Noon Conf 7/19/06

How to Help your Elderly Patient Survive Hospitalization

Karen Hall, M.DAssociate Professor

Division of Geriatric MedicineUniversity of Michigan

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Objectives

• Review pathophysiology of aging

• Define areas of risk

• Outline management

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Case86 year old woman seen at 8pm in EDBrought in by her daughter because of increasing confusion over

past 24-48 hoursPatient moved in with daughter and son-in-law 1 year ago because

of “memory problems” and difficulty caring for herself. In past 24 hours patient has been wandering around the house, is very confused, fell twice, had several episodes of urinary and fecal incontinence. No cough, SOB. No head trauma. Family denies ETOH.

PHx: HTN, GERD, depression, insomnia, osteoporosis, constipation, diarrhea

Medications: lisinopril, HCTZ, Protonix, Fosamax, Nortriptyline at night, fiber supplement, Ambien at night

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CasePx:Vitals: BP 102/58 - sitting 93/46, heart rate increases from 84 to 100 on

sitting, temperature 95 deg F, RR 16Weight 100 lbs, height 5 feet 3 inches (BMI <25)Confused: not oriented to place, time, keeps trying to get out of bed, unable

to give history, keeps asking for her daughterH/N – dry mouth, pupils reactive, no thyromegaly, chest clear, CVS - no signs of heart failure or murmer or arrythmia, JVP at sternal angle, abdomen - soft and no guarding or rebound, patient moans when lower quadrants palpated, CNS – no focal weakness

Labs: Na 129, K 3.3, Cl 97, HCO3 18; Cr 1.6, BUN 48; CBC: WBC 7 with left shift, Hb 9.2, HCT 29, Plts 138

CXR – poor inspiratory effort, no masses or opacitiesUA - + leukocytes, nitrites, bloodCT head – small vessel disease and mild atrophy, no subdural or CVA

.

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CaseAdmitted: diagnosis of UTI/Sepsis with dehydrationOrders: iv NS 500 cc bolus in ED at 10 pm then 100 cc/hrZocin 3.376 g iv q6h (sodium salt)Docusate sodium (stool softener)Foley catheterPrn: Tylenol, morphine iv 1-3 mg, trazodone 25-50 mg for sleepSent to MedPath overnightArrives on unit at 8am

Examined by medical team at 9am – still confused, JVD 2 cm above SA, trace edema both legs

Haloperidal ordered for agitation: 1-3 mg tid prn

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CaseAt 4pm noted to be increasingly agitated – fighting the nursesFalls out of bed and fractures R hipOn exam has crackles in lung fields, JVD 4 cm above SA, 1+ edema,

pulse O2 86 on RA, 91 on 4 liters O2Diuresed with lasix (60 mg bolus, repeat 20 mg x 2)K drops to 2.9 – bolus of 40 mEq then added to ivHip pinned next day, continues confused, has to be restrained to avoid

pulling out ivs, develops troponin leak (MI), DVT, skin breakdown over sacrum, no BM in 4 days

Haloperidol switched to Seroquel without improvement

Becomes increasingly somulent, vomits and aspirates on 2nd postop day

Develops aspiration pneumonia and dies on 5th postop day

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CaseWhat happened to this patient?Delirium Fluid overload Hip fractureHypokalemiaMIDVTDecubitus ulcersAspiration pneumoniaDeath

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Case

Was this outcome inevitable?

Could we have intervened or prevented some of these complications?

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Why do older patients have problems in hospital?

1. Patients of advanced age lose the ability to maintain homeostatic control of physiologic processes. This is particularly true of “old-old” patients: age > 85 years.

Cardiac and vascular compliance decreases: increased systolic BP, decreased diastolic BP, widened pulse pressure (HTN)

Renal GFR decreases: slower excretion of an excess fluid loadDecreased activity of P450 enzyme system in the liver: slower

hepatic metabolism of drugsColonic motility slows: constipation (risk for gastroparesis)Aging-related peripheral neuropathy: decreased autonomic

sensation with acute disease (acute abdomen)Increased incidence of CNS neurodegeneration: dementia

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Iatrogenic Burden• Steel et al. (1981) identified the burden in a university hospital:

815 patients on two medical floors– 36% of patients had at least one iatrogenic illness– 9% had a major iatrogenic illness– 2% had an iatrogenic illness that contributed to death

• Drugs were a major culprit– Nitrates, digoxin, lidocaine, aminophylline, quinidine and other

antiarrhythmics, heparin/warfarin, penicillin, benzodiazepines, antihypertensives, propranolol, “other”

• Cardiac catheterization and falls• Admitted from nursing home or hospital• HO of “poor” or “critical”, admission to ICU• Age only important if correlated with “poor” condition on admit

Steel K, Gertman PM, Cresenzi C et al. Iatrogenic illness on a general medical service at a university hospital. NEJM 1981; 304:638-42.

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Identified Risks• Multiple chronic diseases (65% of Medicare beneficiaries have

two or more chronic conditions; 4 or more = 99x risk)• Multiple physicians (uncoordinated care)• Multiple drugs and inappropriate drugs/doses• Hospitalization (dementia or immobilization)• Pre-morbid functional status (dependent in ADLs)

Prevention:Case management – facilitate communicationGeriatric interdisciplinary team (only for complex cases)Pharmacist consulationAcute Care for the Elderly (ACE) Units – team sensitive to

preventionAdvance Directives

Wolf JL, Starfeld B, Anderson G. Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med 2002; 162:2269-76.

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On admission• Cognition – document mental status and changes

– Delirium, dementia, depression• Pre-morbid functional status

– mobility• Sensory (vision and hearing)• Nutrition• Fluid status• Bowel function• Pain• Skin Integrity• Medication review• Social supports and caregiver status

Granieri EC, Turner GH, Organist L. Geriatric assessment, coordinated case management, and information systems: an integrated model for delivery of services to nursing home residents. Topics Health Info Management 1997; 18:38-46.

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Cognition • Prevalence of dementia increases dramatically with age• <3% of patients under age 65 are demented• >40% of patients over age 85 are demented• Age over 75 are at risk for confusion and delirium if

they are illOR

if we add new stressor (medications with CNS side effects)

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Cognition • MMSE – best test (validated, tests multiple domains)• Mini-Cog – three item short term recall and clock draw (“draw

a clock face, put the hands at 8:20”)• Delirium testing – Confusion Assessment Method (CAM):

acute onset, fluctuating + disorganized thinking or altered level of consciousness

• Orientation less useful as screen because patients in hospital do not have usual cues to date, time etc.

• Ideally should be easily accessible in medical record• Objective assessment allows tracking of response to

interventions

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Delirium• Most important risk factor for adverse

events• Delirious patients are 5x more likely to

have adverse event in hospital (falls, fractures, aspiration)

• Significant risk for institutionalization• Once present may take days-weeks to

clear

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Delirium• Present on admission – needs to be listed as admitting

diagnosis• Her underlying dementia increases her risk of delirium• Screen for reversible causes on admission and

minimize further exacerbation• UTI is extremely common cause – always worth

checking the UA• Other infections (pneumonia) also common cause of

sudden confusion• CNS (stroke, bleed, infection)• Cancer

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Delirium• Hypoxia, low Hb (<9)• Hyponatremia, hypercalcemia, renal

impairment (elevated Cr), dehydration (elevated BUN)

• Hypoglycemia, thyroid (either up or down)• Medications: narcotics, anticholinergics,

neuroleptics, benzodiazepenes, CNS active– “Old” meds may be the culprit – if in doubt

consider withdrawing if possible– Rapid withdrawal of benzodiazepenes is

dangerous

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Mobility • Dependence in 2 or more ADLs predicts increased risk

of complications in hospital• Important to document baseline (what they did 1 month

ago or before illness) and on admission– Ideally should be in easily accessed part of medical record– 60% have lost 2 or more ADLs from baseline

• Document falls – may be first sign of illness• Gait, Timed Up and Go Test, muscle strength

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Mobility • Observe state of the bed – bedcrumbs, can patient

turn over?• Ask patient to slide to edge of bed• Ask patient to get out of bed if possible every day• Early PT/OT – usually 24 hour delay between

admission and being seen by PT

Unfortunately if they continue to be dependent in 2 or more ADLs at discharge – significant risk for institutionalization

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Vision and Hearing • Sensory deprivation can look like

delerium, or worsen delerium

• If hearing aids lost or family concerned about bringing them – use a pocket amplifier ($50 at Radio Shack)

• Get glasses or other visual aids – prompt patient to use them

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Nutrition• Document BMI (<19 is very high risk)

• Weight loss

• Demented patients at risk for malnutrition (protein calorie or vitamin)

• Check albumin on admission

• Consider swallowing/aspiration risk if demented or neuromuscular disease

• Keep track of “NPO” days

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Fluid status• Dehydration is common

BUT

Aggressive replacement of fluids may overload the heart and kidneys

• Patients lying in bed can tolerate lower BP – main goal is adequate perfusion of organs

• Usually replacing up to ~2/3 of deficit in 24 hours is tolerated, but this patient became overloaded with 2 liters of NS in 18 hours

• An exam at midday would have detected the overload

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Electrolytes• Patient was already hypokalemic and likely

to become worse with NS• If replacing K – need to recheck within 6

hours, as patient may have significant renal disease and be unable to excrete a K load

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Bowel function • Ask about pre-existing constipation, find

out when last BM occurred

• Fiber alone or stool softener alone is usually useless if patient is bedbound

• Constipation can lead to gastroparesis and is a risk for vomiting and aspiration

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Used in Clinical Trials

Correlates with symptoms of straining and difficult evacuation

Also correlates with colonic transit (Type 1 or Type 7 stool is correlated with slow or rapid colonic transit Degen LP, Phillips SF. How well does stool form reflect colonic transit? Gut

1996;39:109-113.

Majority of “constipated”patients have stools that are

Type 1-3

University of Bristol, Scand J Gastroenterol, 1997

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Constipating MedicationsOTC

• Sympathomimetics

• NSAIDS

• Antacids: aluminum, calcium

• Ca supplements

• Iron supplements

• Antidiarrheals: loperamide; bismuth

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Prescription Medications• Narcotics - codeine,morphine• Anticholinergics - benztropine, trihexyphenedyl• Antipsychotics - chlorpromazine • Antidepressants - tricyclics• Antiparkinson - levodopa• Antispasmodics - dicyclomine• Antihistamines - diphenhydramine• Ca blockers - verapamil• Diuretics - furosemide

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Treat impaction first• Patients with fecal impaction should have the

impacted feces removed manually or with enemas before starting laxatives– Tap water– Milk and molasses (1 liter:½ cup)– Mineral oil (less effective)– Not soapsuds (increased risk of colitis)– May take several attempts

Wrenn K. Fecal impaction. N Engl J Med 1989;321:658-662

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Constipation

• Non pharmacologic– Bowel training (go to bathroom after

breakfast)– Fiber – Exercise and increased fluid intake

(beneficial for patients who are dehydrated)

Will not be enough for patients in hospital with immobility and medications

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Laxatives• Osmotic laxatives

– Poorly absorbed or nonabsorbed– Draws water along osmotic gradient– Be careful using in renal insufficiency or cardiac dysfunction– Magnesium (MOM)– Lactulose - synthetic disaccharide (10-30 g/day) GAS– Sugar alcohols

• Sorbitol & Mannitol

– Polyethylene glycol & Electrolytes GoLYTELY, NuLYTELY– Polyethylene glycol 3350 (Miralax) (17g/day) EXPENSIVE

• Overuse can cause dehydration

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Stimulant laxativesIncrease intestinal motility and secretionEffective within hours and may cause abdominal

crampsConcern about long term use causing cathartic colon

(loss of haustration and dilatation of the colon) –phenolthalein (old formulation of Exlax) and cascara

Melanosis coli may develop in patients who take stimulant laxatives containing anthraquinones, but this is not a risk for development of colon cancer

Badiali D, Marcheggiano A, Pallone F, et al. Melanosis of the rectum in patients with chronic constipation. Dis Colon Rectum 1985;28:241-245.

van Gorkom BA, de Vries EG, Karrenbeld A, Kleibeuker JH. Anthranoid laxatives and their potential carcinogenic effects. Aliment Pharmacol Ther 1999;13:443-452.

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Stimulant LaxativesUseful in multifactorial refractory constipation

without obstruction• Anthraquinones

– senna (recent trials indicate safe for long term use) Senakot titrate up to 4-6 per day

• Diphenylmethane derivatives– bisacodyl, sodium picosulphate

• “Stool softener”– Docusate sodium (not very effective in severe constipation)

• Avoid cascara, castor oil (very irritating – colitis) and mineral oil (risk of aspiration pneumonia)

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Other treatments rarely used

Cholinergic agents– Bethanechol– Likely to cause cramps, may cause

confusion in older patients with underlying cognitive disorders

• Miscellaneous– Misoprostol 200-400 mcg/day– Colchicine

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“Prokinetic Drugs”• Cisapride - substituted benzamide

– Stimulates peristalsis by increasing acetylcholine release from myenteric plexus

– Increased risk of cardiac arrhythmias

• 5-hydroxytryptamine receptor agonists– Tegaserod - partial 5-HT4 receptor agonist– Improves stool consistency and frequency in

women with irritable bowel syndrome characterized by constipation

Muller-Lissner SA, Fumagalli I, Bardhan KD, et al. Tegaserod, a 5-HT(4) receptor partial agonist, relieves symptoms in irritable bowel syndrome patients with abdominal pain, bloating and constipation. Aliment Pharmacol Ther 2001;15:1655-1666.

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Lubiprostone (Amitza)

• Selectively activates type 2 chloride channels (ClC-2) in apical membrane of the gastrointestinal tractCuppoletti J. Malinowska DH. Tewari KP. Li QJ. Sherry AM. Patchen ML. Ueno R. . SPI-

0211 activates T84 cell chloride transport and recombinant human ClC-2 chloride currents. American Journal of Physiology - Cell Physiology. 287(5):C1173-83, 2004.

• Increased fluid secretion into lumen

• No significant systemic absorption but has absorbed metabolites

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Skin

• Check for pre-existing skin pressure

• Stage 1 non-blanching erythema

• Stage 2-4 actual breakdown

• Order aggressive treatment (turning, mobilization, protection)

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Electrolytes• Patient was already hypokalemic and likely

to become worse with NS• If replacing K – need to recheck within 6

hours, as patient may have significant renal disease and be unable to excrete a K load

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Hematologic• Patient was already anemic and likely to

become worse with fluid replacement• Main issue is oxygenation – this will worsen

her delirium, and needs to be monitored• Her agitation makes continuous pulse O2

difficult, but monitoring during the morning would have detected hypoxia

• Hb below 9 is likely to worsen delirium

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Social Supports• Living with family – memory problems suggest dementia

and this is a major risk for delirium and adverse reactions to medications

• Patient may benefit from family being present – try to arrange family to stay in the room

• Sitter can decrease need for restraints in delirium• Other interventions for delirium

– Private room– Minimize interruptions – same medical team (!), no nightime vitals,

predictable routine (!)– Lower the bed (fall less injurious)– Hip protectors– Minimize iv poles, Foleys etc – less chance of tripping and falling– Mobilize – ambulate if possible with assistance

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Orders• Think about fluid load – when should this be reassessed and

who will do it – write it down• Same for electrolytes, constipation, diet• Avoid prns – yes it is annoying to be woken up but the

patient’s nightime agitation may be due to hypoxia – think before ordering neuroleptics or sedatives if you are cross-covering

• If you have to use neuroleptics - use low doses (no more than 3 “haloperidal equivalents” in one day, less is better) - 0.25 – 0.5 mg doses at any one time

• Atypical neuroleptics less likely to cause extrapyramidal side effects, but studies indicate a modest increase in CVS risk (MI)

• Watch for sedation – aspiration risk

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Orders• Useful to sign out to covering team – “delirious

patient” management• Think ahead – will you need a sitter? Easier to get

one arranged during the day• Discuss with the nurses what to do at night• If hospital has a delirium unit (“Nest” at VA) then

use it• Anticipate alternative placement (CNH) as patient

may remain delirious for days• Get help from Geriatric Inpatient Consult Team,

psychiatry, neurology to manage risks• Warn the family of risks – “risk management”

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Orders• If the patient does end up with an adverse

event – keep trying to minimize further risks• Elderly patients who have developed

complications from delirium may benefit from earlier admission to ICU for intensive monitoring

• Before ICU admission – make sure the goals of treatment are clear (another reason to discuss the risks with the family early in the admission)

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On Discharge• Assuming there was a better outcome…

– Define residual delirium– Arrange for repeat cognitive testing in a few

weeks to define the level of dementia – and record it in the chart

– Work up the anemia if not already done – if possible neoplasm, patient’s cognitive status may be important to define

– Arrange repeat labs soon after d/c – someone will need to be responsible for followup of renal function, electrolytes

• An email to the PCP could be helpful