1. Hospital Care of the Elderly
Resident’s Thursday School
12/03/09
J Rush Pierce Jr, MD, MPH
Hospitalist Section, UNM

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

3. UNM Hospitalist Wiki Site
Resources
UNM Hospitalist Wiki Site

4. 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 2009;360:

5. 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

6. 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?

7. 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

9. 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

10. 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 Sep 10;10:83.

11. Falls prevention in the hospital: strategies

12. 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

13. Recognizing delirium in hospitalized patients: CAM
Both 1 & 2, plus either 3 or 4
Inouye SK. Delirium in older persons. NEJM 2006; 354:

14. 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

15. 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 2–3 days
Inouye SK. Delirium in older persons. NEJM 2006; 354:

16. Delirium: pharmacologic agents
Inouye SK. Delirium in older persons. NEJM 2006; 354:

17. 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

18. The Beers list

19. 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!

20. 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

21. Transitioning care: where?

22. 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”

23. Discharge summary
Only 30% d/c summ available to PCP at first visit (JAMA 2007; 297:834)
In pts referred to SNF’s 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 2009;24:630)
In pts with outstanding tests, only 25% DS recorded any outstanding test, and only 13% recorded all outstanding tests. 10% outstanding test were actionable

24. 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

25. The Discharge “Time – out”

26. 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?

27. 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