Old People in Cold Houses

My elderly patient sits in the dark with a knit cap on her head and a wool scarf wrapped around her neck. Even though it is only October,  I suspect she is already trying to save on fuel costs. She, like some of my older patients, lives in a big old house built in the early 1900’s. Last year I had a patient who sat in his kitchen all day during the winter. The doors to his kitchen were closed and he kept an electric heater on  to take the chill out of the air. When his temperature started to run low, I had him put on a hat and a heavy sweater and drink some hot fluids. I insisted he turn the heat in his house up higher. He was just too close to becoming hypothermic.

I’m worried that this year’s economic situation will really threaten the well-being of my elderly patients this winter. We try to get them all hooked up with fuel assistance funded through the state. Most of them qualify but there are others that are either too proud or have just a bit too much income to meet the strict requirements.

The elderly are more at risk for hypothermia than younger people. They don’t move around very much.  So often I see  patients sitting in their recliners every time I see them no matter what time of day I go. Immobility is a risk factor. Many of my older patients have lost a great deal of weight. There’s not much fat covering their frail bones. I’ve had many female patients  weighing between 85 and 95 pounds. Malnutrition is a big risk factor.

Caregivers need to be on the alert for the signs and symptoms of hypothermia. Anyone with a temperature of less than 35 degrees celsius or 95 degrees farenheit may start to exhibit the signs and symptoms. According to The Merck Manual of Geriatrics the following are signs to be on the lookout for:

 

Symptoms and signs of hypothermia are insidious and may be transient. Elderly people with a body temperature between 35° and 36.1° C often report feeling cold, but patients with a lower body temperature usually do not, although they feel cool to the touch. Many people have cold hands or feet in winter, but patients with hypothermia also have cold abdomens and backs. Their skin has a cadaveric pallor and chill, and pressure points have erythematous, bullous, or purpuric patches. Subcutaneous tissues are firm, probably because of edema, which also causes puffiness, especially of the face. Shivering may not occur. Instead, marked rigidity develops accompanied by a generalized increase in muscle tone; occasionally, a fine tremor is present.

Neurologic findings include thick, slow speech and ataxic gait; deep tendon reflexes are depressed. Sleepiness and confusion may progress to coma. Pathologic reflexes and extensor plantar responses may be present, and pupils may be dilated and sluggishly reactive. Focal signs, seizures, paralysis, and sensory loss may also occur.

Cardiovascular findings are tachycardia and elevated BP initially. Later, hypotension and progressive sinus bradycardia occur. Severe hypothermia can lower BP and heart rate to barely detectable levels; rarely, these findings lead to an erroneous pronouncement of death. Various cardiac arrhythmias (eg, atrial fibrillation and flutter, premature ventricular beats, idioventricular rhythm) may occur. Cardiac arrest due to ventricular fibrillation or asystole is increasingly likely as body temperature falls to < 30° C. Vasoconstriction, if present, may mask hypovolemia, resulting in sudden shock or cardiac arrest when peripheral vasculature dilates during warming (rewarming collapse).

GI findings can include abdominal distention, diminished or absent bowel sounds, and, less often, vomiting. Pancreatitis is usually not apparent until after warming

So it is that time of year for me to be extra vigilant about the health and well-being of my elderly patients. That elderly patient of mine sitting in a cold house with a knit cap on will be someone I will need to keep a close eye on.  I’ll take their temperatures, check their thermostats, and make sure their caretakers know what to look for. Let’s hope we have a mild winter! 

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