Hospital Care of the Elderly

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Hospital Care of the Elderly

• Residents Thursday School
• 12/03/09
• J Rush Pierce Jr, MD, MPH
• Hospitalist Section, UNM

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Outline

• Resources
• Epidemiology, costs, and outcomes
• Functional Assessment
• Falls prevention
• Strategies to prevent delirium
• Avoiding inappropriate drugs
• Transitioning care
• Making rounds on elderly patients

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Resources

• UNM Hospitalist Wiki Site
• www.unmhospitalist.pbworks.com

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Epidemiology, costs and outcome of
hospitalization of elderly
Jencks SF, Williams MV, Coleman EA.
Rehospitalization among persons in the Medicare
Fee-for-service program. NEJM 20093601418-1428
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Hospitalization of the elderly

• 1/4 elderly hospitalized each year
• 1/5 of hospitalized are re-hospitalized within 30
  days only 10 planned
• Half of those re-hospitalized within 30 days had
  not had any office visit in between
• Most common dxs CHF, psychoses, COPD
• Unplanned re-hospitalizations cost 17.4B in 2004

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Functional Assessment

• Importance of function in the elderly
• Functional assessment instruments
• Functional assessment in the hospital
• Why should I do it?
• When should I do it?
• How do I do it?
• What are implications?

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Functional Impairments in Elderly Associated with
Hospitalization

• 15 event discharged to nursing home
• Another 20 discharged without ever recovering
  pre-hospital level of activity
• Another 15 elderly lose ability to perform basic
  self-care activities but regain before going home

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Functional Loss during Hospitalization Targeted
Interventions

• Falls prevention
• Strategies to prevent delirium
• Avoiding inappropriate drugs
• Transitioning care
• --------------------------------------------------
  -------------------
• Optimizing nutrition
• Improving sensory impairments
• Screening/treating depression
• Screening/treating cognitive impairment

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Falls in the hospital - epidemiology

• 5 10 of hospitalized elderly fall during
  hospital stay
• 30 occur within first 48 hours
• 1/2 occur at bedside during transfer
• 1/2 unwitnessed

Vass CD, Sahota O, Drummond A, et al. REFINE
(Reducing Falls in In-patient Elderly)--a
randomised controlled trial. Trials. 2009 Sep
101083.
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Falls prevention in the hospital strategies
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Epidemiology of delirium in hospitalized elderly

• Present of admission in 10
• Develops in another 30 during hospital stay
• Increased rate of in-hospital mortality
• Increased rate of nursing home placement
• Risk factors pre-existing cognitive impairment
  sleep deprivation immobility visual impairment
  hearing impairment dehydration

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Recognizing delirium in hospitalized patients CAM
Both 1 2, plus either 3 or 4
Inouye SK. Delirium in older persons. NEJM 2006
3541157-1165
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Strategies to prevent delirium

• Avoid certain medications (sedatives, narcotics,
  anticholinergics)
• Treat infection and fever
• Detect and correct electrolyte abnormalities
• Frequently re-orient the patient (family, sitter)
• Get out of bed
• Avoid room changes, Foley, restraints

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Delirium principles of pharmacologic treatment

• Reserve this approach for patients with severe
  agitation at risk for interruption of essential
  medical care for patients who pose safety hazard
• Start low doses and adjust until effect achieved
• Maintain effective dose for 23 days

Inouye SK. Delirium in older persons. NEJM 2006
3541157-1165
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Delirium pharmacologic agents
Inouye SK. Delirium in older persons. NEJM 2006
3541157-1165
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Epidemiology of medication use in hospitalized
elderly

• 40 outpt drugs discontinued on admission
• 45 of discharge meds started during hospital
  stay
• 22 of hospitalized elderly have at least one
  serious or life-threatening drug problem

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The Beers list
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Avoiding inappropriate drug use in hospitalized
elderly principles

• Avoid anticholinergics, sedative/hypnotics,
  drugs with CNS side effects
• Pick drugs with shorter half-lives
• Try to simplify the regimen that your patient is
  going home on (frequency of dosing, grouping of
  drugs, expense)
• Use your pharmacists!

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Transitions from hospital care epidemiology

• 1/4 hospitalized elderly are discharged to
  another facility
• 50 experience a medical error at discharge
• 1/5 experience an adverse event at discharge
  (more than half are preventable)
• 1/5 of hospitalized are re-hospitalized within 30
  days only 10 planned

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Transitioning care where?
http//champ.bsd.uchicago.edu/idealDischarge/index
.html
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Transitions from hospital care strategies to
improve success

• Involve multi-disciplinary team
• Anticipate discharge needs early during stay
• Involve the patient and family
• Review and reconcile meds
• Dictate an accurate and timely discharge summary
• If going home, schedule f/u outpt visit in 2
  weeks
• Coordinate care with next provider
• Do a discharge Time out

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Discharge summary

• Only 30 d/c summ available to PCP at first visit
  (JAMA 2007 297834)
• In pts referred to SNFs medication discrepancy
  between DCs and transfer form identified in 52
  of admissions. CV drugs, opiates, psych meds,
  hypoglycemics, antibiotics, and anticoags
  accounted for 50 of descrepancies (JGIM
  200924630)
• In pts with outstanding tests, only 25 DS
  recorded any outstanding test, and only 13
  recorded all outstanding tests. 10 outstanding
  test were actionable

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Draft of Model Discharge Summary

• Dates of Admission and Discharge 
• Final Primary and All Secondary Diagnoses 
• Brief HPI Presenting problem that precipitated
  hospitalization
• Brief Hospital Course by Problem  - Include
  procedure results, and abnormal test results
• Sub-Specialist Recommendations           
• Reconciled Discharge Medication - New or Changed
  Dose Medications, Continued Meds from Admission,
  Stopped Meds 
• Functional Status at Discharge and Discharge
  Destination 
• Follow-up Plan - Follow up Appointments
• Suggested Management Plan
• Pending Labs or Test 
• Any Anticipated Problems and Suggested
  Interventions with documentation of patient
  education (smoking cessation) and understanding

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The Discharge Time out
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Hospitalized elderly Daily Rounds

• Review all meds
• What is the functional capacity?
• Is the patient eating?
• Is the patient getting out of bed?
• Does the patient need all these attachments?
• What is the discharge plan and destination?
• Is the family aware?

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General principles in caring for hospitalized
elderly

• Add FUNCTION to your dx/rx paradigm
• Consider medication regimen as well as meds
• Think early about the destination