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

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

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

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;360:1418-1428

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

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?

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

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

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 10;10:83.

Falls prevention in the hospital: strategies

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

Recognizing delirium in hospitalized patients: CAM Both 1 & 2, plus either 3 or 4 Inouye SK. Delirium in older persons. NEJM 2006; 354:1157-1165

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

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; 354:1157-1165

Delirium: pharmacologic agents Inouye SK. Delirium in older persons. NEJM 2006; 354:1157-1165

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

The Beers list

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!

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

Transitioning care: where? http://champ.bsd.uchicago.edu/idealDischarge/index.html

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”

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

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

The Discharge “Time – out”

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?

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