The Hazards of Hospitalization

Geriatric medicine and care of the older patient

George Heckman MD FRCPC

August 9, 2004

Objectives

How can hospitalization be bad for older persons? The interaction between Frailty and Hospital care

Delirium: How hospital care fails the elderly Geriatric medicine

What is Geriatric Medicine? What is a Geriatrician? Why aren’t there enough?

What can you do? Reading list

Frailty

Why some older persons are more susceptible than others

Frailty: Not just advanced age

Susceptibility to adverse health outcomes Death Hospitalization Functional decline Falls Caregiver burden Atypical or unusual symptoms

Frailty more common with age

Rockwood Drugs&Aging2000; Rockwood CMAJ 1994

Aging and hospitalization

With age, changes affect Muscles Blood pressure control Lung function Bone strength Bladder control Skin Nutrition Cognition

Muscles Aging: loss of muscle mass, strength, and

energy efficiency Hospital: Bed rest, restraints, tethers Effect

5% loss of strength per day Joints tighten up

Consequences Loss of independence in daily tasks, e.g. bathing Falls and related injuries Need 3+ rehab days for 1 day immobility

Blood Pressure Control Aging

Impaired sensing of postural changes Less thirst drive Less water retention by kidneys

Hospital: bed rest makes this worse Effect: Dizziness when standing Consequences

Falls and related injuries

Lung function Aging: Stiffer rib cage reducing

ventilation Hospital: Bed rest further reduces

ventilation Effect: Reduced oxygen levels in blood Consequences: especially if lungs

already diseased Dizziness (leading to falls and injuries) Oxygen supplements (leading to bed rest) Confusion

Bone Strength

Aging: Osteoporosis common Hospital:

Bed rest Poor nutrition

Effect: Accelerated bone loss (up to 50-fold) begins within 10 days

Consequences Increased fracture risk (hip, spine)

Bladder Control Aging:

Reduced bladder capacity, “Twitchy” bladder Prostate enlargement Pelvis floor relaxation, menopause

Hospital: Bed rest, bed rails, restraints, tethers, unfamiliar environment

Effect: Loss of muscle strength Inability to get to or find bathroom

Consequence: Up to 50% incontinence rate within one day

Skin integrity Aging:

Thinner skin, less fat “padding” Poorer blood supply Slower rate of skin cell replacement

Hospital: Bed rest, Shearing, Incontinence

Effect: Increased pressure on buttocks, heals cuts off blood flow

Consequences: Skin ulcers Infection

Nutrition Aging:

Loss of taste, smell, thirst Dentition: dependence on dentures

Hospital: Food may be less appealing Access: bedrails, restraints Illness reduces appetite, increases calorie needs

Effect: Malnutrition, dehydration Consequences:

Loss of muscle strength, bone strength Dizziness, confusion Slower healing

Hospitalization and Cognition

Delirium as a reflection of poor hospital care

What is delirium?

Acquired disorder of cognition Rapid onset Fluctuates Clouding of consciousness Inability to pay attention and

concentrate Triggered by illness, medications, drugs Usually reversible

Dementia

Delirium

Time

Delirium is NOT Dementia …

DementiaDelirium

Time

…but more likely if demented

The delirium syndrome

Prevalence, features, risk factors, outcome

Epidemiology Elderly hospitalized medical patients

15-25% at presentation 5-20% develop in hospital

Surgical patients: 10-60% Terminal illness: 80% Community, nursing home ???

Rockwood Oxford Textbook of Geriatrics 2000; Fisher JAGS 1995;

Massie Am J Psychiatry 1983

Clinical features

… The body’s delicate; the tempest in my mind doth from my senses take all feeling …

Shakespeare, King Lear, Act III, Scene IV

The Early Phases

Develops over hours to days Restlessness Trouble sleeping Anxiety Irritability Person may complain of confusion

Working group on delirium Am J Psychiatry 1998

Full-blown delirium Cannot concentrate

Disorganized, rambling, irrelevant conversation

Altered level of consciousness Agitated (25%) Lethargic, sedated (25%) Mixed, fluctuating (50%)

Psychosis: up to 90% Hallucinations, paranoia

Sandberg J Am Geriatr Soc 1999

Fluctuation

Symptoms wax and wane during day May even have lucid intervals

Some patients may actually remember being delirious

Sundown: worse in evening, night

Risk factors

Predisposing and precipitating

Predisposing factors

Impaired vision , hearing

Severe illness Impaired cognition Dehydration Advanced age Number of other

illnesses

Frailty Alcoholism Depression Certain medications Sleep deprivation Immobility

Precipitating factors

Restraints Malnutrition > 3 new drugs Bladder catheter Complications of

treatment Surgery

Anaesthetic Trauma Medication

withdrawal Environmental

changes Metabolic

disturbance Any acute illness

Model of deliriumPredisposing factors Precipitating factors High vulnerability Noxious insult

Low vulnerability Less noxious insult

Adapted from Inouye JAMA 1996

Duration and consequences Average 10-12 days

May frequently persist beyond one month Short term consequences

Prolonged hospital stay Loss of independence, nursing home placement Death

Long-term consequences Loss of independence, nursing home placement Death Dementia?

Care providers spend less time with the elderly, especially when confused

Delirium can be prevented

HELP is on the way!

Hospitalized Elder Life Program Dr. Sharon Inouye, Geriatrician from Yale University

Risk factor Intervention Outcome

Impaired cognition Orientation protocol Orientation score

Sleep deprivation Sleep protocol Sedative use

Immobility Early mobilization, least restraints

Activities of daily living score

Visual impairment Visual aids, adaptive equipment

Vision correction

Hearing impairment Wax disimpaction, amplifying devices

Whisper in the ear test

Dehydration Screening and repletion

Blood tests of kidney function

Effectiveness of the HELP Program in older hospitalized medical patients

Reduced risk of delirium by 40% days of delirium by 35% sedative use by 24%

Cost-effective for moderate risk group Significant contamination:

Intervention likely more powerful in typical hospital

Geriatrician back-up for complex patients

Preventing bad outcomes from hospitalization of the frail elderly

Intimately related to quality of hospital care Nutrition Dehydration Immobilization

Insufficient physiotherapy resources, restraints, bladder catheters, bed rest

Sleep deprivation Unnecessary medications

Delirium prevention: Summary

HELP demonstrates that simple, low-tech attention to hospital care can have a tremendous impact on patient outcomes

Keys to a successful program Heavy volunteer commitment Modifications to the hospital environment

ACTIVE LOBBYING BY STAKEHOLDERS As family members of hospitalized persons As potentially hospitalized persons who have a

vote

Where do geriatricians fit in?

For that matter, what IS a geriatrician?

What is a geriatrician?

 A physician specialized in the care of the frail elderly who are at risk for Institutionalization Loss of independence Caregiver stress and burn-out Hospitalization Death

The Epidemic of Frailty

Our population is aging In the community, disability reported by

>50 % of adults over 65 >70% of adults over 75

Lifetime risk of needing a nursing home is 40-50%

Geriatricians can improve patient outcomes at all levels of frailty

Geriatrician training

3 to 4 years of undergraduate studies 3 to 4 years of medical school Care of the Elderly Family doctors

3 years of residency Specialist geriatricians

3 years of General Internal Medicine 2 years of Geriatric Medicine

9 to13 years of training

What do we do?

Clinical care Outpatient Clinics Hospital Retirement and nursing homes Usually over 65, but not exclusively

Research: Dr. Inouye Education Advocacy

Who do we see?Geriatric Syndromes

Confusion Falls Loss of independence Incontinence Depression Multiple medical problems and medications Elder abuse Caregiver burden Some or all of the above in the same person

Why are geriatricians needed?

Such syndromes are too often dismissed as normal aging By doctors By nurses By patients and families By the community at large

Often there are one or more correctable causes

How?Comprehensive Geriatric Assessment

A thorough and holistic assessment that aims to reverse and optimize medical, psychological, environmental, and social factors that contribute to Geriatric Syndromes

Requires 75 to 90 minutes+

Goals and outcomes

Reduce caregiver stress Improve and maintain function Improve and maintain cognition Reduce falls Prevent or delay (or facilitate) nursing

home placement Improve quality of life

Geriatric medicine sounds good …

… but there’s a problem …

The geriatrician shortage

British and Canadian standards suggest that 180 to 200 geriatricians are needed for Ontario

There are approximately 75 Why?

Current GeriatriciansPractice Patterns

Recent survey (38 replies) 12 (32%) graduated before 1980 30 (79%) urban University affiliated

20 (53%) do not practice full-time geriatrics 15 unable to financially sustain full-time geriatrics

42% of Care of the Elderly family physicians are unable to sustain full-time geriatrics

Geriatric nurses 71% of geriatricians have one Facilitates seeing more patients 90% of geriatricians cannot afford his/her salary

Funding for Geriatric Medicine

Fee-for-service funding does not recognize that Comprehensive Geriatric Assessment

takes time Counseling and educating patients and

health care workers takes time Coordinating services and agencies by

phones takes time Team meetings are intrinsic to the practise

Take time

A Specialty at risk

Many geriatricians approaching retirement age

Recruitment dwindling 3 in Canada this year Rising student debts OHIP insufficient to sustain practice Recent decision limited salaries to

University centers (70% of geriatricians) 70% of Ontario Seniors live elsewhere

Case study

Dr. K. Specialist Geriatrician in South Central Ontario Pure fee-for-service Practise expenses Has to pay for nurse and part-time clerical Worked out of nurse’s living room Worked 6 days a week Had to quit: no take-home pay

Temporary salary support has been found

Geriatrician shortage

Geriatricians are the core of specialized geriatric services Directly provide care Educate others

Shortage creates barrier to access, especially for Seniors living away from University Centres

Closing thoughts

What can you do …

Summary

Hospitals are designed to deal with acute illness, not frailty

There are things you can expect and do With now have strong evidence that

“back to basics” nursing care works Geriatricians can help the frail elderly

But more are needed

… if an elderly relative is hospitalized? Get involved and be pro-active

Expect to be at the bed-side, especially if delirious

Make sure they are getting Fluids, Food Glasses and hearing aids

Ask to look at medications Why gravol? Why sleeping pills? Why sedatives? Ask for alternative sleep aids

If an elderly relative is hospitalized … Insist on early mobilization and physiotherapy

If they can’t walk, use massage or in-bed stretches Avoid restraints unless absolutely necessary

Talk to them, read the paper, play cards Make sure you also get clear discharge

instructions regarding follow-up, treatments Don’t let them be discharged if you are not

comfortable or unable to look after them Ask for referral to a geriatrician if you are

concerned

… as a tax-paying voter

Get informed (see reading list) Lobby

Individually, or as a group

Need more Geriatricians Gerontological nurses and nurse practitioners Physiotherapists Home care

Lobby for elderly-friendly programs like HELP

… as a concerned Senior

Lobby for mandatory geriatric medicine rotations Medical school Royal College of Physicians and Surgeons

of Canada

Consider forming a Canadian Seniors Lobby group

… as a potentially frail Senior

Eat well Stay active

Exercise your body Exercise your mind Remain socially engaged

Get informed about your health Control your risk factors: heart, cancer Screening Immunizations

Reading list

Prescription for Excellence: How Innovation is saving Canada’s Health Care System, by Michael Rachlis MD, Harper Collins 2004.

Sharon K. Inouye et al. Delirium: A symptom of how hospital care is failing older persons and a window of opportunity to improve quality of hospital care. Am J Med 1999;106:565.

John A. Rizzo et al. Multicomponent targeted intervention to prevent delirium in hospitalized older patients: What is the economic value? Medical Care 2001;39:740.

Stay well!

Thank you