• Elderly people constitute an ever-increasing proportion of patients presenting to the health care system, particularly to the emergency care sector.
  • The health problems of older people are quantitatively and qualitatively different from those of younger people. The special problems of older people require special approaches.
  • The aging process is accompanied by changes in physiologic function. The decrease in the functional capacity of various organ systems can affect the way in which the patient responds to illness.
  • A variety of changes occur in the cardiovascular system as a person ages. The heart hypertrophies (enlarges), arteriosclerosis (the stiffening of vessel walls) develops, and the electric conduction system of the heart deteriorates.
  • A person’s respiratory capacity also undergoes significant reductions with age due to decreases in the elasticity of the lungs and in the size and strength of the respiratory muscles, calcification of costochrondral cartilage in the chest wall, and musculoskeletal changes.
  • Geriatric patients may experience renal system changes. Although the kidneys of an elderly person may be capable of dealing with day-to-day demands, they may not be able to meet unusual challenges, such as those imposed by illness. Therefore, acute illness in elderly patients is often accompanied by derangements in fluid and electrolyte balance.
  • Changes in the endocrine system may lead to diabetes and thyroid abnormalities in older patients.
  • Aging brings a widespread decrease in bone mass in men and women, but especially among postmenopausal women. Bones become more brittle and tend to break more easily.
  • Changes in the nervous system lead to a decrease in the performance of sense organs, as evidenced by visual changes (glaucoma and cataracts are common) and hearing loss.
  • Diseases of the heart remain the leading cause of death among older adults in the United States. Heart attack is the major cause of morbidity and mortality in people older than 65 years, and its potential for mortality increases significantly after 70 years.
  • Stroke is a significant cause of death and disability in elderly people. More than 80% of all stroke deaths occur in persons older than 65 years, and stroke is the leading cause of long-term disability at any age.
  • Chronic lower respiratory disease, influenza, and pneumonia remain in the top five causes for geriatric deaths.
  • A geriatric patient with diabetes is at increased risk for hypoglycemia for several reasons: medications, inadequate or irregular dietary intake, inability to recognize the warning signs due to cognitive problems, and/or blunted warning signs. Delirium may be the only indication of hypoglycemia in an elderly patient.
  • Older diabetics whose blood glucose levels tend to be high are prone to hyperosmolar hyperglycemic nonketotic (HHNK) coma. The most frequent cause for HHNK is infection. Presentation is likely to be acute confusion with dehydration.
  • Gastrointestinal problems in elderly people include peptic ulcer disease, small bowel obstruction due to gallstones, and stomach or duodenal ulcers (peptic ulcer disease).
  • Osteoporosis is characterized by a decrease in bone mass leading to reduction in bone strength and greater susceptibility to fracture. Osteoarthritis is a progressive disease process of the joints that destroys cartilage, promotes the formation of bone spurs in joints, and leads to joint stiffness.
  • In elderly people, delirium often replaces or confounds the typical presentation caused by a medical problem, an adverse medication effect, or drug withdrawal. Disorders that cause delirium may also include poisons, electrolyte imbalances, nutritional deficiencies, and infections such as urinary tract infections and pneumonia.
  • Unlike delirium, dementia is a disease that produces irreversible brain failure. Disorders that cause dementia include conditions that impair vascular and neurologic structures within the brain, such as infections, stroke, head injuries, poor nutrition, and medications.
  • The two most common degenerative types of dementia in older people are Alzheimer’s disease and multi-infarct or vascular dementia, both of which cause structural damage to the brain.
  • Elderly people are particularly prone to adverse drug reactions because of changes in the following: drug metabolism because of diminished hepatic function; drug elimination because of diminished renal function; body composition, including increased body fat and decreased body water, altering the distribution of drugs through the various body compartments; and the responsiveness to drugs of the central nervous system.
  • Alcohol is the preferred substance of abuse among older persons, in whom its use is on the rise. A much smaller but increasing segment of the geriatric population uses illicit drugs.
  • Depression in elderly patients can mimic the effects of many other medical problems (such as dementia). Risk factors for depression in an older person include a history of depression, chronic disease, and loss (function, independence, or significant others).
  • Several factors place an elderly person at higher risk of trauma than a younger person: slower reflexes, visual and hearing deficits, equilibrium disorders, and an overall reduction in agility.
  • Most geriatric trauma cases involve falls or motor vehicle crashes. Falls among elderly people are evenly divided between those resulting from extrinsic (external) causes, such as tripping on a loose rug or slipping on ice, and those resulting from intrinsic (internal) causes, such as a dizzy spell or a syncopal attack.
  • Knowing what is and what is not part of the aging process constitutes the first challenge in assessing elderly patients. A second challenge is that signs and symptoms of disease may be altered from their presentation in younger patients as a consequence of aging.
  • When a patient’s chief complaint seems trivial, it may be necessary to go through a review of systems to confirm that you are not missing important pieces of information. If any of the screening questions yields a positive answer, follow up with further questions.
  • The physical exam of older patients can be difficult. Poor cooperation and easy fatigability may require that you keep manipulations of the patient to a minimum. You may have to peel many layers of clothing off elderly patients to perform an adequate exam.
  • Infections in older persons can be severe and dangerous. Consider sepsis whenever you see a hot, flushed patient who is also tachycardic and tachypneic.
  • Elder abuse is any form of mistreatment that results in harm or loss to an older person. Five types of abuse are distinguished: physical, sexual, emotional, neglect, and financial.