Presentation is loading. Please wait.

Presentation is loading. Please wait.

Hospitalization of the Elderly Tracey Doering, MD May 20, 2008.

Similar presentations


Presentation on theme: "Hospitalization of the Elderly Tracey Doering, MD May 20, 2008."— Presentation transcript:

1 Hospitalization of the Elderly Tracey Doering, MD May 20, 2008

2 The Dangers of Going to Bed Look at the patient lying long in bed. What a pathetic picture he makes. The blood clotting in his veins, The lime draining from his bones, The scybala stacking up in his colon, The flesh rotting from his seat, The urine leaking from his distended bladder, And the spirit evaporating from his soul. Dr. Richard Asher, British Medical Journal, 1947

3 Demographics Population over age 65 is now 13%, and projected to be 20% by Population over age 65 is now 13%, and projected to be 20% by % of hospital admissions 38% of hospital admissions 49% of hospital days 49% of hospital days Severity of illness rising Severity of illness rising Rates of hospitalization are twice as great in pts over age 85 Rates of hospitalization are twice as great in pts over age 85

4 Consequences of Hospitalization 23.3% risk of being unable to return home and require nursing home placement 23.3% risk of being unable to return home and require nursing home placement 35% decline in some basic ADL 35% decline in some basic ADL One study showed 50% of elderly patients experienced some kind of complication related to hospitalization One study showed 50% of elderly patients experienced some kind of complication related to hospitalization

5

6 Hazards Functional decline Functional decline Immobility Immobility Delirium Delirium Depression Depression Restraints Restraints Adverse drug reaction Nosocomial infections Incontinence Malnutrition Pressure Ulcers

7 Functional decline Hansen, etal, JAGS, 47: , 1999

8 Functional Decline Data of five studies combined Data of five studies combined 19% decline at 3 month follow up 19% decline at 3 month follow up If declined in hospital, 41% failed to return to preadmission status If declined in hospital, 41% failed to return to preadmission status 40% declined in IADL function at three months 40% declined in IADL function at three months

9 Functional Decline-Independent Predictors Hospital Admission Risk Profile Hospital Admission Risk Profile Increasing Age Increasing Age Lower MMSE Lower MMSE Lower preadmission IADL scores Lower preadmission IADL scores J Am Geriatr Soc 1996; 44: IDENTIFY FRAILITY AND VULNERABILTY ON ADMISSION J Am Geriatr Soc 2007; 55:

10 Hazards Functional decline Functional decline Immobility Immobility Delirium Delirium Depression Depression restraints restraints Adverse drug reactions Nosocomial infections Incontinence Malnutrition Pressure ulcers

11 Immobility Review of studies showed that bed rest was associated with worse outcomes after medical or surgical procedures, or primary treatment of medical conditions Review of studies showed that bed rest was associated with worse outcomes after medical or surgical procedures, or primary treatment of medical conditions Lancet 1999; 354:

12 Hazards Functional decline Functional decline Immobility Immobility Delirium Delirium Depression Depression restraints restraints Adverse drug reactions Nosocomial infections Incontinence Malnutrition Pressure ulcers

13 Delirium Most common hazard of hospitalization Most common hazard of hospitalization Multifactorial Multifactorial 14-56% have it on admission 14-56% have it on admission 12-60% acquire it 12-60% acquire it 32%-67% go unrecognized 32%-67% go unrecognized Misdiagnosed as dementia Misdiagnosed as dementia Longer length of stay, increased morbidity and mortality, and institutionalization Longer length of stay, increased morbidity and mortality, and institutionalization

14

15 Factors in Delirium Predisposing Predisposing Age Age Impaired cognition Impaired cognition Dependence in ADLS Dependence in ADLS High medical comorbidity High medical comorbidity Precipitating >6 meds, >3 new Psychotropic meds Acute medical illness Vascular or cardiac surgery Hip fx Dehydration Environmental change

16 Medications and Delirium Opioids (especially meperidine) Opioids (especially meperidine) Anticholinergics: antidepressants, antihistamines, anipsychotics, antispasmodics Anticholinergics: antidepressants, antihistamines, anipsychotics, antispasmodics Benzodiazepines Benzodiazepines Cardiac drugs: digoxin, amiodarone Cardiac drugs: digoxin, amiodarone Any drug with action in CNS Any drug with action in CNS

17 Intervention Inouye, etal, NEJM 340:669-76, 1999

18 Management efforts Adequate CNS oxygen delivery Adequate CNS oxygen delivery Fluid/electrolyte balance Fluid/electrolyte balance Teat severe pain Teat severe pain Nutritional intake Nutritional intake Early mobilization and rehab Early mobilization and rehab Early identification on post op complications Early identification on post op complications Eliminate unnecessary meds Eliminate unnecessary meds Environmental stimuli Environmental stimuli

19 Agitated delirium Appropriate diagnostic evaluation Appropriate diagnostic evaluation Calm reassurance, family, sitter Calm reassurance, family, sitter If absolutely necessary: haldoperidol mg every 4 hrs as needed If absolutely necessary: haldoperidol mg every 4 hrs as needed

20 Hazards Functional decline Functional decline Immobility Immobility Delirium Delirium Depression Depression restraints restraints Adverse drug reactions Nosocomial infections Incontinence Malnutrition Pressure ulcers

21 Depression Major depression: 10-21% Major depression: 10-21% Minor depressive symptoms 14-25% Minor depressive symptoms 14-25% Underrecognized Underrecognized Poorer outcomes Poorer outcomes Higher mortality rate, unrelated to severity of medical illness Higher mortality rate, unrelated to severity of medical illness More likely to deteriorate in hospital, and less likely to improve at discharge or at 90 days More likely to deteriorate in hospital, and less likely to improve at discharge or at 90 days

22 Ann Intern Med 1999; 130: 563-9

23 Hazards Functional decline Functional decline Immobility Immobility Delirium Delirium Depression Depression restraints restraints Adverse drug reactions Nosocomial infections Incontinence Malnutrition Pressure ulcers

24 Restraints In 1992, 7.4%-17% of medical pts were restrained In 1992, 7.4%-17% of medical pts were restrained In 1998, 3.9%-8.2% In 1998, 3.9%-8.2% Reasons: prevent disruption of therapy, reduce falls, and confine confused patients Reasons: prevent disruption of therapy, reduce falls, and confine confused patients Evidence does not support this Evidence does not support this Serious negative outcomes result Serious negative outcomes result

25 Hazards Functional decline Functional decline Immobility Immobility Delirium Delirium Depression Depression restraints restraints Adverse drug reactions Nosocomial infections Incontinence Malnutrition Pressure ulcers

26 Adverse drug reactions Most frequent iatrogenic complication Most frequent iatrogenic complication Increased length of stay, higher costs, doubling of risk of death Increased length of stay, higher costs, doubling of risk of death Risk increases exponentially with number of medications Risk increases exponentially with number of medications High risk: greater than 4 or 5 drugs High risk: greater than 4 or 5 drugs

27 Prescribing guidelines Know medications that pt is taking Know medications that pt is taking Individualize therapy Individualize therapy Reevaluate daily Reevaluate daily Minimize dose and number of drugs Minimize dose and number of drugs Start low, go slow Start low, go slow Treat adequately; do not withhold therapy Treat adequately; do not withhold therapy Recognize new symptoms as potential drug effect Recognize new symptoms as potential drug effect Treatment adherence Treatment adherence

28 Medications to avoid Antihistamines Antihistamines Narcotic analgesics Narcotic analgesics Benzodiazepines Benzodiazepines Tricyclic antidepressants Tricyclic antidepressants Histamine-2 receptor antagonists Histamine-2 receptor antagonists

29 Important Problem drugs Warfarin Warfarin Digoxin Digoxin insulin insulin

30 Polypharmacy No single tool can identify the cause No single tool can identify the cause Many medications are often necessary to treat multiple diseases (DM, CHF, hyperlipidemia) Many medications are often necessary to treat multiple diseases (DM, CHF, hyperlipidemia) Some causes: multiple prescribers, multiple pharmacies-drug interactions, and drug duplications Some causes: multiple prescribers, multiple pharmacies-drug interactions, and drug duplications

31 Polypharmacy Prevention Know indication of each medication Know indication of each medication ASK: safer non pharmacologic alternative ASK: safer non pharmacologic alternative ASK: treating a side effect of another med ASK: treating a side effect of another med ASK: Do contraindications exist ASK: Do contraindications exist ASK: duplicate side effects of other meds ASK: duplicate side effects of other meds ASK: Interact with other meds ASK: Interact with other meds ASK: Increase complexity of regimen ASK: Increase complexity of regimen

32 J Amer Geriatrics Society 56: , 2008

33 Hazards Functional decline Functional decline Immobility Immobility Delirium Delirium Depression Depression restraints restraints Adverse drug reactions Nosocomial infections Incontinence Malnutrition Pressure ulcers

34

35 Nosocomial infections 50% of cases are in elderly patients 50% of cases are in elderly patients Urinary tract, lungs and gastrointestinal tract Urinary tract, lungs and gastrointestinal tract Risks: older age, catheters, antibiotics, fecal or urinary incontinence, glucocorticoids Risks: older age, catheters, antibiotics, fecal or urinary incontinence, glucocorticoids Resistant organisms: Get records of cultures from nursing homes Resistant organisms: Get records of cultures from nursing homes

36 Prevention measures Hand washing Hand washing Limit use of broad spectrum antibiotics Limit use of broad spectrum antibiotics Discharge patients as soon as possible Discharge patients as soon as possible Limit use of in-dwelling catheters as much as possible Limit use of in-dwelling catheters as much as possible Reassess need for in-dwelling catheters daily Reassess need for in-dwelling catheters daily

37 Hazards Functional decline Functional decline Immobility Immobility Delirium Delirium Depression Depression restraints restraints Adverse drug reactions Nosocomial infections incontinence Malnutrition Pressure ulcers

38 Urinary incontinence 35% of hospitalized patients 35% of hospitalized patients 5% acquire it in the hospital 5% acquire it in the hospital Remember transient causes: DIAPPERS Remember transient causes: DIAPPERS Not an indication for a catheter Not an indication for a catheter Void q 2 hours Void q 2 hours Falls occur with patients trying to get to the bathroom Falls occur with patients trying to get to the bathroom

39 Nutrition Independent risk factor for mortality Independent risk factor for mortality Assess at admission Assess at admission Minimize NPO orders Minimize NPO orders Consequences of malnutrition: pressure ulcers, impaired immunity, and longer length of stay Consequences of malnutrition: pressure ulcers, impaired immunity, and longer length of stay

40 Covisky, etal JAGS, 47:

41 What the admitting care team can do Establish baseline Establish baseline Compare baseline Compare baseline Prevent iatrogenic illness Prevent iatrogenic illness Understand patient values Understand patient values Initiate discharge planning Initiate discharge planning Make walk rounds with nurse Make walk rounds with nurse Hold family conferences Hold family conferences Immunize Immunize

42 Establish baseline ADLS ADLS IADLS IADLS Mobility Mobility Living situation Living situation Social support Social support Discuss and obtain advance directives Discuss and obtain advance directives

43 Compare baseline Functional assessment-current ADL level Functional assessment-current ADL level Assess mobility Assess mobility Assess cognition Assess cognition Estimate length of stay Estimate length of stay Expected discharge site Expected discharge site

44 Daily rounds Catheters Catheters Central lines Central lines Medications Medications Nasal cannulas Nasal cannulas Telemetry Telemetry restraints restraints Therapies needed? Therapies needed? Target discharge date Target discharge date

45 Discharge Reassess ADLS Reassess ADLS Check mobility Check mobility Do not discharge if: new fever, delirium, hypotension or severe hypertension Do not discharge if: new fever, delirium, hypotension or severe hypertension Assess home needs to be sure they are met Assess home needs to be sure they are met

46 Improve transitions of care Medications Medications Transportation Transportation Medical Supplies Medical Supplies Home or transition setting Home or transition setting Pt participation Pt participation Food and meals Food and meals Financial concerns Financial concerns

47 Readmission 12-66% elderly patients readmitted 1-6 months post discharge 12-66% elderly patients readmitted 1-6 months post discharge Frequently premature and poorly structured Frequently premature and poorly structured

48 Complex Discharge Planning 70 years of age of older and living alone 70 years of age of older and living alone Admitted from nursing home Admitted from nursing home Comatose Comatose Complex medication regimen Complex medication regimen Disorientation, confusion, forgetfulness Disorientation, confusion, forgetfulness History of repeat admissions History of repeat admissions In need of special therapies In need of special therapies

49 Complex discharge Planning Lack of social support Lack of social support Limited activities of daily living Limited activities of daily living Multiple medical diagnoses Multiple medical diagnoses Previously or newly diagnosed as disabled Previously or newly diagnosed as disabled Requiring wound care Requiring wound care Victim of severe accident Victim of severe accident

50 DOES THE PATIENT UNDERSTAND?

51

52 Comprehension Study of 125 patients’ comprehension of 50 of the most common health words found in transcripts of interviews Study of 125 patients’ comprehension of 50 of the most common health words found in transcripts of interviews 98% understood “vomit” 98% understood “vomit” 13% understood “terminal” 13% understood “terminal” 18% understood “malignant” 18% understood “malignant” 22% understood “nerve” 22% understood “nerve”

53 Systematic Approaches Acute Care for the Elderly Units (ACE units) Acute Care for the Elderly Units (ACE units) Hospital Elder Life Program (HELP) Hospital Elder Life Program (HELP) Study results vary Study results vary Some with dramatic reduction in loss of functional status Some with dramatic reduction in loss of functional status Substantial interdisclipinary team interaction Substantial interdisclipinary team interaction

54 ACE UNIT Focuses on 4 components: Focuses on 4 components: 1. Prepared environment for mobility and orientation 1. Prepared environment for mobility and orientation 2. Primary nurse assessment and protocols 2. Primary nurse assessment and protocols 3. Early SW intervention 3. Early SW intervention 4. Geriatrician review 4. Geriatrician review

55 HELP Multicomponent intervention to prevent decline Multicomponent intervention to prevent decline Not unit based Not unit based Volunteers used extensively Volunteers used extensively Broad admission screen Broad admission screen Targeted interventions Targeted interventions

56 Home Hospital Care Patient preferences Patient preferences Potential to avoid hazards of hospitalization Potential to avoid hazards of hospitalization Guidelines issued for pneumonia care at home by ACCP Guidelines issued for pneumonia care at home by ACCP Chest 2007; 127:

57 Palliative care and end of life issues Resuscitation status Resuscitation status Advance Directives Advance Directives Rehospitalize? Rehospitalize? What treatments? What treatments?

58 Summary The hospital can be a hazardous place for elders The hospital can be a hazardous place for elders Don’t assume delirium is dementia Don’t assume delirium is dementia Start discharge planning on day 1-know your patient and their circumstances Start discharge planning on day 1-know your patient and their circumstances COMMUNICATE-particularly goals of care COMMUNICATE-particularly goals of care MOBILIZE! MOBILIZE! Do no harm-avoid iatrogenic illness if possible Do no harm-avoid iatrogenic illness if possible

59 Key References Society of Hospital Medicine Society of Hospital Medicine , ext , ext CD-ROM with a compendium of resources for inpatient care of the elderly CD-ROM with a compendium of resources for inpatient care of the elderly Acute Hospital Care for the Elderly Patient: Its Impact on Clinical and Hospital Systems of Care, Medical Clin NA 92: , 2008 Acute Hospital Care for the Elderly Patient: Its Impact on Clinical and Hospital Systems of Care, Medical Clin NA 92: , 2008


Download ppt "Hospitalization of the Elderly Tracey Doering, MD May 20, 2008."

Similar presentations


Ads by Google