Hospitalization of the Elderly

Hospitalization of the ElderlyHospitalization of the Elderly

Tracey Doering, MDTracey Doering, MD

tracey.doering@baptisthospital.comtracey.doering@baptisthospital.com

May 20, 2008May 20, 2008

The Dangers of Going to BedThe Dangers of Going to Bed

Look at the patient lying long in bed.What a pathetic picture he makes.The blood clotting in his veins,The lime draining from his bones,The scybala stacking up in his colon,The flesh rotting from his seat,The urine leaking from his distended bladder,And the spirit evaporating from his soul.

Dr. Richard Asher, British Medical Journal, 1947

DemographicsDemographics

Population over age 65 is now 13%, and Population over age 65 is now 13%, and projected to be 20% by 2030.projected to be 20% by 2030.

38% of hospital admissions 38% of hospital admissions 49% of hospital days49% of hospital days Severity of illness risingSeverity of illness rising Rates of hospitalization are twice as great in Rates of hospitalization are twice as great in

pts over age 85pts over age 85

Consequences of HospitalizationConsequences of Hospitalization

23.3% risk of being unable to return home 23.3% risk of being unable to return home and require nursing home placementand require nursing home placement

35% decline in some basic ADL35% decline in some basic ADL One study showed 50% of elderly patients One study showed 50% of elderly patients

experienced some kind of complication experienced some kind of complication related to hospitalizationrelated to hospitalization

Hazards Hazards

Functional declineFunctional decline ImmobilityImmobility DeliriumDelirium DepressionDepression RestraintsRestraints

Adverse drug reactionAdverse drug reaction Nosocomial infectionsNosocomial infections IncontinenceIncontinence MalnutritionMalnutrition Pressure UlcersPressure Ulcers

Functional declineFunctional decline

0%

10%

20%

30%

40%

50%

60%

70%

80%

timed >40sec timed 20-40 timed <20

Hansen, etal, JAGS, 47: 360-365, 1999

Functional DeclineFunctional Decline

Data of five studies combinedData of five studies combined 19% decline at 3 month follow up19% decline at 3 month follow up If declined in hospital, 41% failed to return If declined in hospital, 41% failed to return

to preadmission statusto preadmission status 40% declined in IADL function at three 40% declined in IADL function at three

monthsmonths

Functional Decline-Independent Functional Decline-Independent PredictorsPredictors

Hospital Admission Risk ProfileHospital Admission Risk Profile Increasing AgeIncreasing Age Lower MMSELower MMSE Lower preadmission IADL scoresLower preadmission IADL scores

J Am Geriatr Soc 1996; 44: 251-7

IDENTIFY FRAILITY AND VULNERABILTY ON ADMISSION

J Am Geriatr Soc 2007; 55: 1705-11

HazardsHazards

Functional declineFunctional decline ImmobilityImmobility DeliriumDelirium DepressionDepression restraintsrestraints

Adverse drug Adverse drug reactionsreactions

Nosocomial infectionsNosocomial infections IncontinenceIncontinence MalnutritionMalnutrition Pressure ulcersPressure ulcers

ImmobilityImmobility

Review of studies showed that bed rest was Review of studies showed that bed rest was associated with worse outcomes after associated with worse outcomes after medical or surgical procedures, or primary medical or surgical procedures, or primary treatment of medical conditionstreatment of medical conditions

Lancet 1999; 354: 1229-33

HazardsHazards

Functional declineFunctional decline ImmobilityImmobility DeliriumDelirium DepressionDepression restraintsrestraints

Adverse drug Adverse drug reactionsreactions

Nosocomial infectionsNosocomial infections IncontinenceIncontinence MalnutritionMalnutrition Pressure ulcersPressure ulcers

DeliriumDelirium

Most common hazard of hospitalizationMost common hazard of hospitalization MultifactorialMultifactorial 14-56% have it on admission14-56% have it on admission 12-60% acquire it12-60% acquire it 32%-67% go unrecognized32%-67% go unrecognized Misdiagnosed as dementiaMisdiagnosed as dementia Longer length of stay, increased morbidity Longer length of stay, increased morbidity

and mortality, and institutionalizationand mortality, and institutionalization

Factors in DeliriumFactors in Delirium

PredisposingPredisposing AgeAge Impaired cognitionImpaired cognition Dependence in ADLSDependence in ADLS High medical High medical

comorbiditycomorbidity

PrecipitatingPrecipitating >6 meds, >3 new>6 meds, >3 new Psychotropic medsPsychotropic meds Acute medical illnessAcute medical illness Vascular or cardiac Vascular or cardiac

surgerysurgery Hip fxHip fx DehydrationDehydration Environmental changeEnvironmental change

Medications and DeliriumMedications and Delirium

Opioids (especially meperidine)Opioids (especially meperidine) Anticholinergics: antidepressants, Anticholinergics: antidepressants,

antihistamines, anipsychotics, antihistamines, anipsychotics, antispasmodicsantispasmodics

BenzodiazepinesBenzodiazepines Cardiac drugs: digoxin, amiodaroneCardiac drugs: digoxin, amiodarone Any drug with action in CNSAny drug with action in CNS

InterventionIntervention

00.050.1

0.150.2

0.250.3

0.350.4

0.45

Day1

Day3

Day5

Day7

Day9

Day11

usual careintervention

Inouye, etal, NEJM 340:669-76, 1999

Management effortsManagement efforts

Adequate CNS oxygen deliveryAdequate CNS oxygen delivery Fluid/electrolyte balanceFluid/electrolyte balance Teat severe painTeat severe pain Nutritional intakeNutritional intake Early mobilization and rehabEarly mobilization and rehab Early identification on post op complicationsEarly identification on post op complications Eliminate unnecessary medsEliminate unnecessary meds Environmental stimuliEnvironmental stimuli

Agitated deliriumAgitated delirium

Appropriate diagnostic evaluationAppropriate diagnostic evaluation Calm reassurance, family, sitterCalm reassurance, family, sitter If absolutely necessary: haldoperidol 0.25-If absolutely necessary: haldoperidol 0.25-

0.5 mg every 4 hrs as needed0.5 mg every 4 hrs as needed

HazardsHazards

Functional declineFunctional decline ImmobilityImmobility DeliriumDelirium DepressionDepression restraintsrestraints

Adverse drug Adverse drug reactionsreactions

Nosocomial infectionsNosocomial infections IncontinenceIncontinence MalnutritionMalnutrition Pressure ulcersPressure ulcers

DepressionDepression

Major depression: 10-21%Major depression: 10-21% Minor depressive symptoms 14-25%Minor depressive symptoms 14-25% UnderrecognizedUnderrecognized Poorer outcomesPoorer outcomes Higher mortality rate, unrelated to severity of Higher mortality rate, unrelated to severity of

medical illnessmedical illness More likely to deteriorate in hospital, and less More likely to deteriorate in hospital, and less

likely to improve at discharge or at 90 dayslikely to improve at discharge or at 90 days

Depression and mortality

0

20

40

60

80

100

120

follow-up, months

surv

ival

%

<5 symptoms>6 symptoms

Ann Intern Med 1999; 130: 563-9

HazardsHazards

Functional declineFunctional decline ImmobilityImmobility DeliriumDelirium DepressionDepression restraintsrestraints

Adverse drug Adverse drug reactionsreactions

Nosocomial infectionsNosocomial infections IncontinenceIncontinence MalnutritionMalnutrition Pressure ulcersPressure ulcers

RestraintsRestraints

In 1992, 7.4%-17% of medical pts were In 1992, 7.4%-17% of medical pts were restrainedrestrained

In 1998, 3.9%-8.2%In 1998, 3.9%-8.2% Reasons: prevent disruption of therapy, Reasons: prevent disruption of therapy,

reduce falls, and confine confused patientsreduce falls, and confine confused patients Evidence does not support thisEvidence does not support this Serious negative outcomes resultSerious negative outcomes result

HazardsHazards

Functional declineFunctional decline ImmobilityImmobility DeliriumDelirium DepressionDepression restraintsrestraints

Adverse drug Adverse drug reactionsreactions

Nosocomial infectionsNosocomial infections IncontinenceIncontinence MalnutritionMalnutrition Pressure ulcersPressure ulcers

Adverse drug reactionsAdverse drug reactions

Most frequent iatrogenic complicationMost frequent iatrogenic complication Increased length of stay, higher costs, Increased length of stay, higher costs,

doubling of risk of deathdoubling of risk of death Risk increases exponentially with number Risk increases exponentially with number

of medicationsof medications High risk: greater than 4 or 5 drugsHigh risk: greater than 4 or 5 drugs

Prescribing guidelinesPrescribing guidelines

Know medications that pt is takingKnow medications that pt is taking Individualize therapyIndividualize therapy Reevaluate dailyReevaluate daily Minimize dose and number of drugsMinimize dose and number of drugs Start low, go slowStart low, go slow Treat adequately; do not withhold therapyTreat adequately; do not withhold therapy Recognize new symptoms as potential drug effectRecognize new symptoms as potential drug effect Treatment adherenceTreatment adherence

Medications to avoidMedications to avoid

AntihistaminesAntihistamines Narcotic analgesicsNarcotic analgesics BenzodiazepinesBenzodiazepines Tricyclic antidepressantsTricyclic antidepressants Histamine-2 receptor antagonistsHistamine-2 receptor antagonists

Important Problem drugsImportant Problem drugs

WarfarinWarfarin DigoxinDigoxin insulininsulin

PolypharmacyPolypharmacy

No single tool can identify the causeNo single tool can identify the cause Many medications are often necessary to Many medications are often necessary to

treat multiple diseases (DM, CHF, treat multiple diseases (DM, CHF, hyperlipidemia)hyperlipidemia)

Some causes: multiple prescribers, multiple Some causes: multiple prescribers, multiple pharmacies-drug interactions, and drug pharmacies-drug interactions, and drug duplicationsduplications

Polypharmacy PreventionPolypharmacy Prevention

Know indication of each medicationKnow indication of each medication ASK: safer non pharmacologic alternativeASK: safer non pharmacologic alternative ASK: treating a side effect of another medASK: treating a side effect of another med ASK: Do contraindications existASK: Do contraindications exist ASK: duplicate side effects of other medsASK: duplicate side effects of other meds ASK: Interact with other medsASK: Interact with other meds ASK: Increase complexity of regimenASK: Increase complexity of regimen

J Amer Geriatrics Society 56: 861-868, 2008

HazardsHazards

Functional declineFunctional decline ImmobilityImmobility DeliriumDelirium DepressionDepression restraintsrestraints

Adverse drug Adverse drug reactionsreactions

Nosocomial Nosocomial infectionsinfections

IncontinenceIncontinence MalnutritionMalnutrition Pressure ulcersPressure ulcers

Nosocomial infectionsNosocomial infections

50% of cases are in elderly patients50% of cases are in elderly patients Urinary tract, lungs and gastrointestinal Urinary tract, lungs and gastrointestinal

tracttract Risks: older age, catheters, antibiotics, Risks: older age, catheters, antibiotics,

fecal or urinary incontinence, fecal or urinary incontinence, glucocorticoidsglucocorticoids

Resistant organisms: Get records of Resistant organisms: Get records of cultures from nursing homescultures from nursing homes

Prevention measuresPrevention measures

Hand washingHand washing Limit use of broad spectrum antibioticsLimit use of broad spectrum antibiotics Discharge patients as soon as possibleDischarge patients as soon as possible Limit use of in-dwelling catheters as much Limit use of in-dwelling catheters as much

as possibleas possible Reassess need for in-dwelling catheters Reassess need for in-dwelling catheters

dailydaily

HazardsHazards

Functional declineFunctional decline ImmobilityImmobility DeliriumDelirium DepressionDepression restraintsrestraints

Adverse drug Adverse drug reactionsreactions

Nosocomial infectionsNosocomial infections incontinenceincontinence MalnutritionMalnutrition Pressure ulcersPressure ulcers

Urinary incontinenceUrinary incontinence

35% of hospitalized patients35% of hospitalized patients 5% acquire it in the hospital5% acquire it in the hospital Remember transient causes: DIAPPERSRemember transient causes: DIAPPERS Not an indication for a catheterNot an indication for a catheter Void q 2 hoursVoid q 2 hours Falls occur with patients trying to get to the Falls occur with patients trying to get to the

bathroombathroom

NutritionNutrition

Independent risk factor for mortalityIndependent risk factor for mortality Assess at admissionAssess at admission Minimize NPO ordersMinimize NPO orders Consequences of malnutrition: pressure Consequences of malnutrition: pressure

ulcers, impaired immunity, and longer ulcers, impaired immunity, and longer length of staylength of stay

Nutrition

0

10

20

30

40

50

60

well mod mal sev mal

level of nourishment

% in

depe

nden

t

admday 90one year

Covisky, etal JAGS, 47: 532-538

What the admitting care team can What the admitting care team can dodo

Establish baselineEstablish baseline Compare baselineCompare baseline Prevent iatrogenic illnessPrevent iatrogenic illness Understand patient valuesUnderstand patient values Initiate discharge planningInitiate discharge planning Make walk rounds with nurseMake walk rounds with nurse Hold family conferencesHold family conferences ImmunizeImmunize

Establish baselineEstablish baseline

ADLSADLS IADLSIADLS MobilityMobility Living situationLiving situation Social supportSocial support Discuss and obtain advance directivesDiscuss and obtain advance directives

Compare baselineCompare baseline

Functional assessment-current ADL levelFunctional assessment-current ADL level Assess mobilityAssess mobility Assess cognitionAssess cognition Estimate length of stayEstimate length of stay Expected discharge siteExpected discharge site

Daily roundsDaily rounds

CathetersCatheters Central linesCentral lines MedicationsMedications Nasal cannulasNasal cannulas TelemetryTelemetry restraintsrestraints Therapies needed?Therapies needed? Target discharge dateTarget discharge date

DischargeDischarge

Reassess ADLSReassess ADLS Check mobilityCheck mobility Do not discharge if: new fever, delirium, Do not discharge if: new fever, delirium,

hypotension or severe hypertensionhypotension or severe hypertension Assess home needs to be sure they are metAssess home needs to be sure they are met

Improve transitions of careImprove transitions of care

MedicationsMedications TransportationTransportation Medical SuppliesMedical Supplies Home or transition settingHome or transition setting Pt participationPt participation Food and mealsFood and meals Financial concernsFinancial concerns

ReadmissionReadmission

12-66% elderly patients readmitted 1-6 12-66% elderly patients readmitted 1-6 months post dischargemonths post discharge

Frequently premature and poorly structuredFrequently premature and poorly structured

Complex Discharge PlanningComplex Discharge Planning

70 years of age of older and living alone70 years of age of older and living alone Admitted from nursing home Admitted from nursing home ComatoseComatose Complex medication regimenComplex medication regimen Disorientation, confusion, forgetfulnessDisorientation, confusion, forgetfulness History of repeat admissionsHistory of repeat admissions In need of special therapiesIn need of special therapies

Complex discharge PlanningComplex discharge Planning

Lack of social supportLack of social support Limited activities of daily livingLimited activities of daily living Multiple medical diagnosesMultiple medical diagnoses Previously or newly diagnosed as disabledPreviously or newly diagnosed as disabled Requiring wound careRequiring wound care Victim of severe accidentVictim of severe accident

DOES THE PATIENT UNDERSTAND?

ComprehensionComprehension

Study of 125 patients’ comprehension of 50 Study of 125 patients’ comprehension of 50 of the most common health words found in of the most common health words found in transcripts of interviewstranscripts of interviews

98% understood “vomit”98% understood “vomit” 13% understood “terminal”13% understood “terminal” 18% understood “malignant”18% understood “malignant” 22% understood “nerve”22% understood “nerve”

Systematic ApproachesSystematic Approaches

Acute Care for the Elderly Units (ACE Acute Care for the Elderly Units (ACE units)units)

Hospital Elder Life Program (HELP)Hospital Elder Life Program (HELP) Study results varyStudy results vary Some with dramatic reduction in loss of Some with dramatic reduction in loss of

functional statusfunctional status Substantial interdisclipinary team Substantial interdisclipinary team

interactioninteraction

ACE UNITACE UNIT

Focuses on 4 components: Focuses on 4 components: 1. Prepared environment for mobility and 1. Prepared environment for mobility and

orientationorientation 2. Primary nurse assessment and protocols2. Primary nurse assessment and protocols 3. Early SW intervention3. Early SW intervention 4. Geriatrician review4. Geriatrician review

HELPHELP

Multicomponent intervention to prevent Multicomponent intervention to prevent declinedecline

Not unit basedNot unit based Volunteers used extensivelyVolunteers used extensively Broad admission screenBroad admission screen Targeted interventionsTargeted interventions

Home Hospital CareHome Hospital Care

Patient preferencesPatient preferences Potential to avoid hazards of hospitalizationPotential to avoid hazards of hospitalization Guidelines issued for pneumonia care at Guidelines issued for pneumonia care at

home by ACCPhome by ACCP

Chest 2007; 127: 1752-63

Palliative care and end of life Palliative care and end of life issuesissues

Resuscitation statusResuscitation status Advance DirectivesAdvance Directives Rehospitalize? Rehospitalize? What treatments?What treatments?

SummarySummary

The hospital can be a hazardous place for eldersThe hospital can be a hazardous place for elders Don’t assume delirium is dementiaDon’t assume delirium is dementia Start discharge planning on day 1-know your Start discharge planning on day 1-know your

patient and their circumstancespatient and their circumstances COMMUNICATE-particularly goals of careCOMMUNICATE-particularly goals of care MOBILIZE!MOBILIZE! Do no harm-avoid iatrogenic illness if possibleDo no harm-avoid iatrogenic illness if possible

Key ReferencesKey References

Society of Hospital MedicineSociety of Hospital Medicine 1-800-843-3360, ext. 24371-800-843-3360, ext. 2437 CD-ROM with a compendium of resources CD-ROM with a compendium of resources

for inpatient care of the elderlyfor inpatient care of the elderly Acute Hospital Care for the Elderly Patient: Acute Hospital Care for the Elderly Patient:

Its Impact on Clinical and Hospital Its Impact on Clinical and Hospital Systems of Care, Systems of Care, Medical Clin NAMedical Clin NA 92: 92: 387-406, 2008387-406, 2008