2. Hospital care for the elderly Case #1 J Rush Pierce Jr, MD Hospitalist Best Practices March 19, 2011

3. Plan Goals – Improve faculty confidence in caring for hospitalized elderly patients – Improve teaching about hospital care for elderly – Identify systems issues that affect care for elderly Methodology – Write orders and answer some basic questions about a hypothetical hospitalized elderly patient – Discuss care, identify learning issues, share teaching tools, identify systems issues 3/18/20112Hospital care for the elderly: case #1

4. Case - history 83 y/o man slipped on steps, has pain right hip. Xrays show hip fx – ortho plans to operate in 18 hours PMHx – COPD, FEV1 = 1.72 (78% pred), O2 dependent – BPH – HTN – No cardiac dz, NKDA – Meds = Albuterol, tamsulosin 0.8 mg/d, nifedipine-xr 60 mg daily, diazepam 5 mg/night 3/18/20113Hospital care for the elderly: case #1

5. Case – history (contd) FHx/SHx – no smoke x 10 years, no EtOH; lives with daughter, retired farmer ROS = no recent fever or purulent sputum, wears hearing aid and glasses, some memory difficulties past 2 years, unintended 10 # weight loss past year Level of function – independent in ADL; does not drive, daughter handles financial affairs; with portable oxygen is able to go up stairs, carry groceries 3/18/20114Hospital care for the elderly: case #1

6. Case - PE Gen – C/O pain right hip VS 119/61, 63, 16, SaO2 = 93% 2L/min, BMI = 18 Skin turgor normal Chest – distant breath sounds Cor – S1,S2 physiologic, no murmur/gallop Abd – benign Extrem – right leg fore-shortened and externally rotated Neuro – mini-COG score = 1 3/18/20115Hospital care for the elderly: case #1

7. Case - Lab WBC = 8700, H/H = 15.5/46, plts = 110K Na = 143, K = 3.5, Cl = 106, CO2 = 29, BUN = 29, creat = 1.3 CXR – c/w COPD EKG = NSR, c/w COPD 3/18/20116Hospital care for the elderly: case #1

8. Tasks Comment on “clearance” Write admitting orders List most likely preventable post-operative complications Estimate length of stay Plans for immediate post-hospital destination Estimate likelihood of living at home in 1 year 3/18/20117Hospital care for the elderly: case #1

9. Cardiac Clearance 3/18/20118Hospital care for the elderly: case #1

10. What about pulmonary clearance? 3/18/2011Hospital care for the elderly: case #19

11. Admitting orders Routine care What to do with fluids? What to do with home meds? Comfort measures What to do to prevent complications? 3/18/201110Hospital care for the elderly: case #1

12. Orders - routine Fluids Home meds – Albuterol – tamsulosin 0.8 mg/d – nifedipine-xr 60 mg daily – diazepam 5 mg/night Comfort – – Foley, opiates, bowel regimen 3/18/201111Hospital care for the elderly: case #1

13. Orders – preventing complications Venous thromboembolism Pneumonia/respiratory failure Delirium Skin breakdown Others? 3/18/201112Hospital care for the elderly: case #1

14. VTE prophylaxis Prevalence: DVT = 48%; fatal PTE = 4 -14% When to begin? – Heparin, coumadin - day before – LMWH – not before 12 hrs preoperatively Duration? – six weeks 3/18/201113Hospital care for the elderly: case #1

15. Strategies to decrease post-op pulmonary complications in COPD pts Smoking cessation for 8 wks Inhaled ipratropium Inhaled beta-agonists if wheezing Pre-op steroids if COPD not “optimized” Antibiotics in pts with infected sputum; delay elective surgery Pre-op inspiratory muscle training 3/18/201114Hospital care for the elderly: case #1

16. 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 JAGS 2007;55:314-316 0 points 3/18/201115Hospital care for the elderly: case #1

17. Assessing Delirium Risk Ann Intern Med. 1993;119:474-481 Inpatient Prediction Rule --Cognitive impairment --Severe Illness --High BUN/Cr --Vision impairment 1.Low Risk (0)- 10% 2.Int. Risk (1-2) – 25% 3.High Risk (3-4) – 80% 3/18/201116Hospital care for the elderly: case #1

18. 3/18/201117Hospital care for the elderly: case #1

19. Prevention of skin breakdown Pressure sore prevention – Foam mattress (RR = 0.34) – Alternating pressure mattress (RR=0.20) 3/18/201118Hospital care for the elderly: case #1

20. Copyright restrictions may apply. Arch Intern Med 2008;168:1010-1011 Length of stay comparison between the hospitalist and the non-hospitalist 3/18/201119Hospital care for the elderly: case #1