Geriatric Patients in EMS: Assessing the Older Adult

Older adults are a large share of every EMS service's calls, and older trauma patients in particular are often undertriaged. The reason is rarely a lack of skill. It is that the textbook presentations were written for younger bodies: the heart attack without chest pain, the infection without a fever, the shock with a normal heart rate. Assessing a geriatric patient well means expecting the atypical, asking why things happened rather than only what happened, and finding out what normal looks like for this particular person.

Why older adults present differently

Aging reduces reserve in nearly every organ system. An older patient may look stable until very late, and then deteriorate quickly, because there is less room to compensate. Add chronic illness and the medications that treat it, and the signs you are trained to rely on become less reliable. Older adults are conventionally defined as 65 and over, but physiology, not the birth date, is what changes the assessment.

Screen for stroke in a patient with new confusion or weakness

Polypharmacy: read the medication list as findings

Many older adults take several prescription drugs, plus over-the-counter medicines and supplements. The list tells you their medical history, and it also changes how their body responds to illness and injury. Collect it, or bring the bottles, on every call.

• Rate-controlling drugs. Beta-blockers and some calcium channel blockers blunt the heart rate response, so a patient who is bleeding or septic may not become tachycardic. A normal heart rate does not rule out shock.
• Antihypertensives. A patient whose usual blood pressure is high may be hypotensive for them at a reading that looks normal on paper. Ask what their blood pressure usually is.
• Anticoagulants and antiplatelet agents. They raise the risk of serious bleeding after even a minor injury, especially inside the skull. See the falls section below.
• Diuretics. They contribute to dehydration and electrolyte problems, which can present as weakness, dizziness or confusion.
• Diabetes medications. Hypoglycemia in an older adult can look like a stroke, confusion or a fall.
• Sedatives, sleep aids, some pain medications and drugs with anticholinergic effects. They contribute to falls and delirium. The American Geriatrics Society publishes the Beers Criteria, a list of medications that are potentially inappropriate in older adults for exactly these reasons.

Ask about recent changes: a new prescription, a changed dose, a missed or doubled dose, or a medication stopped. Many emergencies in older adults start with one of those. Report the list and any recent change to the receiving facility.

Falls: a presentation, not a diagnosis

According to the CDC, falls are the leading cause of injury and of injury death among adults 65 and older. A fall is one of the calls EMS runs most often in this age group, and it is the call most likely to be closed out too early. The fall is what happened. Your job is to find out why it happened and what it did.

Why did they fall?

• Did they trip, or did they go down? A clear mechanical trip is different from a patient who does not remember falling, felt dizzy first or was found on the floor.
• Fainting from an arrhythmia, a heart attack, dehydration, bleeding or a drop in blood pressure on standing.
• A stroke, a seizure or hypoglycemia.
• An infection, which may have no other obvious sign.
• A medication: a new sedative, a blood pressure drug, a change in dose.
• The environment: poor lighting, rugs, stairs, footwear, pets. This still matters even when there is a medical cause as well.

What did the fall do?

• Head injury, especially in a patient on an anticoagulant or antiplatelet drug.
• Hip and pelvic fracture. The classic sign is a shortened, externally rotated leg, but a patient who cannot bear weight after a fall needs evaluation even without it.
• Spine, wrist, rib and shoulder injuries, which can follow a low-energy fall in fragile bone.
• The long lie. A patient who could not get up for hours can develop muscle breakdown, pressure injuries, hypothermia and dehydration. Ask how long they were on the floor.

Score a GCS, and compare it with this patient's baseline

Delirium and dementia are different problems

Dementia is a chronic, progressive decline in memory and thinking. Delirium is an acute disturbance of attention and awareness, usually caused by something treatable. A patient with dementia is at higher risk of delirium, and the two often coexist. The question that separates them in the field is whether this is new, and the only way to answer it is to establish the patient's baseline from somebody who knows them.

Delirium is not always agitated. Hypoactive delirium, a patient who is quiet, withdrawn and drowsy, is commonly missed because it looks like tiredness or like dementia. The Confusion Assessment Method is a widely used screening tool for delirium, and some services include a version of it in their protocols.

Communicating with an older adult

• Introduce yourself, face the patient, and get to their eye level. Many people with hearing loss rely partly on seeing your face.
• Make sure they have their glasses and hearing aids, and that the hearing aids are on.
• Reduce background noise. Turn down the television if you can.
• Speak clearly and a little slower, in a lower pitch rather than louder. Shouting distorts speech and is heard as anger.
• Ask one question at a time and give time for the answer.
• Talk to the patient, not about them. Family and caregivers are valuable for the baseline, the history and the medication list, but the patient is the person you are caring for, and many older patients can answer for themselves perfectly well.
• Do not assume cognitive impairment from age, hearing loss or slow speech. Assess it.
• Explain what you are about to do before you touch them, and ask before you move them.

The body changes the assessment

• Temperature regulation is impaired. Older adults develop heat illness and hypothermia more easily, sometimes indoors, and may not feel thirsty when dehydrated. Ask about heating, cooling and fluids at home.
• Skin is thin and fragile. It tears and bruises easily, so handle limbs gently, pad equipment and take care removing tape.
• Pressure injuries can start quickly on a hard surface, including a long board or a long wait on the floor.
• A curved upper spine is common. A patient with kyphosis cannot lie flat on a board without gaps; pad to support them where they are rather than forcing them straight.
• Pain may be reported less, or described differently, so a serious problem can seem minor.
• Breathing reserve is reduced, so a respiratory infection or a rib fracture can tip a patient into respiratory failure faster.

Elder abuse and neglect

EMS is often the only outside party to see inside an older person's home, which makes EMS providers important observers of abuse and neglect. Abuse may be physical, sexual or emotional; it includes financial exploitation, neglect by a caregiver, abandonment, and self-neglect, where a person can no longer meet their own basic needs.

• Injuries that do not match the explanation, or explanations that change.
• Bruises in patterns, in various stages of healing (although you cannot reliably age a bruise by its color), or in places falls do not usually reach, such as the inner arms or the trunk.
• A delay in calling for help.
• Poor hygiene, untreated pressure injuries, dehydration or malnutrition in a person who depends on a caregiver.
• Missing medications, or medications clearly not being taken as prescribed.
• A caregiver who will not let the patient speak, answers every question for them, or will not leave the room.
• A patient who seems afraid of a caregiver, or withdrawn in their presence.
• A home that is unsafe, unheated or without food.

Document what you see and hear objectively: the conditions, the injuries and the words people used, in quotes where you can. Do not confront a suspected abuser or investigate. Tell the receiving facility what you observed. Reports of suspected elder abuse usually go to your state's Adult Protective Services, and in many states EMS providers are mandatory reporters, but who must report, to whom and how quickly is state law and differs from state to state. Know your state's rule and your agency's policy before the call.

Capacity, refusals and advance directives

Age is not incapacity, and a diagnosis of dementia does not by itself mean a person cannot make a particular decision. Capacity is assessed for the decision in front of the patient at the time, and our guide Capacity and Refusals covers how to assess it and how to run a refusal that holds up.

Many older adults have advance directives: a do-not-resuscitate order, a portable medical order for life-sustaining treatment (often called a POLST, with different names in different states), a living will, or a health care power of attorney naming a decision-maker. Which of these EMS may honor, what makes one valid, and what you do when a family disagrees with the document are set by state law and your protocol, and they vary. Ask early whether there is one, ask to see it, and involve medical control when it is unclear.

Hand over the baseline and the medication list clearly

The short version

• Expect atypical presentations: the heart attack without chest pain, the infection without fever, the shock with a normal heart rate.
• New confusion is a symptom. Find the cause, starting with glucose, oxygen, infection and medications.
• Read the medication list as findings, and ask what changed recently.
• A fall is a presentation, not a diagnosis. Ask why they fell and how long they were down.
• An anticoagulated patient with a head strike can bleed late. A normal first assessment does not rule it out.
• Establish the baseline from somebody who knows the patient, but talk to the patient.
• Delirium is acute and fluctuating; dementia is gradual. Quiet delirium is the one that gets missed.
• Watch for abuse and neglect, document objectively, and know your state's reporting rule.
• Capacity and advance directives follow state law and your protocol. Age alone decides neither.