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Title: Highest Quality Care for the Hospitalized Elderly The


1
The Hospitalized Elderly General Principles
Highest Quality Care for the Hospitalized Elderly
  • Jason Stein, MD
  • Emory Reynolds Faculty Scholar
  • Emory Hospital Medicine Service

2
Highest Quality Care in the HospitalGoals for
this Module
  • Identify the significance of elderly patients to
    hospitalists
  • Identify the significance of hospitalizations to
    elderly patients
  • Appraise the extent of your hospitals specific
    approach to its geriatric population
  • Describe how the adverse hospital environment
    combines with physiologic aging and
    pathophysiologic changes from disease to impact
    the hospitalists approach to the care of elderly
    inpatients

3
Highest Quality Care in the HospitalLook at
Your Inpatient Census
  • What do half your patients have in common?
  • (whether youre at EUH, ECLH, Cartersville,
  • Dunwoody, Northlake, or Eastside)

4
Highest Quality Care in the HospitalLook at
Your Inpatient Census
  • What is the median age on your census?

5
Highest Quality Care in the HospitalLook at
Your Inpatient Census
  • What is the median age of patients on your
    census?
  • About half your patients are geriatric patients
    (gt 65 years old)
  • patients gt65 years old account for 50 of all
    inpatient days of care in American hospitals1
  • (while comprising just 13 of the population)

1Kozak LJ et al. National Hospital Survey 2000.
National Center for Health Statistics. Vital
Health Stat. 13 (153). 2002.
6
Highest Quality Care in the Hospital Is Your
Patients Age Clinically Significant?
  • Why geriatric patients are important to
    hospitalists
  • Summary
  • Half your admission HPs
  • Half your progress notes
  • Higher complexity demands disproportionate care
    time
  • More than half of your in-hospital deaths (75)
  • Why hospitalizations are important to your
    geriatric patient

7
Highest Quality Care in the Hospital Why
Hospitalizations Are Important to Your Geriatric
Patient
  • Your patients age is clinically significant.

8
Highest Quality Care in the Hospital Is Your
Patients Age Clinically Significant?
  • Hospitalization Facts
  • Older patients have More frequent
    hospitalizations
  • Longer Hospitalizations
  • Higher Mortality

9
Highest Quality Care in the Hospital Is Your
Patients Age Clinically Significant?
  • Hospitalization Facts
  • Older patients have
  • More frequent hospitalizations
  • Patients gt 85 years old
  • 2x the rate of 65-74 year olds
  • 5x the rate of middle aged patients (45-64 year
    olds)

10
Highest Quality Care in the Hospital Is Your
Patients Age Clinically Significant?
  • Hospitalization Facts
  • Older patients have
  • Longer hospitalizations
  • Patients gt 85 years old average 6.2 days
  • Patients 45-64 years old average 4.8 days

11
Highest Quality Care in the Hospital Is Your
Patients Age Clinically Significant?
  • Hospitalization Facts
  • Older patients have
  • Higher mortality
  • Patients gt 85 years old
  • 4x the mortality rate of middle aged patients
    (45-64 year olds)
  • 75 of in-hospital deaths occur in patients gt 65
    years old

12
Highest Quality Care in the Hospital Is Your
Patients Age Clinically Significant?
  • Why hospitalizations are important to your
    geriatric patient

13
Factors Associated With Development of Disability
Beaufort Scale 1 - 12 (scale of wind
velocity) Hurricane 12 (74 mph) Light breeze
1 (1 mph)
Gill TM. JAMA. 2004 292 2115-24
14
Defining A Key Geriatric TermWhat is Functional
Decline?
  • Functional Decline New Disability
  • Loss of ADLs (basic self-care activities)
  • Transfer out of bed to chair independently
  • Toileting yourself
  • Bathing yourself
  • Dressing yourself
  • Feeding yourself

15
HospitalizationA Threat of Its Own
Hospitalization Functional Decline Higher
Mortality
  • Hospitalization Functional Decline
  • -Prolonged hospital stays are associated with
    functional decline1
  • -35 of older hospitalized patients decline in
    baseline ADLs b/t admission and discharge2
  • -Compared with any other event along the road to
    disability in the elderly, hospitalization is a
    greater hazard by a full order of magnitude3

1 Palmer RM. Acute Hospital Care. In Geriatric
Medicine, 4th ed. 2 Kozak LJ et al. Vital Health
Statistics. 200213(153). 3 Gill TM. JAMA. 2004
292 2115-24
16
HospitalizationA Threat of Its Own
Hospitalization Functional Decline Higher
Mortality
  • Functional Decline Higher Mortality
  • basic ADLs absent at discharge
  • strong independent predictor of mortality 4,5

4 Inouye SK et al. JAMA. 1998 279 1187-93. 5
Walter LC et al. JAMA. 2001 85 2987-94.
17
Does your hospital have specific processes to
drive the best possible outcomes for its
geriatric population?Until it does, your
elderly inpatients rely on you alone to deliver
all and only the care they need.
Highest Quality Care in the Hospital
18
Does your hospital have specific processes to
drive the best possible outcomes for its
geriatric population?1. Does anyone perform a
formal assessment of baseline function (2 weeks
prior to hospitalization)?2. Does anyone
perform a formal assessment of current function
(at time of admission)? 3. Do daily rounds
focus on patient-centered interventions?4. If
your hospital has CPOE, do you have a layer of
electronic decision support that focuses on
geriatric prescribing (50 reduction in
falls)?5. Does the discharge process address
persistent functional deficits that require
special support or sites of ongoing care?
Highest Quality Care in the Hospital
Guided Prescription of Psychotropic Medications
for Geriatric Inpatients.Josh F. Peterson, et al.
Arch Intern Med Volume 165802-807 April 11, 2005
19
Highest Quality Care in the Hospital
  • Processes
  • Outcomes

Every system is perfectly designed to achieve
exactly the results it gets.
20
Highest Quality Care in the Hospital
  • Processes
  • Outcomes

Whats the difference?
21
Highest Quality Care in the Hospital
  • Processes
  • Outcomes

What do you care more about?
22
Highest Quality Care in the Hospital
  • Processes
  • ?influence outcomes
  • ?more amenable to measurement
  • ?must be tightly associated to outcomes
  • Outcomes
  • ?what you really care about ultimately
  • ?can be difficult to measure in real time

23
Towards An Optimal ProcessWho Will Get
Functional Decline?
  • Risk Factors Before Admission
  • Age (increasing age)
  • Body (pressure ulcer)
  • Brain (cognitive impairment)
  • Mood (depressive symptoms)
  • Level of functioning (fewer iADLs)
  • Socialization (low social activity level)

iADLs instrumental ADLs tasks necessary to
run a household (telephone, managing money,
shopping, preparing meals, light housework,
getting around the community)
24
Towards An Optimal ProcessWho Will Get
Functional Decline?
  • Risk Factors After Admission
  • Adverse Hospital environment
  • Iatrogenic illness
  • Sensory Deprivation
  • Altered sleep-wake cycles
  • Disorientation
  • Deconditioning
  • Malnutrition

25
Apart From Preventing Iatrogenic Illness,You Can
Dampen the Adverse Hospital Environment
  • Example
  • Deconditioning from
  • Illness-induced immobility
  • ? your usual good care
  • Neglectful bed rest
  • Insufficient PT/OT
  • Environmental barriers
  • e.g. lack of handrails in hallways/rooms
    discourages mobility and self-care
  • ? insist on handrails and 24/7 PT
  • Forced bed rest
  • tethered to IV poles and catheters
  • tethered to the bed by physical or chemical
    restraints
  • ? un-tie your patient

26
Why Are Elderly Patients Especially Vulnerable to
the Risk Factors for Functional Decline?
  • Adverse hospital environment
  • Physiologic impairments with age
  • (e.g. less muscle mass, strength, and aerobic
    capacity)
  • Pathophysiologic impairments from disease
  • (e.g. painful OA poor hearing/vision
    malaise/dyspnea from pneumonia)

27
Why Are Elderly Patients Especially Vulnerable to
the Risk Factors for Functional Decline?
  • Three Key Geriatric Principles for the Hospital
  • 1) At the individual level, variability
    decreases with age
  • 2) Across the geriatric population, variability
    increases with age
  • 3) To maintain baseline performance, many
    elderly already have drawn upon physiologic
    reserves
  • Recognizing the significance of this will make
    you a better provider.
  • How aging is clinically significant

28
How is Aging Clinically Significant?Most Elderly
Are Different from the Young
  • 1) At the individual level, variability decreases
    with age
  • Individual Variability Narrows
  • Organ function deteriorates (1 per year,
    starting 30yo) and dynamic range of organ/system
    performance narrows over time
  • e.g. stride length less nimble (others HR, FVC,
    Temp, Na handling, etc)

Clinical Implication detectable extremes tend to
be associated with significant underlying illness
(or iatrogenesis).
29
How is Aging Clinically Significant?Most Elderly
Are Different From One Another
How is Aging Clinically Significant?Most Elderly
Are Different From One Another
  • 2) Across the geriatric population, variability
    increases c age
  • Population Variability Widens
  • Time Normal aging Disease Genes/Environment
    Wide Variability

Clinical Implication Your next elderly patient
is likely to manifest the ravages of time and
disease in ways that are totally unlike your
previous 20 elderly inpatients.
30
How is Aging Clinically Significant?Many Elderly
Are Running on Fumes
  • 3) To maintain baseline performance, many elderly
    already have drawn upon physiologic reserves
  • Homeostenosis
  • the diminished capacity to maintain homeostasis
  • when stressed
  • (limited physiologic reserve blunted
    compensatory mechanisms)

Clinical Implication next 3 slides
31
?susceptibility to disease ? ability to
compensate(homeostenosis)
The Frail Elderly
32
Homeostasis
You
stress
Compensatory Mechanisms
Physiologic Reserve
You, Compensated
33
Homeostenosis
Frail Elderly
stress
Limited
Blunted
Compensatory Mechanisms
Physiologic Reserve
Tapped Out
Clinically Decompensated
34
Age-Related Changes Relevant to Inpatient Care
  • Clinical Implication The acutely ill elderly
    patient frequently presents with non-specific
    signs or symptoms. The absence of classic
    findings places greater value on the
    hospitalists diagnostic evaluation.

35
Age-Related Changes Relevant to Inpatient Care
  • Body Composition
  • ? lean body mass
  • ? total and visceral body fat
  • ?higher concentration of water soluble drugs
  • longer T1/2 fat-soluble medications
  • risk of excessive medication dose
  • risk of excessive medication schedule
  • ?propensity to DM, HTN, hyperlipidemia
  • risk of under-diagnosis or treatment
  • risk of over-treatment c polypharmacy/ADEs
  • Renal
  • ? GFR
  • ? RAAS and ADH response to hypovolemia
  • ? natriuresis (Na excretion in hypervolemia)
  • ?delayed clearance of water-soluble medications
  • risk of excessive medication dose
  • risk of excessive medication schedule
  • ?blunted ability to return to euvolemia in face
    of volume depletion or overload
  • risk of excessive IV fluid administration
    (type/amount/rate)
  • risk of over-diuresis (or insuff. monitoring)
  • risk of under-diuresis

36
Age-Related Changes Especially Relevant to
Hospital Medicine
  • Pulmonary
  • ? chest wall compliance
  • ? elastic recoil of lungs
  • ? strength diaphragm
  • ? mucocilliary clearance
  • ? P02 and ?A-a gradient
  • ?Higher risk pulmonary infections
  • risk of not vaccinating (PVX and flu shot)
  • risk of overlooking smoking cessation advice
  • ?Lower threshold for hypoxemia
  • risk of occult hypoxemia
  • risk of iatrogenic respiratory depression
  • Normal A-a gradient (age/4)4
  • Cardiovascular
  • Medial sclerosis (stiffening of LV/arteries)
  • ? ß-receptor responsiveness
  • ? maximum HR and CO
  • ?Diastolic dysfunction
  • risk of under-recognized HF
  • risk of underestimated impact from a.fib
  • ?on CO (loss of atrial kick)
  • ?on tolerance of ?HR (rate control)
  • ?blunted HR response to stress
  • risk of overlooking enormous significance of
    sinus tachycardia
  • (work-up sinus tachycardia)

37
Age-Related Changes Relevant to Inpatient Care
  • Gastrointestinal
  • ? swallow coordination/esophageal motility
  • ? lactase levels
  • ? colonic motility
  • ?Dysphagia
  • aspiration risk
  • malnutrition risk
  • ?Lactose Intolerance
  • occult diarrhea risk
  • ?Tendency to constipation
  • risk of remaining occult
  • risk of being exacerbated
  • Immunological
  • ? barrier integrity (skin, mucous membranes)
  • Altered cytokine response to infection
  • ? humoral Ab response to infection
  • ?Susceptibility to skin, urinary, pulmonary
    infxns
  • decubitus ulcer risk
  • urosepsis risk
  • aspiration risk
  • ?Blunted febrile response to infection
  • occult infection risk
  • (work-up T gt 99ºF (37.2ºC))
  • (work-up new ?WBC/bandemia)

(Up to 25 of septic elders can be afebrile.
Using T gt 99ºF 37.2ºC increases sensitivity for
detecting fever to 80 and maintains
specificity90)
38
Patient Cases
39
Case 1 Inappropriate
  • 75 yo woman being admitted after falling at
    home. She hit her head. She lives alone and this
    is her 2nd ER visit in 2 weeks (last treated for
    a facial laceration)
  • Fell in middle of the night on way to bathroom
    (she felt dizzy)
  • Has fallen two other times in last month
  • 1) Tripped over the edge of a rug
  • 2) Lost balance when her cat stepped in her path

40
Case 1 Inappropriate
  • PMH
  • 1. HTN. HCTZ 25mg qd.
  • 2. Depression. Zoloft 100mg qhs and Ativan 1mg
    bid prn.
  • 3. OA. Ibuprofen prn.
  • Social Hx lives alone no tob/ETOH

41
Case 1 Inappropriate
  • PE
  • supine HR 64, BP 132/70
  • standing HR 70, BP 122/68
  • HEENT vision 20/40 (mildly impaired)
  • Neuro LE strength 5/5 B, gait stable
  • Get-Up-and-Go test 10 seconds

42
Case 1 Inappropriate
  • Which of the following is the most appropriate
    next step in managing this patients recurring
    falls?
  • Refer to ophthalmology
  • Discontinue ativan
  • Discontinue HCTZ
  • Refer to physical therapy
  • Substitute buspirone for zoloft

43
Case 1 Inappropriate
  • Which of the following is the most appropriate
    next step in managing this patients recurring
    falls?
  • Refer to ophthalmology
  • Discontinue ativan
  • Discontinue HCTZ
  • Refer to physical therapy
  • Substitute buspirone for zoloft

44
Case 1 Inappropriate
  • Observational studies show medications are the
    most readily modifiable risk factors for falls
  • Especially psychotropics (bdz, neuroleptics,
    TCAs)

45
Case 1 Inappropriate
  • RCTs show specific single interventions to reduce
    falls
  • removal of psychotropic medications
  • home hazard assessment and modification
  • exercise programs

46
Case 1 Inappropriate
  • Falls in elderly
  • usually multifactorial (so address all potential
    contributing factors)

47
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50
Case 2 Adverse Hospital Environment?
  • 78 yo woman with DM 2 admitted with cellulitis,
    top of R foot, which seemed to start
    spontaneously. No improvement after one week
    outpatient Keflex.
  • 3 days of increased pain and redness. Unchanged
    localized swelling. No fever, chills. No open
    wound.
  • She is not able to give you an estimate of the
    highest/lowest BG in the last 2 weeks.

51
Case 2 Adverse Hospital Environment?
  • PMH/Meds
  • DM 2. Recent HgA1C 8.5. No h/o microvascular
    disease.
  • Metformin 500mg bid
  • Glyburide 10mg qd
  • Hypothyroidism. Synthroid increased by PCP 2
    months ago when TSH 8.
  • Synthroid 150 mcg qd
  • 3. HTN.
  • Lisinopril 40mg qd

52
Case 2 Adverse Hospital Environment?
  • PE
  • T 37.4C HR 90 BP 154/85 RR 12
  • Gen non-toxic appearing
  • Lungs/CV/abd normal
  • Ext well-demarcated area of tender erythema
    dorsum of R foot. No ulcer. No fluctuance in
    surrounding soft tissue palpation of adjacent
    bone shows no point tenderness peripheral pulses
    1 B
  • Neuro AO to time, place, situation. Light touch
    intact.
  • Lab BG 188, WBC 9K (70 neutrophils, no bands)
  • EKG NSR, 90
  • Rad non-diagnostic for OM

53
Case 2 Adverse Hospital Environment?
  • Hospital Day 1
  • 1) Cellulitis. Start Vancomycin. Serial exams.
  • 2) Pain. Hydrocodone and acetaminophen.
    Laxative.
  • 3) DM2. Continue home medications. Target good
    glycemic control.
  • 4) DVT prophylaxis. Age and anticipated
    immobility. ?Lovenox 40mg SQ QD.
  • On night of first hospital stay, she cant sleep.
    X-cover writes for ambien 5mg qhs.

54
Case 2 Adverse Hospital Environment?
  • Hospital Day 2
  • Not oriented to month or year. Correctly
    identifies place.
  • NL vitals and O2 sat. NL PE
  • Bedside BG 54. Other labs NL.
  • You start D50W and halve glyburide to 5mg qd.
  • Check back in on her 45 minutes later fully
    oriented to time and place, NL BG.
  • On night of 2nd hospital stay, she complains of
    itching and so cross cover writes for hydroxyzine
    10mg q6hrs prn.
  • Any thoughts, commentary?

55
Case 2 Adverse Hospital Environment?
  • Hospital Day 3
  • On rounds again not oriented to month or year.
  • VS review normal except for a single HR
    recorded at 100 at 5am. O2 sat NL.
  • On PE you note an irregular rhythm, rate 90s.
  • BG 55. EKG ? afib, rate 98.
  • CBC NL, Trop negative, CMP NL except BG 64.
  • Whats going on?

56
Case 2 Adverse Hospital Environment?
  • The most likely cause of this patients hospital
    complications is
  • Polypharmacy with adverse effects from
    hydrocodone and ambien
  • Adverse drug event from hydroxyzine
  • Surreptitious ETOH use and withdrawal following
    hospitalization
  • Forced adherence with adverse effects from
    outpatient medications glyburide and synthroid

57
Case 2 Adverse Hospital Environment?
  • The most likely cause of this patients hospital
    complications is
  • Polypharmacy with adverse effects from
    hydrocodone and ambien
  • Adverse drug event from hydroxyzine
  • Surreptitious ETOH use and withdrawal following
    hospitalization
  • Enforced adherence with adverse effects from
    outpatient medications glyburide and synthroid

58
Case 2 Adverse Hospital Environment?Enforced
Adherence in the Hospitalized Elderly
  • Anticipate likelihood of poor compliance before
    hospitalization
  • e.g. from HPIpatient not responding to
    appropriate or increasing doses of medications
  • Suspect when you see different problems evolving
    at once
  • e.g. in hospitalnew confusion, hypoglycemia,
    low BP, atrial fibrillation

59
Case 2 Adverse Hospital Environment?Enforced
Adherence in the Hospitalized Elderly
  • Why Enforced Adherence is Particularly Relevant
    to Your Elderly Patient
  • High Incidence Polypharmacy - non-compliance
    due to
  • multiple medications
  • cost
  • complexity
  • unwanted side effects, or
  • just lack of support
  • Identifiable and Correctable Homeostenosis -
    effects of medications dosed too high tend to
    reveal themselves (if youre looking)

60
Case 3 Non-specific
  • 81 yo male admitted with altered mental status,
    poor po intake, and involuntary weight loss over
    the last 5 weeks.
  • Baseline Historically very active. Until two
    months ago he was collaborating with his wife on
    writing and distributing a bi-monthly newsletter
    to the WWII vets from his military battalion.
    Until 1 month ago was driving and doing own yard
    work.

61
Case 3 Non-specific
  • Four weeks ago went to PCP with fatigue, rising
    agitation, and with R shoulder pain. Told he
    probably had early Alzheimers. Given Rx for
    Bextra for OA of shoulder.
  • Two weeks ago went back to PCP reporting same
    symptoms and now poor appetite. PCP note
    describes focal point tenderness over
    trapezius. Given Rx for Flexeril and Darvocet
    for muscle spasms, referral to outpatient
    geriatric-psychiatrist.
  • Today he agreed to let his wife to drive him to
    the ER b/c he felt like he couldnt get out of
    bed. He ate almost nothing yesterday. The
    geriatric-psychiatry appointment is four days
    away.

62
Case 3 Non-specific
  • Collateral history
  • Wife tells you hes seeing little women and
    little tigers. Patient corroborates and goes on
    to say hes very much aware that they cant be
    real and that he knows nobody else sees them.
  • Wife also points out that
  • 1) this 5-week illness interrupted a course of
    chemotherapy hed been getting as an outpatient
    for bladder CA
  • 2) theyve been to another hospital ER twice in
    the last month to try to get this explained

63
Case 3 Non-specific
  • Other collateral history
  • You talk to the nurse taking care of him in the
    ER. She tells you he seemed to choke a bit on the
    sandwich shed given him an hour ago. Patient and
    wife acknowledge that hes had difficulty
    swallowing his food.

64
Case 3 Non-specific
  • PMH
  • Bladder CA. Currently receiving outpatient
    chemotherapy.
  • H/O Prostate CA. S/p prostatectomy.
  • H/O Tobacco Abuse. Quit 20 yrs ago after 25
    pack-years.
  • PSH
  • S/p cholecystectomy
  • S/p prostatectomy

65
Case 3 Non-specific
  • Allergies NKDA
  • Meds
  • Risperdal 0.5mg bid
  • MVI c iron daily
  • Bextra qd
  • Darvocet prn
  • Flexeril prn

ROS no fever, chills, malaise. No abd pain,
N/V/D. No SOB/cough. No focal weakness but poor
balance. No CP/LH/syncope.
66
Case 3 Non-specific
  • PE
  • T 100.8F HR 102 BP 120/72 RR 16
  • Gen non-toxic appearing, well-nourished
  • HEENT OP very dry neck supple NL vision
  • CV No JVD, RRR, II/VI systolic murmur at RUS
    border
  • Lungs/abd normal
  • Ext No synovitis. No lesions. 2 peripheral
    pulses.
  • Skin Warm and dry. No rash.
  • Neuro AO to time, place, and situation, and o/w
    NL
  • Lab Na 130, Cl 96, Cr 1.4, WBC 12K (85
    neutrophils), UA ketones, 10-25 RBCs and WBCs. No
    leuk est or nitrite.
  • EKG NSR, 96.
  • Micro urine culture growing gram cocci

67
Case 3 Non-specific
  • Hospital Day 1
  • 1) Hyponatremia. Appears hypovolemic. NS at
    150cc/hr for 2L and re-evaluate.
  • 2) Fever/leukocytosis. 3 sets of blood
    cultures over next 24 hrs. No antibiotic until
    infection confirmed. TEE if blood cultures c/w
    SBE.
  • 3) Dysphagia. Observe at bedside. Formal swallow
    evaluation. Nutritional assessment and support.
    Aspiration precautions.
  • 4) DVT prophylaxis. Age and anticipated
    immobility. ?Lovenox 40mg SQ QD.

68
Case 3 Non-specific
  • Hospital Day 2
  • In AM, urine cultures growing Enterococcus.
  • In PM, blood cultures also growing Enterococcus.
  • Start Ampicillin and Gentamicin
  • Follow Cr closely
  • Order TEE

69
Case 3 Non-specific
  • Hospital Day 3
  • TEE aortic leaflet vegetation, 1cm
    moderate-severe AI, NL LV
  • Subsequent Hospital Course
  • Hallucinations, anorexia, fatigue, and dysphagia
    resolved.
  • Started ace-inhibitor.
  • Follow Up
  • Completed 2 weeks Amp/Gent, another 4 weeks
    Ampicillin. Returned completely to previous
    baseline.
  • Echo 3 months later with no changes in LV.

70
Especially if Your Hospital Lacks Specific
Geriatric Processes
  • Your elderly inpatients need you to minimize the
    impact of hospitalization, with special emphasis
    on appropriate prescribing
  • 2) Your elderly inpatients need you to decipher
    the root cause of their non-specific signs
    symptoms
  • 3) Your elderly inpatients need you to be able to
    explain and address their sinus tachycardia, T gt
    99, and leukocytosis
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