Care of the Hospitalized Geriatric Patient

1
Care of the Hospitalized Geriatric Patient
Ethan Cumbler MD, FACP Associate Professor of
Medicine Director UCH Acute Care For Elderly
Service University of Colorado Denver 2010
2
Objectives
Disclosures The speaker has no conflicts of
interest to disclose

• Recognize patients at highest risk for hazards of
  hospitalization such as delirium and falls using
  simple evidence based screening tools
• Be able to implement elements of an evidence
  based prevention protocol for common hazards of
  hospitalization
• Understand treatment options for delirium

3
Changing Demographics

• In 2000 about 1 in 8 Americans was over age 65.
• By 2030 it will be 1 in 5
• Hospitalization is a time of critical risk for
  the elderly
• We can do better

4
Current State of Affairs

• Majority of inpatient geriatric care is provided
  by physicians without specific training in
  geriatrics.
• Only 7,000 Geriatricians
• 30,000 Hospitalists
• Hospital communications silos inhibit recognition
  and treatment of new geriatric syndromes
• Physician often the last to know about barriers
• Physical
• Social
• Financial
• Outpatient caregivers not involved

5
What Explains the Status Quo?Barriers to Change

• Vulnerable elderly dispersed across teams and
  within hospitals
• Traditional closed ACE units proven successful
  but not widely implemented due to increased
  resource commitments
• Geriatric issues considered less vital than
  admit diagnosis
• Solutions require interdisciplinary approach
• Team infrastructure inadequate
• Focus can be on more rather than making it easy
  to do right

Jayadevappa R. Dissemination and Characteristics
of Acute Care for Elders Units in the United
States. In J Tech Assess in Health Care
200319220-227
6
Hazards of Hospitalization
High Risk Patient
Transition Failure
Falls
Pressure ulcers
Delirium
Adverse drug events
HAZARD
Functional decline
High Risk Situation
High Risk Environment
7
There are Some Who Think the Hospital Is a Fancy
Hotel
8
(No Transcript)
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A Modest Proposal

• System change is required
• Geographic concentration
• Standardized assessment
• Standardized care protocols
• Interdisciplinary care

Acute Care for the Elderly Service
10
Brief Geriatric Assessment

• Ideal Geriatric Assessment
• Fast
• Tolerated by patients
• Provide new information
• Leads to new action

• Confusion Assessment Method (CAM)
• Mini-Cog
• Vulnerable Elders Survey
• 2 Q Depression Screen
• Sensory Aid Assessment
• Falls Screen
• Get-Up-and-Go Test

11
Clinical CaseGertrudes Tragic Tale

• PMH
• Mild Alzheimer's Dementia
• Insomnia
• HTN
• Urge incontinence
• Depression
• Medications
• Lisinopril 10mg daily
• Aspirin 81 mg daily
• Amitryptiline 50mg qhs
• Oxybutinin 5mg bid

• 88 y/o woman admitted for back pain after a fall
  stepping off a curb outside her assisted living
• Xray demonstrates thoracic compression fracture.
• Admit for pain control, inability to ambulate.

12
When Hospitalization is Over.Will Gertrude be
going home?

• How do you predict discharge location on
  admission?

13
Assessing Need for PlacementVulnerable Elders
Survey-13

• Originally developed to identify community
  dwelling elders at risk for functional decline or
  death.
• 10 point score based on
• Age
• Self reported health status
• Ability to perform six physical tasks and five
  activities of daily living.

Saliba D. The Vulnerable Elders Survey A tool
for Identifying Vulnerable Older People in the
Community. J Am Geriatr Soc 2001491691-1699 Min
LC. Higher Vulnerable Elders Survey Scores
Predict Death and Functional Decline in
Vulnerable Older People. J Am Geriatr Soc
200654507-511
14
VES-13
Now validated to predict need for SNF in elderly
admissions Take Home Point Function PRIOR to
admission predicts need for placement
Cumbler E. Vulnerability Assessment on Hospital
Admission Predicts Need for Placement upon
Discharge for Elderly Patients. Journal of the
American Geriatrics Society 2009 57944-946
15
Gertrudes Tragic Tale

• Gertrude is confused about the timeline of events
  
• Does not remember her home medications
• Honey, I dont have to know that at my age when
  asked for the year,
• Can spell WORLD backwards
• Tells you a bright and animated story about her
  dog and how funny it was when he ate peanut
  butter
• Is Gertrude Delirious?

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DeliriumAcute onset of disturbance in
consciousness in which cognition or perception
is altered

• 17-74 cases unrecognized by nurses
• Physicians may do worse
• Over reliance on disorientation/inappropriate
  behavior
• More likely to be missed
• Hypoactive
• Age gt80 yrs
• Vision impairment
• Dementia

Are Nurses Recognizing Delirium? A systematic
review. JOGN 20083440-48 Occurrence of Delirium
is Severely Underestimated in the ICU during
Daily Care. Intensive Care Med 2009
17
DIAGNOSING DELIRIUMThe Confusion Assessment
Method (CAM)

• Patient must demonstrate the following
• Sensitivity 94-100, Specificity 90-95
• Positive LR 9.6 , Negative LR 0.16

OR
Inouye SK et al. Ann Intern Med
1990113941-948 Wong CL. JAMA. 2010304779-786
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ASSESSING DELIRIUM RISK
Medical Inpatient Prediction Rule

• Low Risk (0) 10 risk
• Int. Risk (1-2) 25 risk
• High Risk (3-4) 80 risk

• --Cognitive impairment
• --Severe Illness
• --High BUN/Cr
• --Vision impairment

Inouye, S. Ann Intern Med. 1993119474-481
19
Assessing Delirium Risk

• Mini-Cog
• 3 item recall (ball, justice, tree) (up to 3 pts)
• Clock Draw (10 minutes after 11)
• All or nothing-- 0 or 2 pts
• On Admission
• Scores of 0, 1, or 2 carries a 4-5X increased
  risk for delirium
• True regardless of whether the patient has
  dementia or not

0 points
Alagiakrishnan K et al. Simple Cognitive Testing
(Mini-Cog) Predicts In-Hospital Delirium in the
Elderly. JAGS 200755314-316
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DELIRIUM IS COMMON

• Affects 20 of hospitalized patients over age 65
• Up to 70-80 of older patients in intensive care
• Up to 83 of older patients at the end-of-life
• Affects 36.8 of postoperative patients
• Cataract Surgery 1-3
• General Surgery 10-15
• Orthopedic Surgery 28-61

Miller MO. Evaluation and Management of Delirium
in Hospitalized Older Patients. AAFP
2008781265-1270
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Mechanism of Delirium

• Imbalance of Neurotransmitters
• Acetylcholine ?
• Dopamine ?
• Others ??
• Hypothalamic-pituitary-adrenal axis
• Inflammation
• Cytokines (TNF, Interleukins)
• Occult diffuse brain injury
• Especially following sepsis (ischemic insult)

22
WHY DO WE CARE

• Increased Length of Stay
• By 8 days
• Increased Mortality
• Double the mortality in pts with delirium
• Functional Decline/NH placement
• Prolonged Cognitive Defects
• NEW RESEARCH
• 1/3 of pts d/c to SNF delirious will still be
  delirious 6 months later

Kiely DK, et al. Persistent Delirium Predicts
Greater Mortality. JAGS 20095755-61 Miller MO.
Evaluation and Management of Delirium in
Hospitalized Older Patients. AAFP
2008781265-1270
23
Delirium Prevention
Modifiable risk factor
Prospective Intervention
Cognitive impairment ? Immobility ? Visual
Impairment ? Hearing Impairment ? Dehydration
? Sleep deprivation ?

• Orienting communication
• Early mobilization, reduce restraints
• Visual aides, adaptive equip
• Amplifiers, adaptive equip
• Prevent and correct dehydration
• Uninterrupted sleep, nonpharmacologic aides

40 Relative Risk Reduction
Inouye SK et al. A multicomponent Intervention to
Prevent Delirium in Hospitalized Geriatric
Patients. NEJM 1999340669-676 Vidan MT et al.
An Intervention Integrated into Daily Clinical
Practice Reduces Incidence of Delirium During
Hospitalization in Elderly Patients. JAGS
2009572029-2036
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Sensory Deprivation
                                                
          One of Hebb's sensory deprivation
subjects at McGill.
25
Declassified 1983 CIA Training Manual

• Deprivation of sensory stimuli induces stress
  and anxiety
• Some subjects progressively lose touch with
  reality, focus inwardly, and produce
  hallucinations, delusions, and other pathological
  effects.
• 1984 revision states
• Deliberately causing these symptoms is a serious
  impropriety.

Accessed 2/28/09 at http//www.gwu.edu/nsarchiv/N
SAEBB/NSAEBB27/02-02.htm from National Security
Archive Database
26
Sensory Deprivation
                                                
          One of Hebb's sensory deprivation
subjects at McGill.
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Sleep Deprivation

• Consequences of lack of sleep in healthy
  volunteers include impaired attention and
  irritability
• Record for sleep deprivation is approximately 11
  days
• No longer accepts submissions in this category
  due to deleterious health effects

Light
Vital signs
Noise
Could you sleep?
Illness
Pain
Phlebotomy
Skin care
Drouot X. Sleep in the ICU. Sleep Medicine
Reviews 200812391-403
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Practical Application Order set as -QI
tool -Psychological manipulation -Establishment
of culture -Time saving device
29
Gertrudes Tragic Tale

• Diphenhydramine prn for insomnia
• An indwelling catheter is placed
• Her personal possessions are safely stored in the
  closet
• Clothing
• Glasses
• Dentures
• Hearing aids.
• Maintenance IV fluids, telemetry, and SCDs

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Clinical CaseGertrudes Tragic Tale

• The following morning Gertrude is still sleepy
  when
• The intern assesses her at 600am
• The nurse assesses her at 800am
• The attending assesses her at 1000am
• She sleeps through lunch
• Disoriented and inattentive-- not following
  instructions
• She becomes confused
• Trying to get out of bed
• Pulling at her IVs
• Is she delirious..Who knows?

31
Silos of Care

• Have you ever heard the phrase
• It seemed like the right hand didnt know what
  the left hand was doing

32
Effective Interdisciplinary Communication15
Minute Daily Team Huddle

• Attendings
• Residents
• Interns

• Nursing
• Physical Therapy
• Occupational Therapy
• Pharmacy
• Case Management
• Social Work
• Volunteers

Geographic Concentration
33
ENCOURAGING PATIENT INVOLVEMENT

• We want you to participate in your care
• and be as active as possible while staying safe
• Let your team know about any problems or
  questions.
• If you use glasses, hearing aids, or dentures-
  use them in the hospital just as you do at home.
• Your activity care plan will be based on your
  abilities and illness.
• If possible, walk in the hall multiple times each
  day to keep your strength up.
• Eat meals while sitting up, preferably in a
  chair.
• Your physicians will usually come in to see you
  and discuss
• your plan for the day between 900am and 1100 am
• feel free to invite family or other people in
  your life to be part of the care discussion
• Your team includes an attending physician
  responsible for your overall care plan
• Ethan Cumbler M.D. Heidi Wald M.D.
  Jeannette Guerrasio M.D. Jeanie Youngwerth
  M.D. Judy Zerzan M.D.

34
Response to Delirium TESTING

• Chem7, CBC, U/A
• Troponin, EKG
• CXR
• TSH, Ammonia, B12, ABG?
• LP if fever or neck stiffness
• CT/MRI brain if focal neurologic signs or head
  trauma
• EEG if clinical evidence of seizures
• Drug levels (Digoxin, anticonvulsants)
• Extensive testing of limited value unless driven
  by a specific clinical suspicion

35
Practical Approach

• Remove Problem Medications
• Particularly Anticholinergics, BNZ, and minimize
  Narcotics
• Treat Withdrawal
• Alcohol or benzodiazepines
• Correct Metabolic Disturbances
• Electrolytes, glucose, hydration, ammonia
• Reduce Level of Invasion
• Indwelling urinary catheters and lines
• Assess and Treat Infection
• Adequately Treat Pain
• Scheduled may be better than prn. Non-narcotic
  if possible
• Improve Environment and Mobility?

36
Medical Therapy for Delirium

• No good evidence that Cholinesterase Inhibitors
  (dopepezil) are effective
• No good evidence that Benzodiazepines are
  effective EXCEPT in alcohol withdrawal
• Antipsychotics decrease the degree and duration
  of delirium (typical just as good as atypical)

Cholinesterase Inhibitors for Delirium. Cochrane
Database of Systematic Reviews 2008 Benzodiazepine
s for Delirium. Cochrane Database of Systematic
Reviews 2009 Antipsychotics for Delirium.
Cochrane Database of Systematic Reviews 2007
37
When All Else Fails..ANTIPSYCHOTICS

• Typical Antipsychotics (Haloperidol)
• Does not prevent delirium when given
  prophylactically
• Extrapyramidal side effects with high doses
• Haloperidol 0.25 0.5mg PO BID or prn q 4h.
• Atypical Antipsychotics (Risperidone, Olanzapine,
  Quetiapine)
• Less QTc prolongation compared to haloperidol

Antipsychotics associated with increased
mortality in dementia --Prolonged QTc --Lowers
seizure threshold
38
What About Restraints?
Restraint chains used to control mentally ill
patients, and documentation regarding
Pennsylvania Hospital's purchase of such
restraints in 1751 and 1752.
39
RESTRAINT USE

• Restraints ARE appropriate for behavior that is a
  risk to life or to necessary medical care
• Restraints associated with significant injuries
• Restraints associated with 4 fold increased risk
  of delirium
• Distraction Vest

Dunn KS. Et al. The effect of physical restraints
on fall rates in older adults who are
institutionalized. Journal of Gerentol Nurs
20012740-48 Evaluation and Management of the
Elderly Postoperative Patient at Risk for
Postoperative Delirium. Clin Geriatr Med
200824667-686
40
Gertrudes Tragic Tale

• She gets out of bed to use bathroom at 2 a.m. and
  is found by staff on the floor.
• Urinary catheter still attached to the bed
• Her scalp laceration requires staples.

41
Inpatient Falls

• 2-12 of patients will have a fall in the
  hospital
• 30 with minor injury, 4 with major injury
• Associated increased hospital charges (4233)
• Associated increased LOS (12 days)
• Injuries from falls in the hospital are Never
  Events
• Medicare will no longer pay for them
• Hospital falls with significant injury are JCAHO
  reportable
• sentinel events
• Falls with injury in the hospital pose
  malpractice risk

Coussement J, et al. Interventions for Preventing
Falls in Acute and Chronic Care Hospitals A
systematic review and meta-analysis. JAGS
20075629-36
42
Fall Risk Assessment

• How do we as physicians assess a patients risk
  for this hazard of hospitalization?
• A simple falls screen
• Have you fallen in the last month or are you
  afraid of falling?
• Get-Up-And-Go test
• You learn a lot about strength, balance, and gait
  in 30 seconds.

43
Identifying the High Risk PatientRisk Factors

• Prior fall history
• Gait instability
• Lower limb weakness
• Confusion
• Drugs
• Sedative/hypnotics
• Urinary incontinence

Oliver D, et al. Risk Factors and Risk Assessment
Tools for Falls in Hospital In-patients A
Systematic Review. Age and Ageing 200433122-130
44
The High Risk Environment

• IV drips
• Telemetry
• Sequential compression devices
• Indwelling urinary catheters

45
Modifying the High Risk Environment

• Physicians unaware of catheter
• 21 for Medical Students
• 22 for Interns
• 27 for Residents
• 38 for Attendings
• This is not just about falls
• Iatrogenic infection is a potent hazard of
  hospitalization
• CMS no longer pays for catheter-associated UTIs

Saint S, et al. Are Physicians Aware of Which of
Their Patients Have Indwelling Urinary Catheters.
Am J Med 2000109476-480 Jain P, et al. Overuse
of the indwelling urinary tract catheter in
hospitalized medical patients. Arch Intern Med
19951551425-1429
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Modifying High Risk Therapy

• Psychoactive Medications
• Antidepressants and neuroleptics
• Benzodiazepines
• Lorazepam, Diazepam
• Narcotics
• Meperidine
• Cardiac medications
• Clonidine, short acting Nifedipine, Doxazosin,
  Digoxin
• Anticholinergic medications
• Diphenhydramine, Amitryptiline, Promethazine,
  Cyclobenzaprine
• Combinations of medications with partial
  anticholinergic activity
• Prednisolone
• Theophyline
• Digoxin
• Furosemide

Woolcott JC et al. Metaanalysis of the Impact of
9 Medication Classes on Falls in Elderly Persons.
Arch Int Med 20091691952-1960 Fick, D, et al.
Updating the Beers Criteria for Potentially
Inappropriate Medication Use in Older Adults.
Arch Int Med 20031632716-24 Tune L, et al.
Anticholinergic Effects of Drugs Commonly
Prescribed to the Elderly. Am J Psych
19921491393-1394
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Use of Sleepers in The Elderly

• 15 of elderly inpatients were on a sleep aid
  prior to admission
• 25 received pharmacotherapy for insomnia in the
  hospital
• Non-benzodiazepine hypnotics (zolpidem)
• Most commonly chosen by hospitalists

Cumbler E. Use of Medications for Insomnia in the
Hospitalized Geriatric Population. JAGS 2008
56579-581
48
ResultsUCH ExperienceRandomized patients for
1st 6 months ACE vs usual care

• Resource Utilization
• Documented severity of illness slightly higher
  for ACE
• Case mix index for ACE patients was 1.15 vs 1.05
  in usual care
• Length of stay 3.4 days
• Mean Patient Charges 24,617
• 30 Day readmission rate 12.3
• ACE service model did not significantly change
  resource utilization

49
3600 Evaluation

• House staff
• 100 feel better medical care of the elderly
• Patient Satisfaction
• Staff-- improved
• Care coordination
• Communication
• Job satisfaction

Overall I received very good care
50
Clinician Behavior Mirrors the System in Which
They Practice!
51
ACE ModelWhat Does The Literature Show?

• Less Functional Decline at Discharge
• 13 risk reduction
• Lower rate of Institutionalization
• 22 risk reduction at 1 year
• No influence on LOS
• Trend towards reduced
• Readmission (15 risk reduction but not
  statistically significant)
• Mortality (22 risk reduction at 3 months but not
  statistically significant)

Van Craen K. The Effectiveness of Inpatient
Geriatric Evaluation and Management UnitsA
Systematic Review and Meta-Analysis. J Am Geriatr
Soc 20105883-92 Baztan JJ. Effectiveness of
Acute Geriatric Units on Functional Decline,
Living at Home, and Case Fatality Among Older
PatientsBMJ 2009338
52
Geriatric Syndromes Have Profound Impact

• Hazards
• Delirium
• Deconditioning
• Falls

• Harmed
• The Patient
• The Hospital
• The Provider
• The Insurer

Miller MO. Evaluation and Management of Delirium
in Hospitalized Older Patients. AAFP
2008781265-1270 Kiely DK, et al. Persistent
Delirium Predicts Greater Mortality. JAGS
20095755-61
53
Keys to Care of the Hospitalized Elder

• Simple Risk Assessments
• Avoidance of Problematic Interventions
• Anti-cholinergic and Sedative Medications
• Tethers
• Restraints
• Interdisciplinary Team Communication
• Standardized Care Protocols