Hospitalization of the Elderly
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Hospitalization of the ElderlyHospitalization of the Elderly
Tracey Doering, MDTracey Doering, MD
[email protected]@baptisthospital.com
May 20, 2008May 20, 2008
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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
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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
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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
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Hazards Hazards
Functional declineFunctional decline ImmobilityImmobility DeliriumDelirium DepressionDepression RestraintsRestraints
Adverse drug reactionAdverse drug reaction Nosocomial infectionsNosocomial infections IncontinenceIncontinence MalnutritionMalnutrition Pressure UlcersPressure Ulcers
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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
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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
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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
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HazardsHazards
Functional declineFunctional decline ImmobilityImmobility DeliriumDelirium DepressionDepression restraintsrestraints
Adverse drug Adverse drug reactionsreactions
Nosocomial infectionsNosocomial infections IncontinenceIncontinence MalnutritionMalnutrition Pressure ulcersPressure ulcers
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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
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HazardsHazards
Functional declineFunctional decline ImmobilityImmobility DeliriumDelirium DepressionDepression restraintsrestraints
Adverse drug Adverse drug reactionsreactions
Nosocomial infectionsNosocomial infections IncontinenceIncontinence MalnutritionMalnutrition Pressure ulcersPressure ulcers
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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
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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
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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
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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
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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
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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
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HazardsHazards
Functional declineFunctional decline ImmobilityImmobility DeliriumDelirium DepressionDepression restraintsrestraints
Adverse drug Adverse drug reactionsreactions
Nosocomial infectionsNosocomial infections IncontinenceIncontinence MalnutritionMalnutrition Pressure ulcersPressure ulcers
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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
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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
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HazardsHazards
Functional declineFunctional decline ImmobilityImmobility DeliriumDelirium DepressionDepression restraintsrestraints
Adverse drug Adverse drug reactionsreactions
Nosocomial infectionsNosocomial infections IncontinenceIncontinence MalnutritionMalnutrition Pressure ulcersPressure ulcers
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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
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HazardsHazards
Functional declineFunctional decline ImmobilityImmobility DeliriumDelirium DepressionDepression restraintsrestraints
Adverse drug Adverse drug reactionsreactions
Nosocomial infectionsNosocomial infections IncontinenceIncontinence MalnutritionMalnutrition Pressure ulcersPressure ulcers
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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
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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
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Medications to avoidMedications to avoid
AntihistaminesAntihistamines Narcotic analgesicsNarcotic analgesics BenzodiazepinesBenzodiazepines Tricyclic antidepressantsTricyclic antidepressants Histamine-2 receptor antagonistsHistamine-2 receptor antagonists
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Important Problem drugsImportant Problem drugs
WarfarinWarfarin DigoxinDigoxin insulininsulin
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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
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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
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J Amer Geriatrics Society 56: 861-868, 2008
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HazardsHazards
Functional declineFunctional decline ImmobilityImmobility DeliriumDelirium DepressionDepression restraintsrestraints
Adverse drug Adverse drug reactionsreactions
Nosocomial Nosocomial infectionsinfections
IncontinenceIncontinence MalnutritionMalnutrition Pressure ulcersPressure ulcers
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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
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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
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HazardsHazards
Functional declineFunctional decline ImmobilityImmobility DeliriumDelirium DepressionDepression restraintsrestraints
Adverse drug Adverse drug reactionsreactions
Nosocomial infectionsNosocomial infections incontinenceincontinence MalnutritionMalnutrition Pressure ulcersPressure ulcers
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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
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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
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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
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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
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Establish baselineEstablish baseline
ADLSADLS IADLSIADLS MobilityMobility Living situationLiving situation Social supportSocial support Discuss and obtain advance directivesDiscuss and obtain advance directives
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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
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Daily roundsDaily rounds
CathetersCatheters Central linesCentral lines MedicationsMedications Nasal cannulasNasal cannulas TelemetryTelemetry restraintsrestraints Therapies needed?Therapies needed? Target discharge dateTarget discharge date
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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
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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
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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
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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
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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
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DOES THE PATIENT UNDERSTAND?
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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”
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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
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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
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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
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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
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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?
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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
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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