Hospital Care of the Elderly

Resident’s Thursday School12/03/09

J Rush Pierce Jr, MD, MPHHospitalist 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

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