Zyta Beata Wojszel, M.D., Ph.D. · 2020. 3. 29. · 1 Geriatric syndromes: incontinence, falls. Risk of hospitalization in old age. Zyta Beata Wojszel, M.D., Ph.D. Department of Geriatrics

1

Geriatric syndromes:

incontinence, falls. Risk

of hospitalization in old age.

Zyta Beata Wojszel, M.D., Ph.D.

Department of Geriatrics

Medical University of Bialystok

Urinary incontinence in old age-

overview

Epidemiology of UI in the elderly

Predisposing factors

Mechanisms of UI in the elderly

Diagnostic evaluation &

Therapeutic approach in the elderly

Z.B.Wojszel, M.D., Ph.D.

2

Urinary Incontinence: Definition

Urinary incontinence: any loss of urine which is

unwanted or uncontrolled by the voiding individual

It is not a consequence of normal aging.


Physiology of Micturition

Bladder is a high volume low pressure system

Storage is under sympathetic control

Expulsion is under para- sympathetic control

Frontal lobe provides voluntary control


3

Urinary incontinence in older people

epidemiological data73,8

21,9

4,3

71,4

15,9 12,7

0

10

20

30

40

50

60

70

80

%

URBAN AREA RURAL AREA

no

sporadic

frequent

p

4

URINARY INCONTINENCE

PHYSIOLOGICAL

AGING

MORBIDITY

& DISABILITY

ENVIRONMENTAL

FACTORS


Changes Associated With Greater Age

• Urinary flow rate

• Speed of contraction of detrusor

• ♀ - Collagen:detrusor ratio

• Maximum bladder capacity

• Functional bladder capacity

• Sensation of filling

•Postvoid residual volume of urine

•Urinary frequency

•♂ - Outflow tract obstruction

Wagg A. Urinary incontinence. In: H.M. Fillit, K. Rockwoos, K. Woodhouse (eds): Brocklehurst’s Textbook of Geriatric Medicine and Gerontology.

7th edition. Saunders Elsevier . Philadelphia 2010: 926-938


5

Mean number

of chronic diseases

2,5

3,6

0

0,5

1

1,5

2

2,5

3

3,5

4

URBAN area RURAL area

p

6

Health status & functional abilities

in 75+ years old community dwelling older people

with frequent urinary incontinence (UI)

Wojszel ZB. Geriatryczne zespoły niesprawności […].Trans Humana. Białystok 2009.

N- number of cases; M-mean; SD- standard deviation; *p- Mann- Whitney’s test; GDS- Geriatric Depression Scale;

NSI- Nutritional Screening Initiative DETERMINE Checklist; P-ADL- Personal Activities of Daily Living; I-ADL- Instrumental Activities of Daily Living

TOTAL M ±SD (N)

WITHOUT UI

M ±SD (N) UI

M ±SD (N) p*

Age 80.7±4.7 (507) 80.6±4.6 (464) 82.0±5.7 (43) NS

Number of chronic diseases 3.0±2.0 (499) 3.0±2.0 (457) 3.6±1.9 (42)

7

URINARY

INCONTINENCE

TRANSIENT PERSISTENT


The causes of transient UI

D elirium

I nfections

A trophic urethritis/ vaginitis

P sychological disorders

P harmaceuticals

E xcess urine output

R estricted mobility

S tool impaction


8

MEDICATIONS THAT CAN CAUSE INCONTINENCE

α- adrenergic agonists [medicines for colds]- urinary retention/ overflow UI

α- adrenergic blockers- urethral relaxation- stress UI

ACE-I- cough precipitating stress UI

Anticholinergics- urinary retention, stool impaction, overflow incontinence, cognitive deterioration and troubles in using toilet

Calcium channel blockers- urinary retention, stool impaction/ overflow UI; edema/ polyuria, nocturia;

Cholinesterase inhibitors- urinary frequency, urgency

Diuretics, methylxantines- polyuria, frequency, urgency (↑urine volume)


ß-adrenergic agonists- urinary retention

Lithium- diabetes insipidus like syndrome

Narcotic analgesics- urinary retention, stool impaction, delirium, immobility

Antipsychotics- delirium, immobility

Sedative-hypnotics, antihistamines H1 - anticholinergic activity

Tricyclic antidepressants- anticholinergic activity

SSRI- ↑cholinergic activity /urge UI

Other drugs (gabapentin, pregabalin, glitazones, NSAID)- edema/ polyuria, nocturia

MEDICATIONS THAT CAN CAUSE INCONTINENCE


9

URGE UI → detrusor overactivity

stroke, Parkinson disease, multiple sclerosis, spinal cord disorders,

dementia

STRESS UI → urethral hypermobility or intrinsic sphincter deficiency

OVERFLOW UI → bladder outlet obstruction, underactive bladder contractility

FUNCTIONAL UI → person’s inability or unwilingness to reach toilet facilities in time (deficits of cognition and mobility)

PERSISTENT UI


Urinary incontinence in older people

Common but under-recognized

10

Diagnostic evaluation of UI in the elderly-comprehensive geriatric assessmentall patients

1. Medical history, including urination control card.

2. Physical evaluation.

3. Basic laboratory tests (urinalysis, culture, serum glucose, calcium).

4. PVR volume measurement (bladder scan or catheterization).

5. Functional assessment: cognitive abilities, mood and

emotion (GDS), basic and instrumental activities of daily

living (B-ADL, I-ADL).

6. Environmental and social factors.


Diagnostic evaluation of UI in the elderlyselected patients

7. Gynecologic evaluation

8. Urological evaluation

7. Urodynamic testsonly when obvious diagnosis can affect treatment and

when initial therapy has failed

when invasive, potentially morbid or irreversible treatments are considered

8. Cystoscopy, imaging of the urinary tract in selected cases (pain, hematuria, pelvic tumor) when initial therapy has failed.


11

Urinary Incontinence: Evaluation

Targeted Physical Exam

Cardiovascular - R/O CHF

Abdominal - Percuss for Large Bladder, Palpate for

Fecal Impaction, R/O Other Masses

Rectal - R/O Obstructing Neoplasm, Fecal Impaction

Pelvic - R/O Muscle Laxity, Cystocoele, Rectocoele,

Uterine Prolapse, Atrophic Vaginitis.

Treatment of UI in the elderlywhat factors should be considered ?

the extent to which it burdens the patient and / (or)

caregiver

the patient's motivation and level of cooperation

preferences for care

goals of care

co-morbidities & medications

prognosis, life expectancy

cost of treatment


12

Goals of treatment

Restore full control over urination

Control over urination dependent on caregivers

Prevention of UI consequences-sanitary napkins, diapers, catheters

independent continence

dependent continence

social continence


Therapeutic approach in the elderly (1)

PVR(

13


PVR >300ml

the need for catheterisation?

short-term bladder drainage- when sudden onset of overflow UI caused

by a new drug, anesthesia, or surgery;

intermittent

indwelling

evaluation of drugs/ modifications

pharmacotherapy

alpha-1 receptor blocker/ 5-alpha reductase inhibitor with symptomatic

prostatism, where prostatectomy is not considered necessary;

topical vaginal oestrogen or vaginal oestrogen pessary for

symptomatic atrophic vaginitis

surgical treatment (TURP )



Pharmacotherapy of UI

„start low go slow”!

awareness of adverse drug reactions

anticholinergic drugs (oxybutynin, darifenacin, tolterodine, fesoterodine, trospium)

β3-adrenergic receptor agonist (mirabegron)

desmopressin (exogenous arginine vasopresin)

duloxetine in stress UI

topical vaginal oestrogen or vaginal oestrogen pessary for symptomatic atrophic

vaginitis

alpha-1 receptor blocker/ 5-alpha reductase inhibitor

intravesicular injection of botulinum toxin


14

G1. Alpha-1 receptor blocker with symptomatic prostatism, where prostatectomy is not considered necessary.

G1(i): Lowe FC. Role of the newer alpha, -adrenergic-receptor antagonists in the treatment of benign prostatic hyperplasia-related lower urinary tract symptoms. Clin Ther 2004; 26(11): 1701-13. Review. PubMed PMID: 15639685.

G1(ii): Schwinn DA, Roehrborn CG. Alpha1-adrenoceptor subtypes and lower urinary tracsymptoms. Int J Urol 2008; 15(3):193-9. Review. PubMed PMID: 18304211

G1(iii): Dunn CJ, Matheson A, Faulds DM. Tamsulosin: a review of its pharmacology and therapeutic efficacy in the management of lower urinary tract symptoms. Drugs Aging 2002; 19(2):135-61. Review. PubMed PMID: 11950378.

G2. 5-alpha reductase inhibitor with symptomatic prostatism, where prostatectomy is not considered necessary.

G2(i): Tacklind J, Fink HA, Macdonald R, Rutks I, Wilt TJ. Finasteride for benign prostatic hyperplasia. Cochrane Database Syst Rev. 2010 Oct 6;(10): CD006015. doi: 10.1002/14651858.CD006015.pub3. Review. PubMed PMID: 20927745.

G2(ii): O'Leary MP, Roehrborn CG, Black L. Dutasteride significantly improves quality of life measures in patients with enlarged prostate. Prostate Cancer Prostatic Dis 2008; 11(2):129-33. PubMed PMID: 17592479.

G2(iii): Roehrborn CG. BPH progression: concept and key learning from MTOPS, ALTESS, COMBAT, and ALF-ONE. BJU Int 2008; 101 Suppl 3: 17-21. Review. PubMed PMID: 18307681.

G3. Topical vaginal oestrogen or vaginal oestrogen pessary for symptomatic atrophic vaginitis.

G3 (i): Lynch C. Vaginal estrogen therapy for the treatment of atrophic vaginitis. J Womens Health (Larchmt) 2009; 18(10): 1595-606. Review. PubMed PMID: 19788364.

G3 (ii): Bachmann G, Bouchard C, Hoppe D, Ranganath R, Altomare C, Vieweg A, Graepel J, Helzner E. Efficacy and safety of low-dose regimens of conjugated estrogens cream administered vaginally. Menopause 2009; 16(4): 719-27.PubMed PMID: 19436223.

G3 (iii): Mainini G, Scaffa C, Rotondi M, Messalli EM, Quirino L, Ragucci A. Local estrogen replacement therapy in postmenopausal atrophic vaginitis: efficacy and safety of low dose 17beta-estradiol vaginal tablets. Clin Exp Obstet Gynecol 2005; 32(2): 111-3. PubMed PMID: 16108394.

Section G: Urogenital

System criteria.

START


I1. Antimuscarinic drugs for overactive bladder syndrome with concurrent dementia or chronic cognitive impairment (risk of increased confusion, agitation) or narrow-angle glaucoma (risk of acute exacerbation of glaucoma), or chronic prostatism(risk of urinary retention).

I1 (i): Pagoria D, O'Connor RC, Guralnick ML. Antimuscarinic drugs: review of the cognitive impact when used to treat overactive bladder in elderly patients. Curr Urol Rep 2011; 12(5): 351-7. Review. PubMed PMID: 21607875.

I1 (ii): Kay GG, Abou-Donia MB, Messer WS Jr, Murphy DG, Tsao JW, Ouslander JG. Antimuscarinic drugs for overactive bladder and their potential effects on cognitive function in older patients. J Am Geriatr Soc 2005; 53(12): 2195-201. Review. PubMed PMID: 16398909.

I2. Selective alpha-1 selective alpha blockers in those with symptomatic orthostatic hypotension or micturition syncope (risk of precipitating recurrent syncope)

I2 (i):Lowe FC. Role of the newer alpha, -adrenergic-receptor antagonists in the treatment of benign prostatic hyperplasia-related lower urinary tract symptoms. Clin Ther 2004; 26(11): 1701-13. Review. PubMed PMID: 15639685.

I2 (ii): British National Formulary vol. 61, March 2011: p 506.

Section I: Urogenital

System criteria.

STOP


15


Surgical treatment

preceded by urodynamic studies

after exclusion of reversible causes

preceded by an attempt of conservative treatment

accurate preoperative assessment+ good perioperative care

= lack of postoperativegeriatric complications

(delirium, dehydration, infections, falls)

!



Indwelling urethral catheter

not recommended!

(pressure ulcers, pain in terminally ill patients)

Hygienic supplies

sanitary napkins, diapers, catheters


16

Indications for Chronic Indwelling

Catheter UseUrinary retention that:

Is causing persistent overflow incontinence, symptomatic infections,

or renal dysfunction

Cannot be corrected surgically or medically

Cannot be managed practically with intermittent catheterization

Skin wounds, pressure sores, or irritations that are being

contaminated by incontinent urine

Care of terminally ill or severely impaired for whom bed and clothing

changes are uncomfortable or disruptive.

Preference of patient or caregiver when patient has failed to respond

to more specific treatments

Source: From Kane RL et al.


Supplies usagein 75+ years old community dwelling elderly people

[pant diapers and pads]

Wojszel ZB. Geriatryczne zespoły niesprawności […].Trans Humana, Białystok 2009.

URBAN AREA

GENDER AGE TOTAL

[N=256]MEN

[N=85]

WOMEN

[N=171]

75-79

years old

[N=136]

80+

years old

[N=120]

using pant diapers or pads/ % 3.5 11.8* a 6.6 11.8 9.0

RURAL AREA

GENDER AGE TOTAL

[N=253]MEN

[N=78]

WOMEN

[N=175]

75-79

years old

[N=107]

80+

years old

[N=146]

using pant diapers or pads/ % 11.5 20.0 12.1 21.2^ a 17.4** b

Where: ^p

17

Falls and Mobility

Problems in Older

Adults

Zyta Beata Wojszel, M.D., Ph.D.

An event that results in a person inadvertently coming to rest on the ground or other lower level (not as a result of loss of consciousness, violent blow, sudden onset of paralysis or seizure) (Gibson et al., Kellogg International Work Group, 1987)

An event which results in a person coming to rest unintentionally on the ground or other lower level, not as a result of major intrinsic event (such as stroke) or overwhelming hazard (Tinetti et al., 1988)

Unintentionally coming to rest on the ground, floor or other lower level (Ory et al, FICSIT trials, 1993)

Epidemiology of falls in elderlyDefinitions:


18

Falls

Trigger

Consequence

Epidemiology of falls in elderly

Intrinsic

Extrinsic

Injurious

Non-injurious

Classifications:

Fallers

Non-fallers

Once-only fallers

Recurrent fallers


Epidemiology of falls in elderlyIncidence:

Accidents are the 5th leading cause of death in older

adults

Falls account for 2/3 of these accidental deaths

1/3 of adults over 65 living in the community fall at

least once a year

This rises to ½ of adults over age 80

5% of these falls result in a fracture or

hospitalization

Mobility abnormalities affect 20-40% of adults over

65 and 40-50% of adults over age 85


19

Mortality Of those who are hospitalized, ~50% will not be alive a

year later

Falls constitute 2/3rd of deaths associated with unintentional injuries

In 2000 traumatic brain injury (TBI) accounted for 46% of fatal falls.

Cost Fall-related injuries are among the most expensive health

conditions



Location

Most falls occur outdoors

Women are more likely to report indoor falls

Indoor falls are associated with frailty

Outdoor falls are associated with compromised

health status in more active elderly



20

The rate of falls and their associated complications are ~ twice over the age of 75 years.

10-25% falls induce fractures in this population

Hip fractures are more common after the age of 75 years

Those ≥75 years of age are more likely to report indoor falls

Incidence is higher in certain populations (e.g. institutionalized elderly, diabetics, Parkinson’s disease, post-stroke etc.)



ACOVE Indicators ACOVE = Assessing Care Of Vulnerable Elders

set of quality measures specifically developed for the vulnerable

elderly—those most likely to die or become severely disabled in the next

two years

2007- the 12 new ACOVE indicators are designed to improve the clinical

approach to falls and mobility in older adults

Evidence based focus: 182 articles were reviewed to obtain these indicators

Some have practice guidelines

Chang JT, Ganz, DA. Quality Indicators for Falls and Mobility Problems in Vulnerable Elders. JAGS Oct 2007

55(S2):S327-S334

RAND Health is a major research division of the RAND Corporation, a non-profit institution

that helps improve policy and decision-making through research and analysis.


21

ACOVE Indicator 1 ALL vulnerable elders should have ANNUAL

documentation about the occurrence of

recent falls …

Because

Falls are common

Preventable

Frequently unreported

Often cause injury

Can restrict activity unnecessarily

A recent fall is a potent predictor of future falls

Need a multifactorial falls risk assessment for all of

your vulnerable older adults


Falls Risk Assessment

Features

Medication review

ADL and IADL assessment

Orthostatic blood pressure measurement

Vision assessment

Gait and balance evaluation

Cognitive evaluation

Assessment of environmental hazards


22

ACOVE Indicator 2

IF a vulnerable elder reports 2 or more falls

in the previous year, THEN document a

basic fall history within 3 weeks of the

report …

Because a basic fall history provides the

necessary information to implement an

individualized multifactorial falls risk

intervention strategy


What is a fall history?

Circumstances?

Medications?

Chronic conditions?

Mobility status?

Alcohol intake?

You can use the positives to tailor a fall prevention

program specific for each of your older adults


23

Screening and

Examination of Gait and

Balance

Timed Get Up and Go Test

Single Leg Stand Test

Dynamic Gait Index

Berg Balance Scale……



Measures functional capacity rather than

individual impairment – reflects multiple

domains, useful in detecting mobility

impairment

Time it takes to stand up from arm chair,

walk 3 meters (10 feet), return to chair and

sit down


24


Interpretation of Performance on the Timed Get Up And Go Test

< 10 sec.

Low fall risk; clients are freely mobile; encourage regular exercise

< 20 sec.

Moderate fall risk; clients are independent with basic transfers; most go outside

alone and climb stairs, many are independence with tub and shower transfers. PT

referral may be appropriate.

20-29 sec.

High fall risk; “Gray zone”; functional abilities vary. Physician or multidisciplinary

team assessment recommended.

>30 sec.

Very high fall risk; Many are dependent with chair and toilet transfers; most are

dependent with tub and shower transfers; most cannot go outside alone; few, if

any, can climb stairs independently. Physician or multidisciplinary team

assessment recommended.


Single Leg Stance Test

A measure of static balance that relates

to foot/ankle strategies

Functional implications for gait, especially

on uneven surfaces, and going up/down

curbs or steps

Marker of frailty in elderly persons

Community dwelling older adults unable to

stand for 5 sec. had a 2.1 times risk of

injurious falls


25

ACOVE Indicator 7

IF a vulnerable elder reports 2 or more falls

in the past year, THEN there should be

documentation of a cognitive assessment

in the past 6 months…

Because, detection and management of

cognitive impairment reduces the risk of falls

as part of a multifactorial intervention


ACOVE Indicator 8

IF a vulnerable elder reports a history of 2 or more

falls in the past year, THEN there should be

documentation of an assessment and modification

of home hazards recommended in the previous

year or within 3 months of the report…

Because:

Environmental factors can contribute to risk of falls and

mobility problems

Environmental assessment and modification using an

occupational therapist reduced 12 month relative risk of

falling to 0.64 (95% CI 0.5-0.83) in older adults at higher

risk of falling


26

3 Major Problem Areas

of the Home:

Outside Steps To The Entrance

Inside Stairs To A Second Floor

Unsafe Bathrooms Source: HUD (2001)

ACOVE Indicator 11

IF a vulnerable elder reports a history of 2 or more falls, or 1 fall with injury, in the past year and has an assistive device, THEN there should be documentation of an assistive device review in the past 6 months or within 3 months of the report…

because:

A poorly fitted assistive device or one used inappropriately along with impaired balance or proprioception or excessive postural sway can contribute to instability

Appropriate use of an assistive device will reduce the likelihood of falls and their complications


27

General Gait Assessment:

What to look for in the elderly person at risk for falling

Changes in gait with aging

Average gait speed declines 12% to 16% per decade past 70 yrs.

Stride frequency increases

Stride length decreases at a given walking speed

Double support time increases


General Gait Assessment: What to look for in the elderly person at risk for falling

Gait Characteristics of Fallers

Decreased trunk rotation

Increased knee flexion

Several small steps and reduced speed prior to stepping over low obstacle (12”)

Shorter step and stride length

Slowed gait speeds

Decreased single leg support time and increased double limb support time.


28

Practice GuidelineACOVE

Use exercise to improve measures of balance and

reduce incidence of falls

Use of a multidimensional exercise program that

incorporates balance training and strengthening should

improve postural stability and reduce fall risk


Exercise Recommendations for Older

Adults with Chronic Disease or Frailty

Balance1-7 x/week, dynamic exercises focused on mobility,

static exercise focused on single leg stand, 4-10 different exercises

Progressive, targeting important postural muscle groups, progress by decreasing base of support

Muscle Performance2-3 x/week, 8 to 10 exercises

Aerobic CapacityChronic Dx - 3-5 x/week, 20-60 minutes, 50-70% HrmaxFrailty - > 3 x/week, at least 20 minutes, 11-13 Borg

Scale

Flexibility3-7 x/week, 3-5 reps each major muscle group, 10-30 s.

hold


29

Age, female gender, poor social support, H/O falls, depression and poor lower limb function

lower personal mastery and poor dynamic balance

Fear of falling: Possible

contributors


Fear of Falling

Activity restriction Poor perceived health

Social withdrawal Reduced strength

Poor balance

Increased disability Increased fall risk

Reduced independence

Poor quality of life


30

Risk of hospitalization in old age Content of presentation

• Hospital stays in octogenarians

• Quality of care and outcomes metrics

• Predictors of outcomes

• Disease type and severity

• Multimorbidity

• Functional disability

• Iatrogenic complications

• In surgery

• Preventive strategies-organizational factors

• Discharge proces

• Transitional care


NUMBER AND RATE OF HOSPITAL STAYS, LENGTH OF

STAY AND COSTS BY PATIENT AGE GROUP, USA 2012

Characteristic Hospital stays Mean length

of stay, days

Costs

Number,

thousands

Rate per

1,000

population

Mean cost

per stay, $

Aggregate,

milions $

All hospital

stays

36,500 116.2 4.5 10,400 377,455

Patient age,

years

31

EMERGENCY BED DAYS PER PERSON PER ANNUM,

BY AGE GROUP AND GENDERENGLAND 2010

Imison C, Poteliakhoff E, Thompson J. Older people and emergency bed use. Exploring variation.

Ideas that change helathcare. London: The King’s Fund, 2012.

First attendees to English Emergency Departments in 2010-2011:• 80+- 6.5% (1.05/16.2 million)• 90+- 1.8%Admitted to hospital- conversion rate:• overall (all ages)- 21%• 85+- 62%


TYPE OF HOSPITAL STAY BY PATIENT AGE GROUP

USA 2012

Characteristic Type of hospital stay

Surgical Medical Maternal or

neonatal

% % %

All hospital stays 21.8 56.0 22.2

Patient age, years

32

QUALITY OF CARE & OUTCOMES METRICS

Hospital acquired complications

Length of stay

Re-interventions (such as repeat surgery within 6- and 12 months

of discharge)

Readmissions- 6- and 2-month hospital admissions,

Emergency Room (ER) admissions,

Discharge destinations (home/ long term care institution)- up to 6

months, end of follow-up

Mortality- up to 6 months, end of follow-up

Resource use- services, medications (cost- payments associated

with the healthcare utilization )


PATIENT

33

After adjusting for sex and stroke severity on admission, the very elderly

patients had higher case fatality and disability rates at one year (33.8% versus

13.2%, p = 0.000; 37.8% versus 20.9%, p = 0.000; respectively).

80+

years

34

-478 geriatric ward patients-mean age - 77.9± 6.8 years-follow-up- up to 5.5 years

Negative predictors of long-term

survival:

• Older age

• ADL disability

• Undernutrition surrogates („passive”

hypocholesterolaemia, lower BMI, lower

haemoglobin level) Z.B.Wojszel, M.D., Ph.D.

• 308 patients

• Age- Me= 84 [IQR

82–87] years

• CFS – M=4.75 (± 1.6)

• 20 German ICUs

• ICU-mortality: 17.3%;

• 30-day mortality -

31.2%.

The cause of admission (planned vs. unplanned), (OR 5.74) and the

CFS (OR 1.44 per point increase) were independent predictors of 30-

day survival.


35


IATROGENIC COMPLICATIONS

Infections:

UTIs, pneumonia, surgical site infections, gastrointestinal

infections, and bloodstream infections

Thrombosis: deep vein thrombosis or pulmonary embolism

ADEs

Delirium/ cognitive decline

Immobility/ Falls/ fractures

Malnutrition

Pressure ulcers

Functional decline/ADL dependence


36

• 136 patients 80+year-old-

scheduled for SAVR or TAVI

• delirium-56%

• adjusted HR for death and first

time readmissions - 2.9 (95% CI

1.5 to 5.7)

• 80% of first-time readmissions

within 30 days- patients who

experienced delirium

• Cardiovascular disorders and

injuries were associated with

first-time readmissions


REASON OF HOSPITAL

STAY & MEDICAL

PROCEDURE Z.B.Wojszel, M.D., Ph.D.

37

• 3 00 000 Medicare fee-for-service

beneficiaries hospitalized with heart

failure, pneumonia, or acute coronary

syndrome 2008-2010

Yearly rate of rehospitalisation

• 67%- HF

• 49.5%-AMI

• 55.3%-pneumonia

The extend and timing of risk varied by

readmission diagnosis and initial

admitting condition

Conclusion

Recovery of various physiologic systems

occurs at different rates and post-

discharge interventions to minimize

vulnerability to specific conditions should

be tailored to their underlying risks.


• The average life-span - 5.5 years (STD +/- 10.0)

• 19.5 years for low-risk women of less than 50 years old• to 2.9 years for high-risk octogenarian males

• lower by 0.13 years among patients with impaired as

compared with preserved left ventricular function,

• and by approximately one year among patients with

three or more as compared with no concomitant

comorbidities.


38

Factors associated with postoperative complications

Chronological age

Physiological functional status

Nutritional status

Comorbidities

Cancer stage

Invasiveness of surgery

How to decrease one-year

mortality:• Avoidance of postoperative

complications

• Appropriate preoperative

assessment

• Careful patient selection

• Careful selecting treatment

modalities

• Meticulous postoperative

care

• Limited number of studies

• Standard management guidelines for cc not available

• The need for consensus guidelines


All colectomies performed on

patients aged 80+ years, from

January 2002 to September 2007

(retrospective analysis of an

operating room database)

Laparoscopic colectomy is a

safer option that offers an

improved outcome compared with

open colectomy in elderly patients.

Significant improvements in LOS,

mortality rates, and discharge

destination were observed.

Lap Group Open Group p-value

n 150 95

Mean age, years

(range)

84.85 (80-

95), SD 3.62

84.32 (80-

94), SD 3.620.25

LOP, mean

minutes (range)121 (55-290), SD 76

125 (33-

575), SD 440.63

LOS, mean days

(range)7.11 (2-54), SD 7.7

11.16 (2-

41), SD 7.820.0001⁎

EBL 167 mL (min-2000)225 mL (min-

1800)0.08

Ileus, % (n) 10 (15/150) 22 (22/95) 0.01⁎

MI, % (n) 5.3 (8/150) 5.2 (5/91) 0.96

ARF, % (n) 4.6 (7/150) 6.3 (6/95) 0.80

Wound infection,

% (n)2.6 (4/150) 7.3 (7/95) 0.11

Mortality, % (n) 2 (3/150) 9.5 (9/95) 0.01⁎

Home:NH ratio

(n)2:1 (114/33) 1:1 (43/44) 0.0001⁎

J Surg Educ, 2010; 67 (3): 161-6


https://www.sciencedirect.com.sk48qd0b03d4.han.umb.edu.pl/science/article/pii/S1931720410000371#tblfn1https://www.sciencedirect.com.sk48qd0b03d4.han.umb.edu.pl/science/article/pii/S1931720410000371#tblfn1https://www.sciencedirect.com.sk48qd0b03d4.han.umb.edu.pl/science/article/pii/S1931720410000371#tblfn1https://www.sciencedirect.com.sk48qd0b03d4.han.umb.edu.pl/science/article/pii/S1931720410000371#tblfn1

39

28 960 hospitalizations (19 145TAVR, 9815 SAVR) for

elective aortic valve replacement in octogenarians

between 2012 and 2015.

TAVR and surgical aortic valve replacement are both

reasonable options in high‐risk patients

-TAVR offers more benefits and may be the preferred

approach in high‐risk octogenarians, which is a population with low physiologic reserve and frailty.

-The benefits of TAVR extend to all octogenarians,

irrespective of comorbidity burden.

TAVR SAVR


-31,574 patients aged 80+ diagnosed with colon cancer between 1992 and 2005 Surveillance, Epidemiology, and End Results (SEER)‐Medicare database for patients.

The majority of patients selected for surgery do well, despite their advanced age and numerous comorbidities.

surgery under elective circumstances- a 30‐day mortality rate of only 3%.

for those “oldest old” patients believed to be good candidates for elective surgical intervention, surgery should be considered as a standard of care.

Patients undergoing surgery during an urgent/emergent admission have an increased short‐term mortality risk.

Cancer 2013, 119 (3): 639-647


40

Of the patients 75 years old or older who underwent

elective surgery for gastric or colorectal cancer, only a

few showed a protracted decline in ADL and most

exhibited better QOL after surgery.

This indicates that surgical treatment should be

considered, whenever needed, for elderly patients 75

years old or older with gastric or colorectal cancer.

Estimation of Physical Ability and Surgical Stress is

useful for predicting postoperative declines in ADL

and protracted disability; this could aid in establishing

a directed rehabilitation program for preventing

protracted disability in elderly patients.


Discharge:

- elective surgery- 88%- home

- emergency- 22%- home, local hospital-66%,

7%- nursing home, 5%-died;

-retrospective case review of octogenarian admissions to a regional

neurosurgical unit from January to December 2010 (2,9% of operations,

2.8% of adult admissions)

- 49 elective and 81 emergency admissions

Perioperative mortality

- 80+- elective surgery- 0% emergency- 10.4%

-

41

PREVENTION

STRATEGIES


COMPREHENSIVE GERIATRIC

ASSESSMENT (CGA)

• Multidimensional & interdisciplinary diagnostic process

• Coordinated and integrated plan for treatment

• Follow-up

• Medical comorbidities/ medications

• Functional status and mobility

• Cognitive & emotional status

• Sensory issues

• The patient’s and caregiver’s capacity to provide care and

make decisions


42

Odds ratios for LIVING AT HOME at

end of follow-up (median 12 months)

in elderly patients according to

comprehensive geriatric assessment

after emergency admission.

- More effective than usual

care


Odds ratios for

DEATH OR DETERIORATION

at the end of follow-up (median 12

months) in elderly patients according

to comprehensive geriatric

assessment after emergency

admission at baseline.

- Ward-based CGA

services are more

effective than liaison

services


43

1. Environment interventions.

2. A patient-centered care model - independence and

rehabilitation from the beginning of the hospital stay.

3. A multidisciplinary care team (nurses, physicians,

therapists, social workers, nutritionists, and pharmacists)

providing coordinating care within a dedicated inpatient

unit.

4. Coordination of care (a daily interdisciplinary round).

5. Nurse-driven protocols (geriatric syndromes).


POCD -disorders affecting orientation, attention, perception, consciousness,

and judgment that develop after surgery (embolism, hypo-perfusion, and

inflammatory response).

CAUSES• patient- related factors: age, educational level, mental health, and

comorbidities

• surgical-, and anaesthesia-related factors- duration and complexity of

surgery

PREVENTIVE STRATEGIES

Preoperative assessment –risk assessment and an opportunity to optimize

organ-specific disease and comorbidities.

Enhanced Recovery After Surgery (ERAS) /“accelerated recovery” (“stress

free anaesthesia and surgery”)- preoperative, intraoperative, and

postoperative components: restrictive intravenous fluid therapy, use of

laparoscopy in combination with appropriate anaesthesia, analgesia with

early enteral feeding, and early postoperative mobilizationZ.B.Wojszel, M.D., Ph.D.

44

The prehabilitation group had a higher burden of

comorbidities and was more physically and visually impaired

at baseline.


At adjusted logistic regression analysis, delirium incidence was reduced

significantly from 11.7 to 8.2% (OR 0.56; 95% CI 0.32–0.98; P = 0.043).

No statistically significant effects were seen on secondary outcomes.


45

DISCHARGE

SETTING



46


• Patient and caregiver communication-

discharge instructions

• Inpatient provider and follow-up provider

communication

• Medication reconciliation

• Selection of discharge location and level of

post discharge care

• Post discharge follow-up

TRANSITIONS IN CARE


47

Effect of the Patient-Oriented Safe Transition (POST)programme on health‐related quality of life.

Through the transition programme, it was identified that the medical

costs and caregiver burden can be reduced and the HR‐QOL of patients can be improved.


Summing up

THM


48

Frail older adult

multiple comorbidities

polypharmacy

cognitive impairment (delirium and/or dementia)

nonspecific presentation

Hospital setting

risk of adverse events

increasingly specialized, protocol-driven care

procedure (laparoscopic colectomy vs open colectomy; endovascular aneurysm

repair, conventional open repair, and conservative treatment in elderly patients with

ruptured abdominal aortic aneurysm).

hospital discharge planning and continuity of care

place of discharge (home versus convalescence resource)

Community setting

Integration of services within and without hospital-

transitional care

Factors influencing post discharge outcomes


THANK YOU

FOR YOUR ATTENTION

Documents

Zyta Beata Wojszel, M.D., Ph.D. · 2020. 3. 29. · 1 Geriatric syndromes: incontinence, falls. Risk of hospitalization in old age. Zyta Beata Wojszel, M.D., Ph.D. Department of Geriatrics