August 5, 2024

As a society, we are living longer and the birthrate is decreasing. This combination of events has made the elderly the largest growing proportion of the population. As many of you know, aging impacts our body systems. These impacts cause less reserve and increased morbidity and mortality when comparing the same disease process in an elderly person to their younger counterpart. Aging affects the following systems: 

• Pulmonary: We have less alveolar surface area as we age. This makes less surface area for oxygen exchange. Also, our muscles are weaker so we can’t breathe as deeply, and our chest wall is stiffer. All these lead to less pulmonary reserve. 

• Cardiac: The heart doesn’t squeeze as hard as we age, and the arteries are stiffer. This leads to decreased cardiac output and the inability to compensate for shock. 

• Renal: The kidneys don’t filter as efficiently as we age. Therefore, toxins and fluids may be retained. 

• Hepatic: The liver atrophies or decreases in size as we age. This may cause a buildup of toxins in the body.  

• GI: The GI tract slows down as we age. This can cause the elderly to feel full earlier and eat less, which can cause malnourishment. The elderly are often constipated as well. 

• Immune: The immune system is weaker and slower to respond, which makes the elderly more susceptible to infections and sepsis. They also need higher doses of vaccinations. 

• Musculoskeletal: Muscle mass and bone density decrease as the body ages. The elderly are more at risk for hypothermia, fractures, and skin tears.

• Neurological: The brain atrophies with age. The nerve responses are slower. This can increase the risk of falls and intracranial hemorrhage. Also, there can be cognitive decline and the onset of dementia. 

As shown by all the changes above, the elderly have less reserve and are at increased risk for poor outcomes due to the physiologic changes that occur as the body ages. 

Be safe and have a great summer,

Anthony Daher, MD

August 12, 2024

As we continue reviewing aging and its effects on the body, we must consider the impact on cognitive function. An estimated 6.9 million Americans suffer from dementia, but there are many different forms, and it is considered a spectrum of disease. The most common is Alzheimer’s dementia, which accounts for 70% of all dementia. Other forms include Parkinson’s, Lewy Body, and Vascular Dementia.  

Dementia is a progressive decline in cognitive function affecting short-term memory before progressing. It is caused by a buildup of amyloid and tau protein in the brain. Alzheimer’s is diagnosed with a combination of laboratory and neurologic tests. A new blood test for tau protein is currently in development, which may alter the future of diagnosing Alzheimer’s dementia. 

• Early Stage 

• The person with early-stage dementia is still very functional but may have difficulty with concentration. They may need frequent reminders to accomplish tasks. 

• Middle Stage 

• As dementia progresses to the middle stage, the person may get lost easily or wander away from home. They may need hands-on care at this point and their personality may change. They may become easily upset. 

• Late Stage 

• Once a person develops late-stage dementia, they are severely confused and may no longer recognize their family. They will need continuous care. 

Our approach to the dementia patient must also change. It is important to speak in a slow, deliberate manner. We must eliminate distractions to allow them to concentrate on our questions or instructions. The instructions should be single as patients with dementia struggle with multistep tasks. Also, remember that patients pick up on our nonverbal cues. Speak in a calm, reassuring tone to help put the patient at ease.

Lastly, remember that caring for a dementia patient can be stressful. The stress that we encounter is only a fraction of the stress that family feels with continuous care of their loved one with dementia. Their response may vary greatly. Some families may be in denial. Others may feel frustration. Caregivers are often isolated from their social support as caring for their loved one takes all their time. Try to understand the situation from their perspective. It will make providing care easier. 

Be safe and have a great week,

Anthony Daher, MD

August 19, 2024

As we age, physiologic changes occur. These changes make the body less able to compensate for illness and cause increased morbidity and mortality, especially in trauma. The elderly are more likely to die from their trauma and have worse outcomes at the same trauma severity scores than their younger counterparts. One-year mortality for a trauma patient over age 75 is 32.2% as compared to 6.9% for those aged 18-54—almost a 5-fold increase! Another review of the trauma database showed a 6.8% increase in mortality for every year over age 65. A study showed elderly patients are less likely to be taken to a trauma center. The elderly are taken to trauma centers 33% of the time as compared to 47% in the general population. This is often because the seriousness of the injury is not obvious in the initial presentation. The elderly may not have as much pain or tachycardia as expected from a patient in shock. Because of this disparity, geriatric-specific trauma criteria were proposed. 

Ohio Geriatric Trauma Field Destination Criteria 

Trauma center evaluation indicated if any:  

1. GCS < 14 w/known or suspected TBI  

2. SBP < 100 mmHg  

3. Fall from any height w/known or suspected TBI  

4. Multiple body system injuries  

5. Struck by vehicle  

6. Any proximal long bone fracture after MVC  

7. Elderly patients with co-morbidities (consider)  

These criteria were shown to be more sensitive in determining the need for treatment in a trauma center. Using these specific criteria, the sensitivity in determining the need for trauma center care improved from 61% to 93% compared to the general Ohio Adult Trauma Triage criteria. We should all be careful in assessing our geriatric trauma patients and in our choice of destination for these trauma victims. 

Be safe and have a great week,

Anthony Daher, MD

August 26, 2024

The elderly often call 911 for a lift assist. This is a common call that EMS providers should take seriously. Lift assists account for about 5% of all EMS calls and most are repeat calls to the same address. There is also a 50% chance of a repeat call from the same person in the next 30 days.  

A study in 2013 followed patients for 14 days after they called for a lift assist. The researchers found that 21% of the patients had to be taken to the Emergency Department (ED) within those 14 days. Fifty percent of those taken to the ED were admitted. The study also showed that 1% of those who called for a lift assist died within two weeks after calling 911.  

A full assessment is required for all lift assist calls. Questions that should be asked include: 

• Why did the person end up on the ground? 

• Did they have an arrhythmia?  

• Are they dehydrated?  

• Do they have an infection? 

Note that any abnormal vital signs might be a clue to a more serious problem. 

Our geriatric population in the United States has increased in proportion. The percentage of Americans over age 65 is currently 17% and is expected to climb to 23% of the population by 2050. As shown in the Figure 1 below, the population of people 65+ increased from 54.1 million in 2019 to 80.8 million in 21 years, an increase of about 49%. The population is living longer and the birth rate is decreasing.

More of our patients will be older than ever, so we must be aware of the physiologic changes in all the body’s organ systems. These changes cause an increase in morbidity and mortality due to illness and trauma when compared to younger patients. Neurologic system deterioration may cause dementia, affecting many of our patients. We must be informed of the challenges in caring for these patients and the stress that it puts on their families, who often take the burden of trying to care for them.

Be safe and have a great week,

Anthony Daher, MD