According to International Trauma Life Support (ITLS), seventy percent of all ambulance transports involve the mature age group. Further, ITLS says thirty percent of all ambulance transports currently involve people over sixty-five. As we grow older, the body poses special challenges and changes. The high percentage of healthcare used by older people should not surprise us; however, the early start of the aging process---changes begin as young as 30--does surprise most people, and even in EMS we know little about normal body changes. If EMS providers can understand the natural variations brought by time, they can effectively treat aging bodies.

Consider the changes of time by body systems

With the years, nerves that transfer messages to move muscles for activities such as picking up a fork or driving a car become less effective at transmitting messages. Slower messages to the muscles mean slower reaction times and a greater likelihood of dropping things. Then, too, slowed reactions to emergencies can result in auto accidents that were formerly avoided. Programs such as 55 Alive reinforce good driving habits and can help compensate for slowed movements.

Similar to the slowing of messages, cells governing the senses become less numerous over time so that experiences can lose their savor. This becomes literally true with declining taste buds; food just doesn't taste as good, so we eat less and are less inclined to eat. Meat, for example, doesn't taste right, so we eat less protein. Women who give up on meat tend to easily become anemic. In extreme cases, anemia can kill. The loss of taste may mean we eat so little that we court malnutrition. In many households containing single seniors, cooking for one grows less attractive.

Consider the bones in the body next. As humans age, calcium leaches from the bones; this makes older people more likely victims of fractures. Joint and tendon degeneration leads to stiffness and decreasing flexibility with an increasing tendency to fall. The falls people might never suffer as youths occur more frequently with advancing age and result in breaks that can become life threats. According to ITLS, falls account for the majority of injuries in geriatric populations.

Bones such as the spinal column settle and height actually shortens. Dowager humps grow so that falls that can become spinal injuries grow difficult to splint with a backboard unless you use plenty of padding and support around the protruding prominences of the back.

Where bones articulate other issues of aging appear. Arthritis affects joints, challenging fine manipulations, once more increasing the frequency of dropped items. More dropped items increase the likelihood of bruises, bumps, and burns. Even if fine muscle control remains, constant pain can cause voluntary motion restriction. When arms and legs hurt, people don't use them. The less people use their arms and legs, the less able to use them they become. Again, the likelihood of falls increases along with dropped objects.

With lessening mobility the potential for isolation also increases. Loneliness and concomitant depression threaten people in isolation. Isolated patients don't want people around and most people prefer to avoid a Gloomy Gus so mental health suffers.

Muscle mass also declines over time, and, unless people exercise to maintain muscles, they will grow weaker and fatter. The decrease in the number of nervous system cells coupled with declining muscular strength feed falls. A curl of rug a homeowner once brushed by may now send him or her sprawling, resulting in an EMS call.

Aging eyes, too, contribute to falls. The lens of the eye clouds and pupil size decreases. The eye cannot focus as well, particularly at night. Long before retirement, people grow farsighted and cataracts can thicken, shrinking the precision of sight. Loss of focus makes it hard to see depths, and all this means accidents can increase and drivers may shun night travel.

The most important muscle--the heart--tends to pump less effectively with the passage of time and has less excess capacity to compensate for trauma and illness. After the age of thirty the heart gradually loses up to thirty percent of its pumping capacity. Because its electrical conduction system (like the nervous system in general) degenerates, the heart becomes subject to electrical and rhythmic disturbances--PVC's, atrial fibrillation, bursts of PSVT, bradycardias--which can cause bouts of weakness, fainting, sudden falls (again), and even cardiac arrest. Although many of these changes result from normal aging, the prevalence of heart disease in the U. S. population complicates natural aging.

If the heart loses ground so, too, does the rest of the vascular system. Circulation to the lungs and tissues decreases thirty percent, making it harder to keep tissues oxygenated and free of waste products. In times of stress as in hypoperfusion, dangerous byproducts of anaerobic metabolism grow even more difficult to eliminate.

Kidneys, the great cleaners of blood, also undergo a subtly transformation. The cells in the kidneys that filter the blood of drugs and urine shrink in number, increasing the body's sensitivity to the actions of drugs and poisons. Smaller amounts of both drugs and poisons have a greater exaggerated effect on the body. Because of the body's more unpredictable responses treating disease as we age becomes more uncertain with more variable drug dosing regimens.

The amount of air retained in the lungs--dead space air--increases, leaving less room for exchanged air with each breath. The bones of the chest grow rigid, which, along with weakening diaphragm and chest muscles, limits chest expansion and air movement. By the age of seventy-five a patient can lose as much as half of vital capacity. Add a reduced gag reflex and decreasing numbers of cells that fight bacteria in the lungs, and lungs grow more susceptible to infection and harder to free of it. Pneumonia poses an even more deadly treat to the elderly than to the younger population. Then, too, any history of tobacco use exacerbates lung changes. All this adds up to dyspnea on exertion.

Digestion, which should provide fuel for the blood and kidneys, changes. Gut motility reduces over time leaving stomachs sensitive and slow to consume all types of food. Suddenly, old favorites can upset the stomach. Saliva production shrinks which, in combination with other gastrointestinal changes, can result in poor absorption of nutrients and poor metabolization of medications. Because of reduced motility and dry intestines, constipation increases and the possibility of obstruction grows. Dietary deficiencies increase and the outcome for medical treatments grows more uncertain as even drugs must properly interact with the body's chemicals.

Immune systems and their ability to resist infection and compensate for systemic problems weaken. Older Americans more frequently fall prey to infections of the skin, wounds, lungs, and tissues. These infections can more easily lead to life threats. What never slowed down children can suddenly end a life.

The natural changes of the body increase the incidence and seriousness of injury. Trauma comes from a variety of causes. The falls that cause the majority of geriatric trauma result in fractures to the hip, thigh, wrist, and head injuries. According to ITLS, older Americans have a disproportionately greater chance of dying in trauma than other age groups. Our health care system and particularly emergency medical services do not treat the older trauma patient as effectively as the young patient. Because of our natural changes treatments in trauma must grow more specialized and adapted to our changed bodies.

Sounds depressing, doesn't it? Yet, you can't hold back time forever, advertisements to the contrary notwithstanding. It's natural. It comes. What you can do is anticipate the limitations of the body.

Use your knowledge to improve outcomes for your many older patients starting with prevention

First, "age-proof" houses. This involves anticipating age in the opposite sense as when young parents "baby-proof" a house. Much as everyone would like to escape again to the time of youth, aging happens in a long life. In order to weather the gentle storms of aging, anticipate the weather rather than dream of youth. Acknowledge the potential for bodily changes.

Fall-proof the homes in your service area to avoid the most common cause of injuries in older populations. Anticipate vision changes by promoting clarity so your population will see obstacles and avoid them. Recommend that citizens change light bulbs as soon as they burn out and replace bulbs with new long-life bulbs that will save on energy expenses as well as reducing the frequency of burned out bulbs. Help your community engineer safety into all houses by using night lights with automatic sensors so that no one will surrender to the temptation to save money or avoid wakefulness by moving in the dark. Encourage everyone to get those new eyeglasses rather than put them off so everyone can see what it really is.

To further avoid falls, offer to survey houses with older residents to eliminate tripping traps. Extension and electrical cords should never stretch across any corridor or traffic path. Throw rugs should be removed as they turn too easily into flying carpets that dump the unwary on the ground. Another threat to stability comes in the form of family pets, particularly at night. Elderly cats and dogs, much like their human masters and mistresses, slow down as they age. Both pets and owners grow less nimble, less able to dance from between each other's feet. This mutually shared slowness makes tripping over pets in the gloom of night a real danger. Encourage families to keep pets consigned to a separate room whenever possible and especially at night. Toys, newspapers, magazines--anything that doesn't belong on the floor--poses a threat to balance and orthopedic integrity. Discourage your households from leaving water glasses and china on the floor beside living room chairs.

Because slower nerve cells slow reactions, your older community members should make several trips to the car for bulky items like groceries. Having a free hand to grab railings can prevent a fall. The increased number of trips will also give men and women free easy exercise to keep those bones and muscles strong. Also, avoiding overburdens improves balance. A useful helper is a table or stand outside the front door so bags have a place while householders fumble for keys.

Although nerves may pass the messages more slowly, your neighbors can protect themselves from falls by keeping stairways clear of obstacles, and maintaining vision at its best. Reinforce good driving habits by offering AARP's 55 Alive driving program. Keeping driving habits sharp can also lower your car insurance as many companies give credit for taking the driving course.

Encourage nutrition, healthcare and exercise

There are malnourished seniors in this, one of the richest nations in the world. Encourage a proper diet and participating in collective meals with family, at clubs, and church dinners can help. That chicken dinner you use as a fundraiser at your department can actually provide a social and nutritional support. Government programs like Meals on Wheels and Senior Nutrition Centers also provide both social interaction and food for those on limited incomes.

Regardless of how healthy your patients feel, encourage them to visit a doctor regularly. They should receive numerous periodic tests--tetanus shots, tDap, prostate specific antigen, BPH exams, mammograms, pap smears, pneumonia vaccines, blood pressure checks, cholesterol and triglyceride tests, blood glucose, and bone density--which a good personal physician will track and order. Offer your station as a clinic site. These measures offer prevention as much as treatment. It is far easier to prevent a disease than it is to cure it.

Finally, enourage your community to practice the most important and marvelous therapeutic treatment physicians have identified: exercise. Exercise lowers blood pressure. Exercise controls blood sugar levels. Exercise strengthens muscles, bones, and especially the most important muscle: the heart. Exercise improves posture and gives greater control walking and moving. Exercise can help maintain lung capacity to breathe. Exercise keeps sex enjoyable. Exercise improves the immune system and ability to recover from falls and illnesses. Exercise practiced with a partner improves social lives. Exercise speeds recovery from musculoskeletal injuries that might otherwise cripple us (just ask any physical therapist). Exercise controls weight and improves mobility impaired by too many steaks and cookies. According to the U.S. Physical Activity Guidelines Advisory Committee, activity results in a thirty percent reduction in the risk of dying from all causes. Exercise is the single most important thing you can do for yourself without a prescription and probably the easiest, whether you choose to walk at the mall, ride a bike, swim, or buy a treadmill.

Aging bodies come naturally. How we react to that aging controls the efficacy of our lives and whether we work with the natural or become its victims. Know where your body will go and how it can help you live.

Jim Medeiros has taught EMT classes for the Lord Fairfax EMS Council in Winchester, VA, worked as its Field Coordinator for EMS Education, and helped start an EMT-Intermediate program at Lord Fairfax Community College in Middletown, Virginia. Currently employed as a paramedic, he works for Valley Medical Transport and teaches with its parent company, Valley Health, in Winchester. Jim Medeiros can be contacted at: jmedeiro@valleyhealthlink.com.

Related:

• EMS Magazine: The Geriatric Patient: How to tailor your assessment and care
• EMS Magazine: Taking EMS Into Tomorrow: Are you ready for the next big thing in EMS?
• EMS Magazine: Beyond the Basics: Geriatric Care
• Trauma Care Bias Targeted in Maryland: Study reports that older patients receive worse treatment for injuries
• Novel Ways to Improve Triage of Elderly Patients