HOSPITAL CARE OF OLDER PATIENTS

1. HOSPITAL CARE OF OLDER PATIENTS Bill Lyons, M.D. UNMC – Geriatrics

2. TO BE COVERED • Motivation: Why care about this? • Functional decline in the hospital • Two studied interventions • Admitting the older patient • Daily work rounds • Prognosis after hospitalization

3. CASE • 88 yo community-dwelling woman with PD admitted with CHF exacerbation; Fe-defic anemia found incidentally • Managed with careful diuresis, O2 and ACEi, triple therapy, transfusion, and Fe for PUD and Helicobacter pylori • Rocky course in hospital – fall, pelvic fracture, delirium – followed by d/c to SNF

4. BACKGROUND • USA: Persons 65+ are 13% of population, but account for ~50% of hospital expenditures • Rates of hospitalization are twice as great for 85+ age group compared to those 65-75 • Between a quarter and a third of older patients admitted to hospital for medical illness lose independent function in one or more ADL by D/C

5. NOT THE USUAL HOSPITAL MEDICINE • “Although functional outcomes are not usually the focus of care in the hospital, they may be critical determinants of … • …the quality of life, • …cost of care, and • …prognosis among older patients.” -- R. Palmer, MD

6. NOT THE USUAL HOSPITAL MEDICINE • You have attained Geriatric Enlightenment when you can focus on more than the acute problem(s) which led to the hospitalization.

7. PREDICTORS OF IN-HOSPITAL FUNCTIONAL DECLINE • Increasing age • Lower preadmission IADL capabilities • Cognitive impairment • Depression symptoms • Malnutrition

8. HAZARDS OF BED REST • Deconditioning; loss of muscle mass • Orthostasis • Pressure ulcers • Constipation • Osteoporosis • Pneumonia

9. POOR ORAL INTAKE IN THE HOSPITAL • Acute illness itself • Unappetizing cuisine and presentation • Food served at undesired time • Special diets (unappetizing) • Frequent NPO orders

10. DO YOU NEED THESE TETHERS AND ATTACHMENTS? • Nasal cannula • Central lines • Telemetry units • Bladder catheters • Restraints

11. TWO SYSTEMATIC INTERVENTIONS • Acute Care for Elders (ACE) Units • Hospital Elder Life Program (HELP)

12. ACE Unit • Specialized inpatient medical unit focuses on “prehabilitation” with 4 components: • Prepared environment for mobility and orientation • Primary nurse assessment and protocols • Early SW intervention in interdisciplinary framework for d/c planning • Geriatrician review

13. ACE Unit, cont’d • RCT of 651 patients in Cleveland academic medical center • Greater ADL independence at d/c • Less frequent nursing home admission • Slightly shorter LOS • Akron community hospital • Better process measures and satisfaction • Better composite ADL-decline-or-NH-placement

14. ACE Unit, cont’d • Intervention reduced cost at academic center ($6608 vs. $7240 per hospitalization) • No significant financial impact in community hospital CS Landefeld, R Palmer, S Counsell et al

15. HOSPITAL ELDER LIFE PROGRAM • Multicomponent intervention to prevent functional and cognitive decline in hospitalized older patients • Not unit-based; extensive use of volunteers • Admission screen for: cognitive impairment, sleep deprivation, immobility, dehydration, vision impairment, hearing impairment

16. HELP, cont’d • Targeted interventions (protocols) implemented by interdisciplinary team • Delirium incidence reduced by one third • Reduced risk of ADL decline • Cost neutral for intermediate-risk patients S Inouye et al

17. WHAT THESE INTERVENTIONS TEACH US • Targeting important for cost-effective program • Nursing leadership, education, empowerment are crucial • Common to both interventions: CGA and QA • Interdisciplinary approach is important • Important to start discharge planning at admission

18. ADMITTING THE OLDER PATIENT • Landefeld suggests systematic assessment for 11 items: • 1 ATRIAL FIBRILLATION • Present in 5% or more of hospitalized elders • Often incidental finding • Take pulse; order ECG; anticoagulate?

19. ADMITTING THE OLDER PATIENT, cont’d • 2 MALNUTRITION • Common • Independently predicts death, functional dependence, institutionalization • 3 NEED FOR IMMUNIZATION • Influenza • Pneumococcus

20. ADMITTING THE OLDER PATIENT, cont’d • 4 COGNITIVE IMPAIRMENT • Risk factor for delirium, restraint use, falls, difficulties with adherence to therapy • Consider MMSE; CAM for delirium • 5 IMMOBILITY AND FALLS • Ask about it! • Observe arising, standing, ambulation • Encourage ambulation; low threshold for PT

21. ADMITTING THE OLDER PATIENT, cont’d • 6 SENSORY IMPAIRMENT • Difficulty seeing, hearing? Use glasses, HA? • Jaeger card, whisper test on physical exam • Bring in glasses, HA from home • 7 DEPRESSION • Independent predictor of d/c to SNF, mortality • Major or minor depression present in ~1/3 • Feel sad, depressed, or hopeless? • Lost interest or pleasure in doing things?

22. ADMITTING THE OLDER PATIENT, cont’d • 8 DISABILITY • Assess ADL and IADL function • Determine causes of functional dependence • Early involvement of PT, OT, SW, family • 9 SUBOPTIMAL PHARMACOTHERAPY • Huge turnover in med list (40% at admission, 45% at discharge) • Check indications, dose, interactions • Clinical pharmacist involvement

23. ADMITTING THE OLDER PATIENT, cont’d • 10 MISTREATMENT • “Do you feel safe returning to where you live?” • 11 ADVANCE DIRECTIVES AND GOALS OF CARE • Is prolonged survival a primary goal of therapy for this patient? • Preferred intensity of care?

24. DAILY WORK ROUNDS • ADL status and trajectory? • Eating? • Eliminating and continent? • Mobility? Has this patient been out of bed? • Does she need all those attachments? • Anticipated discharge location and arrangements?

25. PROGNOSIS AFTER HOSPITALIZATION • Prognostic index using ~1500 patients 70+ yo discharged from general medical service of tertiary care hospital • Mean age 81 • Female 67% • Identified 6 independent risk factors for 1-year mortality following discharge L Walter et al, JAMA 2001

26. Male sex: 1 point Dependent in 1-4 ADL at discharge: 2 points Dependent in all ADL at discharge: 5 points CHF: 2 points Solitary cancer: 3 points Metastatic cancer: 8 points Admission Cr>3: 2 points Admission alb 3.0-3.4: 1 point Admission alb <3.0: 2 points RISK FACTORS FOR 1-YEAR MORTALITY

28. CASE DISCUSSION • Foley left in 5 days for meticulous I/O • NPO for endoscopy, plus constipation and anorexia from FeSO4 given tid • Became presyncopal and tripped over catheter on HD3, low-grade fever with UA(+) on HD5

29. SUMMARY • Different population requiring different approach • Emphasis on function, and preventing decline • Best outcomes result from systematic approach, regardless of admitting diagnosis • Emphasis on interplay between prognosis and goals of care