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CHAMP: Care of the Hospitalized Aging Medical Patient For Medical Students

CHAMP: Care of the Hospitalized Aging Medical Patient For Medical Students. Shellie Williams, M.D. University of Chicago. Objectives. Understand current trends in hospitalization of the elderly. Identify issues to address at admission to limit functional decline.

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CHAMP: Care of the Hospitalized Aging Medical Patient For Medical Students

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  1. CHAMP: Care of the Hospitalized Aging Medical PatientFor Medical Students Shellie Williams, M.D. University of Chicago

  2. Objectives Understand current trends in hospitalization of the elderly. Identify issues to address at admission to limit functional decline. Increase recognition of delirium in elderly. Devise overall plan for addressing hospital care of elderly.

  3. Hospitalization of the Elderly:Hospital Focus 45-50% discharges US hospitals >65yo Hospital focus: managing illness, not improved function. Diminishing LOS 8.7 days5.7 days (1990-2000) Increased procedures iatrogenic events

  4. Geriatric Focus of Hospitalization Improving/Maintaining functional status Facilitating safe transition to community Identifying and addressing geriatric syndromes Physical 4 “D” Delirium Dementia Depression Diet Psycho social FUNCTION

  5. Geriatric Review of Systems: Daily Sensory function Bowels/bladder Appetite/Nutrition Sleep Cognition Mobility Pain

  6. Key Risks of Hospitalizing Elderly: Functional Decline (Adl, IAdl) Institutionalization (Dispo Card) Cognitive Decline (CAM) Mortality (Walter Index)

  7. Function and the Hospitalized Elder: Activities of Daily Living (ADLs): Assess self care capability Bathing Dressing Toileting Continence Transfers Gait Feeding Instrumental ADLs (iADLs): Assess living independence Telephone use Travel Shopping Meal Preparation Housekeeping Medication management Financial management

  8. Functional Decline and the Hospitalized Elder 1279 pts >70yo ADL measure at DC and 3mo post-DC 31% decline baseline-adl at DC 59% unchanged; 10% better at DC 3 months: 11% died 40% further adl deficits Sager, M. Arch In Med 1996; 156: 645-2

  9. Etiology of Functional Decline Insomnia Constipation Medications *BZD *Antihyper-tensives Fatigue Incontinence Malnutrition Pain Sensory deficits Iatrogenic Atelactasis DVT Ulcers Functional Decline/ Deconditioning Immobility Depression/frustration General Weakness Restraint (Physical, Behavioral, Conceptual-foley, iv) Confusion Acute medical illness

  10. Hospitalization and Bed-rest: • Table 1. Effects of Bed Rest • System Effect • Cardiovascular ↓ Stroke volume, ↓ cardiac output, ^ pvr, orthostatic hypotension, < plasma volume • Respiratory ↓ Respiratory excursion, ↓ oxygen uptake, ↑ potential for atelectasis • Muscles ↓ Muscle strength, ↓ muscle blood flow • Bone ↑ Bone loss, ↓ bone density • GI Malnutrition, anorexia, constipation • GU Incontinence • Skin Sheering force, potential for skin breakdown • Psychological Social isolation, anxiety, depression, disorientation

  11. Functional DeclineOther Geriatric Syndromes: • Pressure Ulcers • Delirium • Dehydration • Malnutrition • Falls 13x increased • Incontinence • Insomnia • Pain • Restraint devices: IV, Foley, PEG, wrist Creditor, M. Ann In Med 1993; 118:219-23.

  12. Walter Prognostic Index1 year prognostic index patient >/= 70 Factor Points Male 1 ADL dependence dispo 1-4 2 All 5 CHF 2 Cancer solitary/mets 3/8 Createnine >3.0 2 Albumin 3-3.4/<3.0 1/2

  13. Walter Prognostic Index1 year prognostic index patient >/= 70 1 year mortality: 1-4 points 4% 2-3 points 19% 4-6 points 34% >6 points 64% >6 consider hospice or EOL focused care. Appropriate for prognostic consideration in pts with cancer, chf, dementia, copd, acute irreversible process.

  14. Diagnosis: Confusion Assessment Method (CAM) (1) Acute change in mental status with a fluctuating course (2) Inattention AND (3) Disorganized thinking OR (4) Altered level of consciousness Inouye SK et al. Ann Intern Med. 1990; 113: 941-948 Sensitivity: 94-100%, Specificity: 90-95%

  15. How to Distinguish Delirium from Dementia Features seen in both: Disorientation Memory impairment Paranoia Hallucinations Emotional lability Sleep-wake cycle reversal Key features of delirium: Acute onset Impaired attention Altered level of consciousness

  16. Assume it is Delirium until Proven Otherwise Delirium may be the only manifestation of life-threatening illness in the elderly patient

  17. Predisposing Factorsi.e. baseline underlying vulnerability Baseline Dementia 2.5 fold increased risk of delirium in dementia patients 25-31% of delirious patients have underlying dementia Medical co-morbidities: Acute medical illness Visual impairment Hearing impairment Functional impairment Advanced age History of ETOH abuse Male gender

  18. Precipitating Factorsi.e. noxious insults Medications Bedrest Indwelling bladder catheters Physical restraints Iatrogenic events Uncontrolled pain Fluid/electrolyte abnormalities Infections Medical illnesses Urinary retention and fecal impaction ETOH/drug withdrawal Environmental influences

  19. Some drug classes that are associated with delirium Medications with psychoactive effects: 3.9-fold increased risk 2 or more meds: 4.5-fold Sedative-hypnotics: 3.0 to 11.7-fold Narcotics: 2.5 to 2.7-fold Anticholinergic drugs: 4.5 to 11.7-fold

  20. Prevention of Delirium: It can be done! Find patients with 1-4 of the following predisposing characteristics: Visual impairment (worse than 20/70 corrected) Severe illness Cognitive impairment (MMSE<24/30) High BUN/Cr ratio (>18) (Inouye SK et al. Ann Intern Med. 1993; 119:474-481)

  21. Take Home Points: Delirium in the Elderly A multi-factorial syndrome: predisposing vulnerability and precipitating insults Delirium can be diagnosed with high sensitivity and specificity using the CAM Prevention should be our goal If delirium occurs, treat the underlying causes Always try non-pharmacologic approaches Use low dose anti-psychotics in severe cases

  22. Targeted Interventions for Prevention of Decline: • Fall precautions/PT: hx dementia, confusion, fall in prior 12 months • Dysphagia diet/speech eval: stroke, difficulty swallowing, aspiration • Bowels: prunes, mobility, home foods • Social work/case manager: limited community support, self neglect, cog deficits • Nutrition/supplements, 1:1 Feeding: Hx weight loss, low albumin, advanced dementia, liberal diet

  23. Geriatric Complications and Screens for Assessing:

  24. Geriatric Screens Web Access: • CAM: http://www.healthcare.uiowa.edu/igec/tools/cognitive/CAM.pdf • Mini-Cog http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/clock_drawing_test.pdf • ADL: http://www.healthcare.uiowa.edu/igec/tools/function/katzADLs.pdf • Options for assisting with ADLs: http://www.family-friendly-fun.com/disabilities/adaptive-equipment.htm • IADL: http://www.annalsoflongtermcare.com/article/7453 • Braden scale: http://www.ruralfamilymedicine.org/educationalstrategies/braden_scale_for_predicting_pres.htm • Pressure Ulcer Staging: http://woundconsultant.com/sitebuilder/staging.pdf • Decisional Capacity: See next slide + http://www.nejm.org/doi/full/10.1056/NEJMcp074045

  25. Appelbaum,P. NEJM 2007; 357:1834-1840 November 1, 2007

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