The Geriatric Patient

     Geriatric patients aren't just "old adults"—they come with their own challenges, which include social, cognitive and physical aspects. As EMS providers, most of our basic patient assessments and interventions need to be tailored for this population. Here are some tips on how to achieve this.

Assess Your Assessment
     Although the physical-assessment algorithm of the geriatric patient will not differ from that of patients in younger age groups, there are some useful tips you should implement during your interaction.

     Some geriatric patients may be reluctant to tell you what's wrong. They may feel they are being a "burden" or that they "don't want to bother you" with their problem. They may have an extensive history they have related so many times they wonder why they should tell you when you'll only be with them for 20 or so minutes, and then they'll have to tell a nurse, a doctor, and the list goes on. Difficulties in communication are frustrating for those who cannot gather their thoughts, enunciate clearly or understand what is being said to or asked of them. Now, add a medical or traumatic injury, or both. It's the EMS provider's job to coax this information out of his patient to be able to initiate appropriate care that can be maintained throughout the rest of the system.

Communicate
     If at all possible, communicate directly with your patient. Although this may seem obvious, you would be surprised how many people listen to the geriatric patient's relative, friend or neighbor, when that patient can and does communicate quite well for him or herself. If the patient uses glasses, hearing aids or even dentures, make sure they are being used—it will make communication a lot easier for both of you.

     Always let the patient know everything you are doing—clinically and otherwise. This communication is all the more important in what are unfamiliar surroundings for them. Even when you step behind them in the ambulance (to grab an additional piece of equipment or speak on the radio), let them know you are still there. Remember, you drive around in an ambulance routinely, they don't, and they may be uncomfortable in your environment.

Manners Matter
     Ask the patient how she would like to be addressed. For example: "May I call you Bernice, or do you prefer Ms. Smith?" This simple step goes a long way in establishing patient/rescuer rapport. Don't call them "Pops," "Hon," "Sweetie" or any other cute nickname. They didn't live through 70 or more years to be treated like that. They grew up in a different time--a more formal one that we need to understand and respect.

Mind Those Meds
     Many elderly patients suffer from what EMS providers call "bag-o'-meds" syndrome, or "meds in a shoebox." You may recognize this from a call you've been on where it seems every medication you've ever heard of is in the patient's home. It is important to note that many meds are kept in weekly organizers that don't show the medication name/dose/strength or regimen. Many times, a family member, visiting nurse or aide sets this up for the patient. Bring it along. Another note about medication bottles: Often, the medication in the old, worn bottle with the label half gone is not what it says it is. The reasons vary as to why the patient reuses the same bottle: It's easier to open, easier to remember, or easier to recognize the color/size/shape. Check every bottle. The patient may have the same prescription from different doctors and/or different pharmacies that are unaware the patient is taking multiple doses.

     Check all possible locations for prescription and nonprescription bottles. Take them all with you and don't forget any vitamin supplements or herbal remedies. Many elderly patients who take a large number of pills use pillboxes poured out by their home health aide or other visiting nurse service. Take this with you, as well, as it can indicate whether they have been taking the prescription.

Let's Get Physical
     Physical presentation of geriatric patients is different from that of other patient groups. Some basic differences to be aware of are:

• Skin will usually be thinner and more fragile; bruising and tearing are common and it usually takes longer for wounds to heal. Be careful when taking a blood pressure, applying/removing tape, bandaging, etc.
• Significant hearing loss is common. Communicate in a normal tone, but slowly. Speak to the patient face to face. Don't yell.
• Musculature in general is decreasing and is often coupled with stiff, inflexible joints, as well as arthritis. Movement is slower and can be painful. Be aware and be patient.
• Eyesight tends to diminish with age. Cataracts are prevalent, and surgery to remove them can affect pupil reaction. Vision can be severely limited, even with glasses.

     Also remember that in traumatic events, a less significant mechanism of injury (MOI) may adversely affect geriatric patients more than other patients. A fall from a standing height, for instance, may be painful to a pediatric or adult patient, but debilitating to the elderly. Coup/contrecoup brain injuries and breakage of intra-cerebral vessels can occur in lower-speed MVAs with greater ease due to the shrinkage of tissue. Finally, older bones can be completely calcified and prone to snap when less force is applied, especially in older females suffering from osteoporosis.

Give Them the Power
     Like most adults, your geriatric patients will want some measure of autonomy. They want to have a say in their own care. We need to work with them, whether it means allowing them to pick their own hat color or lock their own door. Keeping the patient updated on the intervention you will be providing is also important. Instead of saying, "This is an 02 mask" or "This is an IV," tell them "this is some more oxygen; it may help your breathing," or "this is just some medication/fluid to help your heart." Communicate with patients on a level they will understand. This can seem silly to you, but it isn't to them. Giving a geriatric patient autonomy shows respect and goes a long way in building the patient-caregiver relationship.

Lifting the Patient
     During the lifting, moving and transportation of a geriatric patient, remember that their normal body cushioning may be diminished, and it is easier for them to get "banged up" than some of your other patients. Using pillows, blankets and linen will help protect them and make the journey more comfortable. Ask what position is most comfortable and adjust appropriately. Conditions like kyphosis and extreme arthritis may require creative padding, packaging or movement techniques.

Inventive Interventions
     Prehospital interventions need to be approached from a unique perspective when handling the geriatric patient. Standard splinting techniques may have to be adjusted with more padding. You might need to use a padded short splint to keep an IV in place, or another pillow to help position a patient with a hip fracture. For c-spine immobilization, search out the gaps caused by the patient's unique musculature and fill them with sheets, blankets, etc.

Watch the Weather
     Geriatric patients are more susceptible to changes in the weather than some other age groups. Older patients may not feel as comfortable as you do in hot or cold temperatures. Don't guess--ask the patient about his comfort level. It's also important to use blankets on elderly patients during winter months and make sure their head and extremities are covered before going outside.

Conclusion
     In the early 1990s, Acadian Ambulance Service managers in Louisiana analyzed their customer base and took the initiative to develop a highly interactive course known as "Carpe Diem," which focused on the distinctive needs of the geriatric patient in regard to social, physical, cognitive and many other aspects. For more information, visit www.acadian.com.

     Similarly, the current Geriatric EMS (GEMS) program developed by the National Association of State EMS Training Coordinators and the American Geriatric Society is designed to meet the need for additional training in geriatrics for EMS providers. It behooves EMS providers at all levels to seek out courses like these to increase their ability to evaluate and treat this patient population. For more information, visit www.gemssite.com.

     The elderly can be some of the most unique and challenging patients we will see. This group of EMS patients is growing, so you will surely be seeing and treating more of them.

This article is dedicated to the memory of the author's grandmother, Ms. Rose Freidman--a true matriarch.

The author would like to thank Katherine E. O'Connor, BS, EMT-P, and David Violante, AS, EMT-P, for their assistance with this article.

Raphael M. Barishansky, MPH, is chief of public health emergency preparedness for Prince George's County (MD) Health Department. A frequent contributor to and editorial advisory board member of EMS World Magazine, he can be reached at rbarishansky@gmail.com.