Mrs. Johnson is 97 years old. She lives on her own in the small house where she raised her children. She has a history of emphysema and heart failure, and she had a heart attack five years ago. She's normally oriented and witty in her conversation. Today, however, she's not acting right. Neighbors called you because when they stopped by for their normal morning visit, she wasn't yet dressed and was confused about the time and date. Your initial assessment confirms the patient is confused about the date, and she keeps asking why you're in her house. As you begin to evaluate Mrs. Johnson for causes of her altered mental status (AMS), your partner comments, "She's 97 after all, what do you expect?"
Further assessment and history from the neighbors suggest Mrs. Johnson hasn't been feeling well for the past several days. Her skin is hot to the touch, and she tells you she has abdominal pain. Her blood pressure is 88/42 with an irregular pulse of 110. She takes Digitalis, Lasix and Coumadin. She also takes an inhaled steroid and has a rescue inhaler of albuterol. You apply oxygen and establish an IV. It appears your patient may be septic.
Physical Changes & Aging
Aging is associated with many physical changes. As a person gets older, their blood vessels become less resilient as do their lungs. Because of this, they may have a difficult time compensating for shock or respiratory emergencies. The decrease in lung compliance can also increase the risk of pneumonia. The gastrointestinal track slows down, and urine production decreases, which can affect nutrition, hydration and electrolyte balance. Additionally, changes in gastrointestinal and renal function can alter their ability to absorb and eliminate drugs. A decrease in visual acuity and hearing loss (presbycusis) are normal changes associated with aging, which can cause communication barriers. Reflexes become slower, but changes in mental acuity aren't considered a normal part of aging, but rather, a part of a disease process
Most senior citizens over the age of 65 live on their own. The U.S. Census Bureau reported that between the years 2006 and 2008, 12.6% of the American population was over the age of 65, and of that group, 88.6% lived in their own homes. Exact numbers are difficult to determine based on differing definitions, but less than 5% of the geriatric population live in nursing homes. Senior citizens represent an active group within our population. For example, within the U.S. Senate, 27 senators are over the age of 70. Although growing old does increase the risk for long-term illnesses and disease processes, it's not a disease.
Assessing Geriatric Patients
Assessing a geriatric patient can be difficult. Geriatric patients commonly have several chronic diseases, meaning one complaint may have several contributing factors. This is known as comorbidity of illness. For example, diabetes may mask the symptoms of a heart attack or heart failure and pulmonary edema may make pneumonia difficult to detect. Medicine prescribed to treat chronic illness may challenge your assessment skills as well. For example, beta blocker drugs used to treat hypertension won't allow the heart rate to increase to compensate for such conditions as hemorrhage. In some cases, drug interactions or non-compliance with medications, is the cause of symptoms. In one study, nearly 15% of all geriatric admissions were caused by adverse drug reactions or non-compliance (1).
AMS, as seen with our patient, is a common chief complaint in the elderly, but it should never be considered a normal process of aging. If a patient has a history of dementia, attempt to establish the patient's normal baseline mental status from caretakers. Then, determine how that has changed. Although common in seniors, dementia doesn't have an acute onset. Dementia is a gradual deterioration of cognitive function and has several underlying causes—Alzheimer's disease being most common (2,3). If a patient presents with a sudden change in mental status, then other causes must be considered. Common causes of acute changes in mental status in geriatric patients include stroke and sepsis.
Be thorough in your assessment of the geriatric patient remembering the chief complaint may have many different underlying causes. Help facilitate communication by limiting background noise from radios or other providers on scene and face the patient when you talk to them. Be polite, addressing the patient as Mr. or Mrs. rather than "honey" or "sweetie." Ask about recent illnesses and traumatic events. Gain a good sense of the patient's baseline function level. Try to determine what is different today and the reason for the 9-1-1 call. Many geriatric patients may be fearful of leaving their homes, so be calm and reassuring. In many situations, the EMS provider may not be able to pinpoint the exact cause of the patient's complaint. It's important to identify and treat life threats and transport for further evaluation. Above all, avoid attributing your findings to the patient "just being old."
1. Malhotra S, Karan RS, Pandhi P, Jain S. Drug-related medical emergencies in the elderly: Role of adverse drug reactions and non-compliance. Postgrad Med J. 2001;77:703–707.
2. Rosen’s Emergency Medicine, Concepts and Clinical Practice 6th edition. Mosby. 2006;2:1655
3. Taber’s Cyclopedic Medical Dictionary, 20th Edition. F.A. Davis. 2001; 553.