumb
• Middle East - pointing with 1 finger is impolite
• OK sign
• obscene in Germany and Bulgaria
• in Japan means zero or worthless

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Cultural Diversity - Physical Contact

• Eastern Europeans are comfortable with touching
• Asians prefer less physical contact
• Chinese are uncomfortable with physical contact
  but will use a handshake for greeting
• Latin Americans show affection easily and
  handshakes are strong warm
• Egypt - tend to be touch oriented

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Cultural Diversity - Gestures

• Middle East - left hand reserved for hygiene.
  Dont shake hands left-handed or accept a gift
  with left hand
• Native Americans - offensive to step on a foot -
  apologize immediately

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Culturally Diverse Patients - African Americans

• Handshaking is appropriate
• Eye contact is appropriate
• Culture vocally expressive
• Close friends tend to be viewed as family
• Tends to be matriarchal society
• Skeptical of westernized medicine

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Culturally Diverse Patients - Arab Americans

• Prefer handshaking
• Direct eye contact acceptable
• Verbally expressive
• Family shares in decision making process
• Folk remedies are common
• soup, prayer
• Fond of westernized medicine

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Culturally Diverse Patients - Chinese Americans

• Direct eye contact and speaking out may be viewed
  as being disrespectful
• Nodding is a sign of respect and not
  understanding
• Oldest males in the group make decisions
• Folk remedies are common
• May interact with westernized medicine

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Culturally Diverse Patients - Mexican Americans

• Handshaking is appropriate
• May avoid eye contact out of respect
• Tends to not complain of pain
• Silence is maintained out of respect or due to
  not understanding
• Males usually head of the household
• Folk remedies are common

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Culturally Diverse Patients - Financially
Challenged

• May refuse health care due to its costs
• We need to be an advocate for these people and
  make sure they are offered initial medical
  screening
• Know your community and county resources to offer
  to this group of people
• As a reminder, use your own resources wisely

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Culturally Diverse Patients - Financially
Challenged

• Signs of impairment
• homelessness
• chronic illness with frequent hospitalizations
• poor personal hygiene
• self-employment

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Resources for Referral

• PADS - public access to provide shelter
• provide meals and shelter October 1 - April 30
• open 7 pm - 7 am
• goals -
• connect person with resources to be able to leave
  the street
• commit to own effort for health and recovery
• to gain personal and economic self-sufficiency
  with safe, affordable permanent housing
• HealthReach Clinic - medical screening
• 847-360-8800 (Waukegan)

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Resources for Referral

• Catholic Charities
• to help families individuals overcome tragedy,
  poverty, other life challenges
• Lake County
• adult agency 847-377-4504
• juvenile agency 847-377-7800
• Salvation Army 847-336-1800
• Connection Crisis Referral Hotline [phone]
• Department Chaplain
• Hospital Social Worker

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Culturally Diverse Patients

• During Assessment and Management
• Recognize need for assistive devices
• Respect the patients beliefs
• Ask permission to initiate procedures
• Obtain interpreter if unable to communicate
  because of language barrier
• Allow ample time and area of
  privacy
• Notify receiving hospital of
  special needs

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Groups By Region

• Asian
• Afghanistan, Armenia, Azerbaijan, Bahrain,
  Bangladesh, Bhutan, Brunei, Burma, Cambodia,
  China, Georgia, Hong Kong, India, Indonesia,
  Iran, Iraq, Israel, Japan, Jordan, Kazaksta,
  North Korea, South Korea, Kuwait, Kyrgyzstan,
  Laos, Lebanon, Malaysia, Maldives, Mongolia,
  Myanmar, Nepal, Oman, Pakistan, Phillipines,
  Qatar, Russia, Saudi Arabia, Singapore, Sri
  Lanka, Syria, Taiwan, Tajkistan, Thailand,
  Turkey, Turkmenistan, United Arab Eminates,
  Uzbekistan, Vietnam, Yemen

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Groups By Region

• Far East - the orient - East Asia and Southeast
  Asia
• Brunei, Cambodia, Peoples Republic of China,
  Republic of China, East Timor, Hong Kong,
  Indonesia, Japan, Korea Laos, Macau, Malaysia,
  Myanman, Phillipines, Thailand Vietnam
• Asian American -
• term used to describe East Asian peoples older
  term was oriental
• term refers to person of that ethnic decent
  born in or immigrated to the United States

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Groups By Region

• Eastern European
• Albania, Belarus, Bosnia Herzegovina, Bulgaria,
  Croatia, Czech Republic, Estonia, Hungary,
  Lataiva, Lithuania, Macedonia, Moldova, Poland,
  Romanis, Russia, Serbia Montenegro, Slovakia,
  Slovenia, Ukraine

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Groups By Region

• Middle East - South Central Asia, Southwest
  Asia, Egypt
• Bahrain, Cyprus, Egypt, Iran, Iraq, Israel,
  Jordan, Kurdistan Region, Kuwait, Lebanon, Oman,
  Palestinian Territories, Qatar, Saudi Arabia,
  Syria, Turkey, United Arab Emirates, Yemen
• Native American
• a person having origin in any of the original
  peoples of North American and who maintain
  cultural identity through tribal affiliation or
  community recognition

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Groups By Region

• Many groups overlap regions
• Older population usually refer to themselves by
  their ethnic region (ie Chinese, Mexican)
• Younger population usually refer to themselves by
  racial terms (ie Asian, Latino)
• Cannot always judge the ethnicity based on
  appearances - ask the patient if you need
  clarification

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Geriatrics
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Challenges in the Geriatric Population

• Fear of losing autonomy/independence
• mobility - walking and by car
• want to continue to live on own
• Patient fears financial burden of hospitalization
• Patient is embarrassed by burden they become to
  family and friends
• Multiple disease processes affecting health
• Difficulty in communicating pain and fears

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Challenges in Dealing With the Geriatric
Population

• Patient fatigues easily
• Many layers of clothing hamper detailed
  examination
• Need for modesty and privacy
• May minimize their symptoms
• fear that they may be hospitalized, illness will
  cost money they dont have, illness may cause
  nursing home or alternate living arrangements
  with lose of independence

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Challenges in the Geriatric Population

• Often suffer from concurrent illnesses
• Chronic problems make assessment of acute
  problems difficult
• Aging affects response to illness/injury
• Social/emotional factors have great impact on
  health
• Depression isolation - highest suicide rates in
  people over 65

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Sensory Related Changes

• Vision
• cataracts cause blurring of vision unable to
  distinguish between blue purple
• if cataracts opaque (cloudy), may not see
  pupillary response with a penlight
• be in front of person make touch contact with
  the patient before beginning to speak
• Hearing
• decreased hearing
• diminished sense of balance
• speak slowly and distinctly check for hearing
  aids write notes if necessary

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• Taste smell
• altered (decreased sensitivity)
• creates decreased appetite which causes poor
  nutritional condition
• Touch
• neuropathies cause decrease sensitivity to
  tactile senses
• increased risk of injury without patients
  awareness (ieburns from heating pads sores on
  feet becoming infected)
• Pain
• lowered sensitivity - smaller amounts of
  pain medication are necessary

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Communicating with the Geriatric Population

• Make eye contact before speaking
• Always identify yourself
• Position yourself at the patients eye level
• Locate hearing aid, eyeglasses, dentures
• Turn on lights, turn off TV to minimize
  distractions
• Use surname (Mr., Mrs., Ms.) until permission
  given to address patient otherwise
• Be patient and gentle - give time for the patient
  to respond to your questions

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Evaluating the Environment

• Condition, cleanliness safety of
  housing arrangement
• Nutritional status evidence of food quality
  quantity in the home
• Personal hygiene evidence of ability to
  maintain self independently
• Multiple prescription bottles with multiple
  prescribers noted
• drugs may be negatively interacting if
  the patient has not informed all physicians of
  all medications they are taking

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Obtaining A History in the Geriatric Population

• Resources for medical information
• Vial of life - form of vital medical personal
  information placed in a container that is kept in
  refrigerator
• red heart-shaped magnet placed on outside of
  refrigerator
• medic alert tags
• custom engraved bracelet or necklace with
  important information on medical conditions, drug
  food allergies, prescribed medications,
  emergency contacts

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Physiological Changes Affecting Mobility

• Diminished vision
• Loss of exercise tolerance
• Diminished breathing capacity - become short of
  breath quicker and lose energy to complete tasks
• Slowed psychomotor skills - losing independence
• Decreased reflex time to prevent falls - more
  prone to injury

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Mobility in Geriatrics

• Bone loss affects mobility
• Osteopenia - less than the normal amount of bone
• Osteoporosis - bone mass so reduced that the
  skeleton loses its integrity and becomes unable
  to perform its supportive function
• Loss of bone strength and size
• Loss of flexibility
• Vulnerable areas in women
• spine, wrist, hip, collarbone, upper arm, leg,
  pelvis
• Treatment - meds, weight bearing exercises like
  walking and lifting weights

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Cardiovascular Changes in Geriatrics

• Left ventricle thickens and enlarges
  (hypertrophy) decreasing compliance
• Decreased responsiveness to catecholamine
  stimulation
• Diminished ability to raise the heart rate in
  response to stress
• Decreased function of SA AV
  nodal cells increasing risk of
  dysrhythmias
• Cardiac output decreased by 30

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• Arteries become increasingly rigid
• Increased blood pressure to pump through rigid
  blood vessels
• Reduced blood flow to all organs
• Decreased peripheral resistance
• Widened pulse pressure - increasing systolic
  blood pressure
• Heart muscle stiffens
• Postural hypotension - vessels less reflexive and
  blood pressure drops when patient stands up too
  fast
• Atherosclerosis - progressive, degenerative
  disease of medium and large sized arteries

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Cardiovascular Disease

• Risk factors for developing cardiovascular
  disease
• Previous MI
• Angina
• Diabetes
• Hypertension
• High cholesterol level
• Smoking
• Sedentary lifestyle

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Geriatrics and Acute Myocardial Infarctions

• Elderly do not present with typical signs or
  symptoms of acute myocardial infarctions
• Silent MIs are marked by atypical complaints
  such as fatigue, nausea, abdominal pain and
  breathlessness
• High index of suspicion for MI with unusual or
  absent warning signs/symptoms
• Mortality doubles after age 70

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Heart Failure

• A clinical syndrome where the hearts mechanical
  performance (pumping) is compromised and cardiac
  output cannot meet the bodys needs
• Caused by ischemia, valvular disease,
  dysrhythmias, hyperthryoidism, anemia,
  cardiomyopathy
• In elderly, large incidence of non-cardiac causes
• Generally divided into right and left heart
  failure
• Ventricular output insufficient to meet the
  metabolic demands of the body

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Heart Failure

• Left ventricular failure
• left ventricle fails as a forward pump
• back pressure of blood in the pulmonary system
  leads to pulmonary edema
• Right ventricular failure
• right ventricle fails as a forward pump
• back pressure of blood into the systemic venous
  circulation leads to venous congestion
• Congestive heart failure
• reduced stroke volume causes an overload of fluid
  in body tissues

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Signs and Symptoms of Heart Failure

• Dyspnea
• Fatigue
• Orthopnea - often sleeping on extra pillows to be
  more upright
• Dry, hacking cough progressing to frothy sputum
• Dependent edema due to right heart failure (check
  most dependent part of body depending on mobility
  - feet or sacral area)
• Nocturia - urinating at nighttime
• Anorexia, ascites (fluid in abdomen)

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Protocol Treatment Pulmonary Edema

• Routine medical care
• Oxygen via nonrebreather initially
• BVM and intubation if needed
• Stable patient with B/P gt100 systolic
• Nitroglycerin 0.4 mg sl (can repeat every 5
  minutes to a maximum of 3 doses)
• venodilator - reduces return of blood to heart to
  reduce workload of heart
• Lasix 40 mg IVP (80 mg if on lasix)
• diuretic and venodilator - reduces fluid return
  workload on the heart

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Pulmonary Edema contd

• Stable patient contd
• If B/P gt100 systolic, morphine 2 mg slow IVP
• repeat 2mg every 3 mins as needed max 10 mg
• reduce anxiety venodilator
• Consider CPAP if B/P gt 90
• Unstable patient B/P lt100 systolic
• contact medical control
• consider cardiogenic shock protocol
• dopamine drip to raise blood pressure
• fluid challenge would not be appropriate in
  patient with crackles/rales (wet lungs)
• treat dysrhythmias as they present

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Dysrhythmias and Geriatrics

• Common dysrhythmias
• PVCs when over 80 year old
• atrial fibrillation - increased risk for stroke
• Morbidity/mortality
• Serious due to decreased tolerance due to
  decreased cardiac output
• The cerebral hypoperfusion leads to an increase
  in falls
• Can lead to TIAs and CHF
  (ineffective pumping)

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Aneurysm

• A bulge in a blood vessel if large enough can
  put pressure on surrounding structures
• May be aortic or cerebral
• Associated risk factors
• Smoking
• Hypertension
• Diabetes
• Atherosclerosis
• Hyperlipidemia
• Polycythemia
• Heart disease

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Hypertension

• Blood pressure ranges
• optimal lt120/lt80
• normal range lt135/lt85
• hypertensive range gt140/gt90
• Risk factors for developing hypertension
• African Americans
• elderly
• geographics (Southeastern United States)
• males (after menopause, women equally vulnerable)
• socioeconomic status - lower the status the
  greater the risk

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Hypertension

• Morbidity/mortality
• B/P greater than 160/95 doubles mortality in men
• If blood pressure remains uncontrolled, damage
  seen to circulation (vascular system) and organs
• cardiovascular disease (CVD) - stroke, MI, heart
  failure
• end-stage renal disease

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Hypertension

• Awareness of the disease, its treatment, and
  control have improved but are still suboptimal
• Prevention and control
• Regular physical check ups
• Follow medication routine if prescribed
• Weight control
• Exercise
• Decreasing salt intake
• Socially/emotionally active
• Smoking cessation
• Decreasing alcohol consumption

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Hypertensive Emergencies

• Definition
• acute elevation of systolic blood pressure
  gt230/gt120
• Signs symptoms
• epistaxis (nosebleed)
• headache
• visual disturbances
• neurological changes - altered mental status and
  seizures
• nausea vomiting

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SOP Treatment Hypertensive Emergencies

• Routine medical care IV-O2-monitor
• Blood pressure in both arms and record
• keep arm level with the heart
• Vital signs and neuro status every 5 minutes
• P-R-B/P-AVPU status-pupillary response-GCS
• Lasix 40 mg IVP (80mg if on Lasix at home) -
  diuretic vasodilator
• If Medical Control orders, give NTG sl-
  vasodilator

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Stroke - Cerebrovascular Accident

• 3rd leading cause of death in the USA
• Occlusive stroke - 80 incidence
• causes brain ischemia
• time to hospital treatment (fibrinolytic clot
  bluster) must be lt3 hours from time of onset
• most important question - what time did the
  symptoms start?
• Hemorrhagic stroke - 20 incidence
• higher percentage of death

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Risk Factors For Stroke

• Elderly
• Atherosclerosis
• Hypertension
• Immobility
• Limb paralysis
• Congestive heart failure
• Atrial fibrillation
• Diabetes
• Obesity

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Signs and Symptoms of Stroke

• Elevated blood pressure
• Altered mental status or mood
• Coma
• Paralysis or extremity weakness
• Slurred speech
• Seizures
• Note Suspect stroke in any elderly person with a
  sudden change in mental status. Always check
  blood sugar level in setting of altered mental
  status

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Cincinnati Stroke Scale Assessment

• Facial droop - have patient smile big enough to
  show their teeth
• Arm drift - patient closes their eyes and extends
  arms out straight for 10 seconds
• Abnormal speech - have the patient repeat back a
  response given (speech may have already been
  detected during normal conversation)

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Documentation of Cincinnati Stroke Scale Results

• Facial droop
• right, left, or no droop present
• Arm drift
• right, left, or no arm drift
• Abnormal speech
• slurred speech or clear speech
• Even normal responses with no deficits must be
  documented to show the assessment was performed

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Endrocrine Emergencies in Geriatrics

• Diabetes and Thyroid Disease
• Due to the aging process and multiple disease
  processes the signs and symptoms may not appear
  to be classic
• Suspect thyroid disease in an elderly patient who
  has vague symptoms of illness
• 20 of the elderly have diabetes
• 40 have impaired glucose tolerance
• Type II (non-insulin dependent) is the most
  common form of diabetes and related to obesity

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Endocrine Disorders

• Hypothyroidism
• Low metabolic state
• ? appetite with weight gain
• Vague musculoskeletal complaints
• Lethargy, fatigue, sluggishness
• Cold intolerance
• Constipation
• Anemia
• Depression, forgetfulness
• Hyponatremia (? Na)
• Moon face

• Hyperthyroidism
• Weight loss
• Mentation changes - nervousness, irritability
• Tachydysrhythmias, palpitations
• Hyperactivity, nervousness, irritability
• Heat intolerance
• Abdominal pain
• Diarrhea
• Weak leg muscles
• ?perspirations

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Endocrine Complications Prevention

• Hyperthyroidism
• impaired glucose tolerance - problems with sugar
  processing (pre-diabetic condition)
• type II diabetes
• tachycardia
• atrial fibrillation

• Hypothyroidism
• bradycardia

• Prevention
• maintain healthy weight
• remain compliant with medication regime
• maintain healthy lifestyle
• excercise

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Integumentary (skin) Emergencies

• Risk factors
• Epidermal cellular turnover decreases
• Slower wound healing
• Increased risk for secondary infection
• Increased risk of skin tumors, fungal or viral
  infections
• Hair becomes finer and thinner

69
Pressure Ulcers

• Results from hypoxia to tissue cells
• Usually over bony areas
• Common in immobile patients
• those confined to bed or wheelchairs
• Increased incidence in patients with
• altered sensory perception
• skin exposure to moisture, especially prolonged
• decreased activity inability to shift
  positions
• poor nutrition
• friction or shear (ie being pulled and dragged
  across a surface instead of being lifted)

70
Prevention of Pressure Ulcers

• Immobile patients turned every 2-4 hours
• Adequate hydration and nutrition provided
• Personal hygiene maintained
• Environment kept clean
• Insure immobile patients do not have wrinkled
  bedsheets or clothes
• Prescribed antibiotics or medications provided as
  ordered

71
Traumatic Deaths in Geriatrics

• Trauma is the fifth leading cause of death
• Mortality rates markedly increased in the elderly
• One-third of traumatic deaths are in 65 - 74 year
  olds secondary to vehicular trauma
• 25 result from falls
• 50 of persons gt80 years old
  die from falls
• Post-injury disability more
  common in the elderly

72
Risk Factors Related to Trauma

• Osteoporosis and muscle weakness increases the
  risk of fractures
• women more vulnerable after menopause
• men are also at risk for this disease
• Reduced cardiac reserve decreases ability to
  compensate for blood loss
• Decreased respiratory function increases risk for
  adult respiratory distress syndrome (ARDS)
• Impaired renal function decreases ability to
  adapt to fluid shifts
• Unsteady gait increases risks of falls

73
Traumatic Emergencies

• Orthopedic Injuries
• Pelvic fractures are highly lethal due to severe
  hemorrhage and associated soft tissue injury
• Decreased pain perception may mask major fracture
• A large percentage of elderly will die within one
  year of a hip fracture

74
Orthopedic Injuries

• Hip fractures most common acute injury
• Elderly are susceptible to stress fractures of
  femur, pelvis, tibia
• Packaging should include adding bulk and padding
  between the patient and the back board
• Kyphosis (rounding of the back) may require extra
  padding under shoulders to maintain alignment
• often caused by osteoporosis, arthritis,
  vertebral slippage

75
External Rotation
76
Fracture site
77
Fracture repaired with plate screws
78
Orthopedic Injuries From Falls

• Major cause of morbidity/mortality
• 10,000 deaths each year
• One third of elderly fall at home each year
• 1 in 40 are hospitalized
• Cause significant mobility problems
  and functional dependence
• Evaluate home for safe conditions
• use of non-skid rugs
• adequate lighting - hallways and at night
• sturdy hand rails on stairs and in bathrooms
• items within reach (ie kitchen)
• environment clear of clutter

79
Traumatic Head Injuries

• Poorer outcome when injury associated
  with loss of consciousness
• Brain shrinkage as one ages allows more space and
  greater brain movement
• Increased incidence of subdural hematoma
• ? frequency of falls lead to more head injuries
• brain shrinkage allows for more room to bleed
• bleeding is venous - slow development of symptoms
• headache
• mental status changes

80
Spinal Column Injuries

• Progressive arthritic and degenerative changes
  and osteoporosis associated with the aging
  process lead to higher incidence of bony injuries
• Injuries have a negative impact on the function
  and quality of life
• Pain ? ability to perform activities of daily
  living
• A psychosocial impact and threat to loss of
  independence

81
Compression Fractures of Spine

• Occurs in 25 of post-menopausal women in the USA
  (up to 40 in women over 80)
• Applied force may be minimal (lifting an object,
  stepping out of tub, sneezing) or more
  significant (major fall, MVC)
• Acute onset low back pain, tenderness to
  palpation usually over T 8-12 and L 1-4
• Rarely neurological symptoms
• Transport in position of most comfort
• Treatment symptomatic conservative -
  rest, pain control, physical therapy

82
Burns in the Elderly

• 1000 die each year from home fires
• People over 60 have higher mortality rate from
  burns
• Increased morbidity/mortality due to preexisting
  disease, skin changes (thinning slower healing
  time), altered nutrition, increased risk to
• infection, decreased reaction time to
• move away from source

83
Treatment of Burn Injuries

• Fluid important to prevent renal tubular damage
  from altered blood flow through the kidneys
• Normal aging changes cause a decreased response
  in heart rate and stroke volume to hypovolemia
• Hydration assessed in initial hours after burn
  injury by B/P, pulse, and urine output (1-2
  ml/kg/hour minimally)
• Rapid IV administration may cause volume overload
  (monitor lung sounds and vital signs frequently)

84
Burn Injury Prevention

• Install fire alarms in residence - 1 per floor
• Practice fire safety with appliances, candles,
  cigarettes, lighters
• Never leave food unattended on stove
• Do not cook while wearing baggy sleeves
• Practice fire evacuation routes
• Install easy to read phones to dial 911
• Investigate need for Lifeline assistance
• way for senior to contact help when needed

85
Toxicology Geriatrics

• Alterations in body composition, drug
  distribution, metabolism and excretion increases
  the risk for toxicity in elderly when exposed to
  over-the-counter medications, prescription
  medications, and other substances

86
Risk Factors Related To Toxicology

• Decreased kidney function alters elimination
• Increased likelihood of CNS side effects
• Altered GI absorption
• Decreased liver blood flow alters metabolism and
  excretion
• History of alcoholism
• Vision and memory changes
  result in noncompliance
• Poor dexterity and eyesight decreases
  ability to choose correct medication and/or
  dosage

87
Prevention

• Label medications clearly and in larger print
• Provide assistance with nutrition and medication
  administration as needed
• Consult with physician frequently
• Make sure all physicians are aware of all
  medications taken
• over-the-counter prescription
  herbal remedies
• Limit OTC drug administration
• Segregate storage in medicine
  cabinet
• ingested medications on one shelf
• topical medications on a different shelf

88
Elder Abuse

• May occur in home or institutional setting
• EMS is mandated by State of Illinois to report
  suspicions to hot line
• Abuse
• any physical injury, sexual abuse or mental
  injury inflicted on a person, aged 60 or older,
  other than by accidental means
• Neglect
• failure to provide adequate medical or personal
  care or maintenance in which failure results in
  physical or mental injury or deterioration of
  condition

89
Elder Abuse Reporting

• Document objectively and describe injuries using
  measurements and colors and not vague terms
• Report suspicions to ED staff
• Abuse Hot Line
• M-F 0830 - 1700 1-800-252-8966
• All other times 1-800-279-0400

90
Medications for Home Use

• Antidepressants
• Antianxiety
• Anticoagulants
• Lipid management
• ACE inhibitors
• Beta blockers
• Calcium channel blockers

• Diuretics
• GI system
• Insomnia and sleep disorders
• Erectile dysfunction

91
Medications for Home Use

• Antidepressants
• depression is a chronic illness of feeling
  hopeless and of losing interest
• SSRI (selective serotonin reuptake inhibitors)
• improves mood
• lexapro, prozac, paxil, zoloft
• Tricyclic antidepressants
• amitriptyline, nortriptyline
• MAO inhibitors
• could have potentially life-threatening drug
  food interactions
• nardil, parnate

92
Medications for Home Use

• Antianxiety
• to relieve anxiety
• benzodiazepines most common category
• Anticoagulants
• to inhibit the ability to clot does not dissolve
  an existing clot
• coumadin, lovenox, heparin, plavix, aspirin

93
Medications for Home Use

• Lipid management
• to reduce cholesterol and LDL levels which when
  elevated increases risks of coronary heart
  disease (CHD)
• statins lipitor, lescol, zocor, pravachol,
  mevacor, baycol, crestor, pitava
• non-statin zetia, niacin, velchol, torcetrapib,
  panavir

94
Medications for Home Use

• ACE inhibitors
• allow blood vessels to enlarge or dilate to
  decrease B/P
• used to control B/P, treat heart failure, prevent
  kidney damage in hypertensive diabetic patients
• catopril (capoten), lotensin, vasotec, lisinopril
  (prinivil zestril), monopril, ramipril
  (altace), aceon, accupril, univasc, mavik

95
Medications for Home Use

• Beta blockers
• relieves stress on heart by blocking some
  involuntary nervous system control on the heart
• slows heart rate, decreases force of
  contractions, reduces blood vessels contractions
• used to treat cardiac dysrhythmias, atrial
  fibrillation, hypertension, angina, post-MI
  (reduces morbidity), glaucoma, migraines, anxiety
• most generic names end in olol
• atenolol (tenormin), metoprolol (lopressor),
  propranolol (inderal), nadolol (corgard),
  carvedilol (coreg)

96
Medications for Home Use

• Calcium channel blockers
• block entry of calcium into muscle cells of heart
  and arteries to decrease the strength and rate of
  heart contractions and dilate arteries
• used to treat high blood pressure, arrhythmia
  (atrial fibrillation), angina, used post-MI
• verapamil (calan, isoptin), diltiazem (cardizem),
  nifedipine (procardia), bepridil (vascor),
  amlodipine (norvasc)

97
Medications for Home Use

• Diuretics
• to reduce the vascular fluid volume
• used to treat heart failure, hypertension, fluid
  retention
• aldactone, aldactazide, bumex, diuril,
  hydrochlorothiazide, HCTZ, hydrodiuril, dyazide,
  dyrenium, lasix (furosemide)
• Diabetes
• inadequate insulin activity for glucose
  metabolism
• actos, amaryl, avandia, diabeta, glucophage,
  glucotrol, prandin, precose, starlix

98
Medications for Home Use

• GI system
• to treat acid reflux, excess acid, GERD,
  irritable bowel
• aciphex, asacol, mylanta, pepcid, prevacid,
  prilosec, propulsid, reglan, rolaids, tagamet,
  tums, zantac, lomotil, bentyl, imodium

99
Medications for Home Use

• Insomnia and sleep disorders
• sleep deprivation affects the bodys metabolism
• insomniacs are at increased risk for host of
  diseases decreases motor skill and affects
  memory and mental performance
• being awake 24 hours is equivalent to a blood
  alcohol level of 0.1
• ambien, halcion, restoril, lunesta
  benzodiazepines like lorazepam (ativan), diazepam
  (valium)

100
Medications for Home Use

• Erectile dysfunction
• to improve erectile function (impotence) in men
  and sexual arousal in women
• increases amount of blood flow, does not
  automatically produce an erection but allows one
  after physical and psychological stimulation
• not to be taken if MI, stroke or life-threatening
  dysrhythmia in last 6 months
• not to be mixed with nitrate use (NTG) in same 24
  hours period -blood vessel dilation could be too
  much to reverse could cause death
• viagra (sildenafil), cialis, levitra

101
Pearls of Medication

• Benzodiazepines
• use mixed with alcohol increases depressant
  effects - watch for respiratory depression
• Anticoagulants
• increases risk for bleeding complications
• Beta blockers
• patient wont respond with tachycardia even in
  shock due to effects of drugs
• Hypertensive patient
• a normal reading (ie 110/80) may be shock for
  the patient with a chronically elevated blood
  pressure

102
Medications

• Important to remember to bring in all medications
  from the patients home
• prescription
• herbal remedies
• non-prescription over-the-counter
• Hospitals are working hard on helping patients
  get a handle on their medications and trying to
  avert possible unhealthy interactions

103
References

• Bledsoe, B. E., Porter, R. S., Cherry, R. A.
  Paramedic Care Principles Practices. Brady
  2006.
• www.aafp.org
• www.allaboutvision.com
• www.americanheart.org
• www.aoa.org/documents/CPG-8.pdf
• www.clara.abbott.com
• www.dynomed.com/encyclopedia/encyclopedia/spine/
  Compression_Fracture.htm
• www.glaucoma.org
• www.nihseniorhealth.gov
• www.nlm.nih.gov/medlineplus/cataract.html
• www.pads-crisis-services.net
• www.richmondeyecare.com/vets2html

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Cultural Diversity, Geriatrics, Home Medications
Questions ??