Adults aged 65 years and older are the foremost utilizers of EMS and are at excess risk for adverse events.¹ Studies overwhelmingly agree this high level of use by older adults is appropriate.^2–6 Elders have greater needs for emergency care than other age groups.⁷ They are often acutely ill and nearly 30% of elder EMS patients require high intensity care. The potential exists for the elder population to overwhelm EMS networks due to their numbers and their complex interwoven needs that do not fit neatly into our systems design. EMS was designed for acute emergent action not for the multifaceted nuanced concerns experienced by our nation’s elders. Understanding the full scope of this issue is essential to define opportunities for targeted improvements in practice and policy, thereby preparing EMS providers and systems for the oncoming geriatric tsunami.

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  Describe common physiological differences in geriatric patients.

  
  
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  Describe common causes of altered mental status in geriatric patients.

  
  
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  Describe key physiological differences in elderly patients relating to the prehospital care of trauma-related emergencies.

  
  
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  Discuss blood thinning medications and the prehospital evaluation and management of geriatric patients.

  
  
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  Describe common social and economic issues affecting overall health and well-being of geriatric patients.

  
  
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  Describe the special features of the prehospital evaluation and management of nursing home and long-term care facility patients.

  
  
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  Describe the initial prehospital evaluation and management of suspected elder abuse and neglect.

The aging demographic is well documented. In 2012, over 40 million people in the United States are aged 65 and older. This number is projected to more than double to 89 million in 2050. By 2050 fully one-fifth of the US population will be ages 65 and older.⁸ Otherwise stated, from 2000 to 2050 the number of older adults is projected to increase by 135%, with those aged 85 years and older increasing by 350%.⁹ This is particularly crucial since those over 85 have the highest rate of EMS transport.¹⁰ The proportion of elder EMS use increases from 27% among those aged 65 to 84 years to 48% among those older than 85 years.¹¹ This could result in even greater proportions of the older and most complex EMS patients.¹²

Medicine’s improving ability to treat disease has increased illness prevalence in elders,¹³ augmenting demand for EMS beyond those of population numbers alone. Our health care workforce has a shortage of paraprofessional providers to meet this demographic need.¹⁴ With age come illnesses not seen in younger persons, and atypical presentations of many diseases. Medical diagnosis and management of elders is complex and significantly different than in younger individuals. Symptoms are nonspecific and mask severe problems with high morbidity and mortality; comorbidities are common, and treatments vary. This requires existing providers to master geriatric issues.

The impact of the elder population on EMS can be anticipated and focuses on four main areas:

1. 
   

   On the provider level, deficiencies in geriatric specific education have been acknowledged.¹⁵ The need for paramedical personnel to train in geriatric topics prompted the American Geriatrics Society and the National Council of State EMS Training Coordinators to develop an optional course, “Geriatrics Education for EMS,” which is now available to interested EMS providers.¹⁶ As documented by the Institute of Medicine (IOM), geriatric specific competencies must be achieved and maintained: “Recommendation 4.2: All licensure, certification, and maintenance of certification for health care professionals should include demonstration of competence in the care of older adults as a criterion.”¹⁷ Reports such as this from the IOM may soon mandate compliance with geriatric specific education to maintain professional certification.

   
   
2. 
   

   Since the 1990s, elders have required more time and resources, and had higher rates of admission to both the hospital and critical care units.^18–20 Older adults now compel a higher level of EMS to meet a greater proportion of severe illness, with life-threatening incidents occurring 5.2 times more frequently in this population.²¹

   
   
3. 
   

   Current EMS are not set up for the needs of our aging population.^22–24 A true paradigm shift needs to occur from the current structure of emergency services delivery limited to acute interventions, to a broader model capable of managing complex subacute issues with acute decompensation. Providers will likely also face a change in focus from treatment of acute to more chronic illness.¹⁴

   
   
4. 
   

   Finally, EMS must better manage transitions from long-term care, nursing homes, and elder day care facilities to optimize connections between patients using these entities and the modes of health care they require.²⁵

Predictable physiologic changes occur as a function of aging, although the onset of these changes varies by many years among individuals. These can be general in nature or specific to an isolated organ system, thereby causing very specific failure of function. Some geriatric medical texts describe “the 1% rule” that most organ systems lose function at roughly 1% a year, beginning around age 30. Loss of function is undetected until a critical or threshold level is crossed. The higher the demand on an organ system, the less loss can be tolerated.

Table 50-1 lists major organ systems, the changes that occur with physiologic aging, and some of their clinical correlates.

Altered mental status (AMS) is not a diagnosis but is a symptom heralding a wide array of medical, traumatic, and toxicologic syndromes.²⁶ AMS is found in only 4% to 10% of all ED patients²⁷ but exists in up to 30% of the elderly patient subset.²⁸ However, only 20% to 30% of these cases are recognized in the ED, resulting in increased mortality.²⁹ EMS workers can be pivotal in increasing recognition and improving treatment of this dangerous entity. AMS results from etiologies involving both a primary central nervous system (CNS) event as well as a secondary process affecting the CNS. Elderly patients are much more likely to have changes in mental status resulting from a secondary process. AMS has a bimodal distribution across age. Traumatic and toxicologic causes occur much more often in the younger adult, whereas in the elderly, neurologic etiologies and organ system dysfunctions are the most frequent causes of AMS.³⁰

Accurate terminology for levels of cognitive impairment is essential for effective communication and treatment across health care settings. This can be seen in Table 50-2.

AMS is not a natural consequence of aging. In healthy individuals cognitive function is preserved even at extremes of age. AMS is a manifestation of disease states, toxins, medication interactions, metabolic abnormalities, or trauma. In order to care for geriatric patents any provider must take two important steps. First, eliminate age bias by understanding cognitive impairment is a disease state. Second, divide those with AMS into broad categories:

1. 
   

   Chronic alteration of mental status: This category consists of the dementias, primarily Alzheimer disease. Alzheimer is overwhelmingly common, and it is predicted to attack up to 13.2 million in the United States by 2050.³¹ Alzheimer is a chronic slowly progressive terminal disease and the sixth leading cause of death in elders.³²

   
   
2. 
   

   Acute worsening of chronically altered mental status: This is the second most common category encountered by EMS personnel and usually results from a secondary process that affects the CNS. Overall, it should be understood that almost any disorder could cause AMS in elderly patients.³³

   
   
3. 
   

   Acute alteration of baseline normal mental status: This is the least common of all causes of AMS in elders encountered by EMS.

Causes of AMS in the elderly population are distinct from those in younger patients. Table 50-3 lists broad categories of AMS etiologies, more specific examples in each category, and percentages of elders who present with each category of AMS.

The key in assessment of AMS in elders is to establish the new mental state in comparison to the baseline for that particular patient. As the first health care provider on the scene, the paramedic has the opportunity to identify the acute problem as well as to establish the patient’s baseline level of function. If the patient is stable, this baseline should be determined by whatever means possible. This may mean speaking to the patient, family members, or caregivers. In order to obtain this baseline level, ask about memory problems, ability to ambulate, communicate, and perform self-care. Second establish the timeframe over which this change has occurred. Did the change take months, days, or minutes? Does the change wax and wane? Query the caregivers about any possible precipitants. Was there a recent fall? Are there any medication changes? Also, simply ask what the caregiver thinks is going on. Finally, and perhaps more importantly, obtain contact information for the caregiver, so that future providers can quickly contact them.

EMS providers caring for elders must distinguish between two key situations:

1. 
   

   Delirium: An abrupt disorientation for time and place, usually with illusions and hallucinations. The mind wanders, speech may be incoherent, and the patient is in a state of confusion. Additionally they can experience extremes of arousal and activity ranging from extreme excitement or agitation to acutely decreased consciousness and motor activity. This low slow activity is often unrecognized as delirium.

   
   
2. 
   

   Dementia: A slow progressive loss of awareness for time and place, usually with inability to learn new things or remember recent events. The person may be lost in a time years prior to today. Remote memories may be intact. Total loss of function and regression to an infantile state may eventually result.¹⁰

The distinction between delirium and dementia is critical (Table 50-4). Delirium is an acute, reversible, potentially life-threatening problem that requires extreme emergency care. Acute change in mental status is a key feature of delirium. Delirium is a potentially life-threatening medical emergency.³⁴ Patients with delirium generally have underlying acute medical conditions that require rapid diagnosis and treatment.³⁵ It is usually important to describe delirium as a symptom secondary to some other disease process. This alerts the provider to discover the acute process underlying the delirium. Dementia, on the other hand, is very slowly progressive and requires support, but it is not an emergency treatment priority. Remember, comparing each patient to himself or herself in the recent past is the best clue to a critical problem. An acute or rapid deterioration signals delirium. Slow progression signals dementia.

Compared to younger people, elder patients frequently sustain injury as a direct result of their underlying medical conditions. Due to aging, the majority of these injuries are more severe and more difficult to diagnose and treat.³⁶ There are two key concepts to understanding geriatric trauma.

1. 
   

   Physiologic changes make trauma increasingly more serious with advancing age:

   
   
   
   
   1. 
      

      Identical mechanisms can cause more severe immediate injury in older adults as well as greater delayed or internal injuries.

      
      
   2. 
      

      Vital signs may be normal in elders even in states of severe shock.³⁷

      
      
   3. 
      

      Physical examination can underrepresent extent of injury in older adults.

      
      
   4. 
      

      Lower physiologic reserve can decrease ability to recover.

   
   
   
   
2. 
   

   Trauma is often the direct result of underlying medical conditions. These conditions must often be addressed simultaneously with the treatment of injuries to stabilize the patient.

The older patient will likely require more interventions than the younger patient with identical injuries. This includes EMS evaluation and treatment, ED evaluation and treatment, surgical care, intensive care unit services, and all care up to and including rehabilitation. However, even obviously severely injured elders are less likely than younger patients to receive care in a trauma center.³⁷ The selective undertriage of elder patients with severe injury to level one trauma centers by EMS providers is well documented.^38–40

The usually accepted physiologic triage variables of blood pressure and heart rate are not useful predictors of level one trauma interventions or mortality in older adults.³⁸ In fact, in trauma, the mortality of older adults increases at systolic blood pressure readings <110 mm Hg.⁴¹ So vital signs considered normal in younger populations may represent shock in patients aged over 65 years. The finding of decreased end organ perfusion in the face of normal blood pressure and heart rate readings is termed occult hypotension and has been noted in over 40% of injured older adults.⁴² The failure of trauma center diversion based on occult hypotension is high.

Low impact mechanisms such as ground level falls are known to cause severe traumatic injury and result in high mortality in older adults.⁴³ Simple ground level falls are reported to result in 34.6% of all deaths in elder patients.⁴⁴ The failure of trauma center diversion based on low-level mechanisms is high.

The Guidelines for the Field Triage of Injured Patients 2012⁴⁵ are the newest guiding principles from the American College of Surgeons, the Centers for Disease Control (CDC), and the National Highway Traffic Safety Administration (Box 50-1). These guidelines are intended to help prehospital providers select the most appropriate destination hospital for an individual patient. The new guidelines recognize that physiologic, anatomic, and mechanism of injury criteria all fail to identify older adults in need of level one trauma center care. They now propose a fourth level criteria or “Special Considerations” to correct this high rate of undertriage to level one centers for older adults.