Rocky course in hospital fall, pelvic fracture, delirium

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HOSPITAL CARE OF OLDER PATIENTS

• Bill Lyons, M.D.
• UNMC Geriatrics

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TO BE COVERED

• Motivation Why care about this?
• Functional decline in the hospital
• Two studied interventions
• Admitting the older patient
• Daily work rounds
• Prognosis after hospitalization

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CASE

• 88 yo community-dwelling woman with PD admitted
  with CHF exacerbation Fe-defic anemia found
  incidentally
• Managed with careful diuresis, O2 and ACEi,
  triple therapy, transfusion, and Fe for PUD and
  Helicobacter pylori
• Rocky course in hospital fall, pelvic fracture,
  delirium followed by d/c to SNF

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BACKGROUND

• USA Persons 65 are 13 of population, but
  account for 50 of hospital expenditures
• Rates of hospitalization are twice as great for
  85 age group compared to those 65-75
• Between a quarter and a third of older patients
  admitted to hospital for medical illness lose
  independent fcn in one or more ADL by D/C

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NOT THE USUAL HOSPITAL MEDICINE

• Although functional outcomes are not usually the
  focus of care in the hospital, they may be
  critical determinants of
• the quality of life,
• cost of care, and
• prognosis among older patients.
• -- R. Palmer

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NOT THE USUAL HOSPITAL MEDICINE

• You have attained Geriatric Enlightenment when
  you can focus on more than the acute problem(s)
  which led to the hospitalization.

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PREDICTORS OF IN-HOSPITAL FUNCTIONAL DECLINE

• Increasing age
• Lower preadmission IADL capabilities
• Cognitive impairment
• Depression symptoms
• Malnutrition

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HAZARDS OF BED REST

• Deconditioning loss of muscle mass
• Orthostasis
• Pressure ulcers
• Constipation
• Osteoporosis
• Pneumonia?

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POOR ORAL INTAKE IN THE HOSPITAL

• Acute illness itself
• Unappetizing cuisine and presentation
• Food served at undesired time
• Special diets (unappetizing)
• Frequent NPO orders

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DO YOU NEED THESE TETHERS AND ATTACHMENTS?

• Nasal cannula
• Central lines
• Telemetry units
• Bladder catheters
• Restraints

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TWO SYSTEMATIC INTERVENTIONS

• Acute Care for Elders (ACE) Units
• Hospital Elder Life Program (HELP)

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ACE Unit

• Specialized inpatient medical unit focuses on
  prehabilitation with 4 components
• Prepared environment for mobility and orientation
• Primary nurse assessment and protocols
• Early SW intervention in interdisciplinary
  framework for d/c planning
• Geriatrician review

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ACE Unit, contd

• RCT of 651 patients in Cleveland academic medical
  center
• Greater ADL independence at d/c
• Less frequent nursing home admission
• Slightly shorter LOS
• Akron community hospital
• Better process measures and satisfaction
• Better composite ADL-decline-or-NH-placement

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ACE Unit, contd

• Intervention reduced cost at academic center
  (6608 vs. 7240 per hospitalization)
• No significant financial impact in community
  hospital
• CS Landefeld, R Palmer, S Counsell et al

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HOSPITAL ELDER LIFE PROGRAM

• Multicomponent intervention to prevent functional
  and cognitive decline in hospitalized older
  patients
• Not unit-based extensive use of volunteers
• Admission screen for cognitive impairment,
  sleep deprivation, immobility, dehydration,
  vision impairment, hearing impairment

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HELP, contd

• Targeted interventions (protocols) implemented by
  interdisciplinary team
• Delirium incidence reduced by one third
• Reduced risk of ADL decline
• Cost neutral for intermediate-risk patients
• S Inouye et al

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WHAT THESE INTERVENTIONS TEACH US

• Targeting important for cost-effective program
• Nursing leadership, education, empowerment are
  crucial
• Common to both interventions CGA and QA
• Interdisciplinary approach is important
• Important to start discharge planning at admission

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ADMITTING THE OLDER PATIENT

• Landefeld suggests systematic assessment for 11
  items
• 1 ATRIAL FIBRILLATION
• Present in 5 or more of hospitalized elders
• Often incidental finding
• Take pulse order ECG anticoagulate?

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ADMITTING THE OLDER PATIENT, contd

• 2 MALNUTRITION
• Common
• Independently predicts death, functional
  dependence, institutionalization
• 3 NEED FOR IMMUNIZATION
• Influenza
• Pneumococcus

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ADMITTING THE OLDER PATIENT, contd

• 4 COGNITIVE IMPAIRMENT
• Risk factor for delirium, restraint use, falls,
  difficulties with adherence to therapy
• Consider MMSE CAM for delirium
• 5 IMMOBILITY AND FALLS
• Ask about it!
• Observe arising, standing, ambulation
• Encourage ambulation low threshold for PT

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ADMITTING THE OLDER PATIENT, contd

• 6 SENSORY IMPAIRMENT
• Difficulty seeing, hearing? Use glasses, HA?
• Jaeger card, whisper test on physical exam
• Bring in glasses, HA from home
• 7 DEPRESSION
• Independent predictor of d/c to SNF, mortality
• Major or minor depression present in 1/3
• Feel sad, depressed, or hopeless?
• Lost interest or pleasure in doing things?

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ADMITTING THE OLDER PATIENT, contd

• 8 DISABILITY
• Assess ADL and IADL function
• Determine causes of functional dependence
• Early involvement of PT, OT, SW, family
• 9 SUBOPTIMAL PHARMACOTHERAPY
• Huge turnover in med list (40 at admission, 45
  at discharge)
• Check indications, dose, interactions
• Clinical pharmacist involvement

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ADMITTING THE OLDER PATIENT, contd

• 10 MISTREATMENT
• Do you feel safe returning to where you live?
• 11 ADVANCE DIRECTIVES AND GOALS OF CARE
• Is prolonged survival a primary goal of therapy
  for this patient?
• Preferred intensity of care?

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DAILY WORK ROUNDS

• ADL status and trajectory?
• Eating?
• Eliminating and continent?
• Mobility? Has this patient been out of bed?
• Does she need all those attachments?
• Anticipated discharge location and arrangements?

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PROGNOSIS AFTER HOSPITALIZATION

• Prognostic index using 1500 patients 70 yo
  discharged from general medical service of
  tertiary care hospital
• Mean age 81
• Female 67
• Identified 6 independent risk factors for 1-year
  mortality following discharge
• L Walter et al, JAMA 2001

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RISK FACTORS FOR 1-YEAR MORTALITY

• Male sex 1 point
• Dependent in 1-4 ADL at discharge 2 points
• Dependent in all ADL at discharge 5 points
• CHF 2 points
• Solitary cancer 3 points

• Metastatic cancer 8 points
• Admission Crgt3 2 points
• Admission alb 3.0-3.4 1 point
• Admission alb lt3.0 2 points

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CASE DISCUSSION

• Foley left in 5 days for meticulous I/O
• NPO for endoscopy, plus constipation and anorexia
  from FeSO4 given tid
• Became presyncopal and tripped over catheter on
  HD3, low-grade fever with UA() on HD5

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SUMMARY

• Different population requiring different approach
• Emphasis on function, and preventing decline
• Best outcomes result from systematic approach,
  regardless of admitting diagnosis
• Emphasis on interplay between prognosis and goals
  of care

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FURTHER READING

• Callahan EH et al. Geriatric hospital medicine.
  Med Clin N Am 200286707-729.
• Lyons WL, Landefeld CS. Improving care for
  hospitalized elders. Annals of Long-Term Care
  20019(4)35-40