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The Hospitalized Elderly: General Principles

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  1. Highest Quality Care for the Hospitalized Elderly The Hospitalized Elderly: General Principles Jason Stein, MD Emory Reynolds Faculty Scholar Emory Hospital Medicine Service

  2. Highest Quality Care in the HospitalGoals for this Module • Identify the significance of elderly patients to hospitalists • Identify the significance of hospitalizations to elderly patients • Appraise the extent of your hospital’s specific approach to its geriatric population • Describe how the adverse hospital environment combines with physiologic aging and pathophysiologic changes from disease to impact the hospitalist’s approach to the care of elderly inpatients Emory Reynolds Program Emory Hospital Medicine Service

  3. Highest Quality Care in the Hospital:Look at Your Inpatient Census What do half your patients have in common? (whether you’re at EUH, ECLH, Cartersville, Dunwoody, Northlake, or Eastside) Emory Reynolds Program Emory Hospital Medicine Service

  4. Highest Quality Care in the Hospital:Look at Your Inpatient Census What is the median age on your census? Emory Reynolds Program Emory Hospital Medicine Service

  5. Highest Quality Care in the Hospital:Look at Your Inpatient Census What is the median age of patients on your census? About half your patients are geriatric patients (> 65 years old): • patients >65 years old account for ~50% of all inpatient days of care in American hospitals1 (while comprising just 13% of the population) 1Kozak LJ et al. National Hospital Survey: 2000. National Center for Health Statistics. Vital Health Stat. 13 (153). 2002. Emory Reynolds Program Emory Hospital Medicine Service

  6. Highest Quality Care in the Hospital:Is Your Patient’s Age Clinically Significant? • Why geriatric patients are important to hospitalists… • Summary: Half your admission H&Ps Half your progress notes Higher complexity demands disproportionate care time More than half of your in-hospital deaths (75%) • Why hospitalizations are important to your geriatric patient… Emory Reynolds Program Emory Hospital Medicine Service

  7. Highest Quality Care in the Hospital:Why Hospitalizations Are Important to Your Geriatric Patient Your patient’s age is clinically significant. Emory Reynolds Program Emory Hospital Medicine Service

  8. Highest Quality Care in the Hospital:Is Your Patient’s Age Clinically Significant? • Hospitalization Facts: Older patients have:More frequent hospitalizations Longer Hospitalizations Higher Mortality Emory Reynolds Program Emory Hospital Medicine Service

  9. Highest Quality Care in the Hospital:Is Your Patient’s Age Clinically Significant? • Hospitalization Facts: Older patients have: More frequent hospitalizations • Patients > 85 years old: • 2x the rate of 65-74 year olds • 5x the rate of middle aged patients (45-64 year olds) Emory Reynolds Program Emory Hospital Medicine Service

  10. Highest Quality Care in the Hospital:Is Your Patient’s Age Clinically Significant? • Hospitalization Facts: Older patients have: Longer hospitalizations • Patients > 85 years old average = 6.2 days • Patients 45-64 years old average = 4.8 days Emory Reynolds Program Emory Hospital Medicine Service

  11. Highest Quality Care in the Hospital:Is Your Patient’s Age Clinically Significant? Hospitalization Facts: Older patients have: Higher mortality • Patients > 85 years old: • 4x the mortality rate of middle aged patients (45-64 year olds) • 75% of in-hospital deaths occur in patients > 65 years old Emory Reynolds Program Emory Hospital Medicine Service

  12. Highest Quality Care in the Hospital:Is Your Patient’s Age Clinically Significant? • Why hospitalizations are important to your geriatric patient… Emory Reynolds Program Emory Hospital Medicine Service

  13. Factors Associated With Development of Disability Beaufort Scale: 1 - 12 (scale of wind velocity) Hurricane = 12 (74 mph) Light breeze = 1 (1 mph) Gill TM. JAMA. 2004; 292: 2115-24 Emory Reynolds Program Emory Hospital Medicine Service

  14. Defining A Key Geriatric TermWhat is Functional Decline? Functional Decline = New Disability Loss of ADLs (basic self-care activities) • Transfer out of bed to chair independently • Toileting yourself • Bathing yourself • Dressing yourself • Feeding yourself Emory Reynolds Program Emory Hospital Medicine Service

  15. Hospitalization:A Threat of Its OwnHospitalization = Functional Decline = Higher Mortality Hospitalization = Functional Decline -Prolonged hospital stays are associated with functional decline1 -35% of older hospitalized patients decline in baseline ADLs b/t admission and discharge2 -Compared with any other event along the road to disability in the elderly, hospitalization is a greater hazard by a full order of magnitude3 1 Palmer RM. Acute Hospital Care. In: Geriatric Medicine, 4th ed. 2 Kozak LJ et al. Vital Health Statistics. 2002;13(153). 3 Gill TM. JAMA. 2004; 292: 2115-24 Emory Reynolds Program Emory Hospital Medicine Service

  16. Hospitalization:A Threat of Its OwnHospitalization = Functional Decline = Higher Mortality Functional Decline = Higher Mortality # basic ADLs absent at discharge strong independent predictor of mortality 4,5 4 Inouye SK et al. JAMA. 1998; 279: 1187-93. 5 Walter LC et al. JAMA. 2001; 85: 2987-94. Emory Reynolds Program Emory Hospital Medicine Service

  17. Highest Quality Care in the Hospital Does your hospital have specific processes to drive the best possible outcomes for its geriatric population?Until it does, your elderly inpatients rely on you alone to deliver all – and only – the care they need.

  18. Highest Quality Care in the Hospital Does your hospital have specific processes to drive the best possible outcomes for its geriatric population?1. Does anyone perform a formal assessment of baseline function (2 weeks prior to hospitalization)?2. Does anyone perform a formal assessment of current function (at time of admission)? 3. Do daily rounds focus on patient-centered interventions?4. If your hospital has CPOE, do you have a layer of electronic decision support that focuses on geriatric prescribing (~50% reduction in falls)?5. Does the discharge process address persistent functional deficits that require special support or sites of ongoing care? Guided Prescription of Psychotropic Medications for Geriatric Inpatients.Josh F. Peterson, et al. Arch Intern Med Volume 165:802-807 April 11, 2005

  19. Processes Outcomes Highest Quality Care in the Hospital Every system is perfectly designed to achieve exactly the results it gets. Emory Reynolds Program Emory Hospital Medicine Service

  20. Processes Outcomes Highest Quality Care in the Hospital What’s the difference? Emory Reynolds Program Emory Hospital Medicine Service

  21. Processes Outcomes Highest Quality Care in the Hospital What do you care more about? Emory Reynolds Program Emory Hospital Medicine Service

  22. Processes: influence outcomes more amenable to measurement must be tightly associated to outcomes Outcomes: what you really care about ultimately can be difficult to measure in real time Highest Quality Care in the Hospital Emory Reynolds Program Emory Hospital Medicine Service

  23. Towards An Optimal ProcessWho Will Get Functional Decline? Risk Factors Before Admission • Age (increasing age) • Body (pressure ulcer) • Brain (cognitive impairment) • Mood (depressive symptoms) • Level of functioning (fewer iADLs¥) • Socialization (low social activity level) ¥iADLs = instrumental ADLs: tasks necessary to run a household (telephone, managing money, shopping, preparing meals, light housework, getting around the community) Emory Reynolds Program Emory Hospital Medicine Service

  24. Acts of Omission Jurisdiction = Hospital Services (Physical Space, Workplace Culture, Multidisciplinary Team skill and availability) (but you still play a role) Acts of Commission Jurisdiction = You Towards An Optimal ProcessWho Will Get Functional Decline? Risk Factors After Admission: “Adverse” Hospital environment • Iatrogenic illness • Sensory Deprivation • Altered sleep-wake cycles • Disorientation • Deconditioning • Malnutrition Emory Reynolds Program Emory Hospital Medicine Service

  25. Apart From Preventing Iatrogenic Illness,You Can Dampen the Adverse Hospital Environment Example: Deconditioningfrom… • Illness-induced immobility your usual good care • “Neglectful” bed rest: • Insufficient PT/OT • Environmental barriers e.g. lack of handrails in hallways/rooms discourages mobility and self-care  insist on handrails and 24/7 PT • “Forced” bed rest: • tethered to IV poles and catheters • tethered to the bed by physical or chemical restraints  “un-tie” your patient Emory Reynolds Program Emory Hospital Medicine Service

  26. Why Are Elderly Patients Especially Vulnerable to the Risk Factors for Functional Decline? “Adverse” hospital environment + Physiologic impairments with age (e.g. less muscle mass, strength, and aerobic capacity) + Pathophysiologic impairments from disease (e.g. painful OA + poor hearing/vision + malaise/dyspnea from pneumonia) Emory Reynolds Program Emory Hospital Medicine Service

  27. Why Are Elderly Patients Especially Vulnerable to the Risk Factors for Functional Decline? Three Key Geriatric Principles for the Hospital 1) At the individual level, variability decreases with age 2) Across the geriatric population, variability increases with age 3) To maintain baseline performance, many elderly already have drawn upon physiologic reserves Recognizing the significance of this will make you a better provider. How aging is clinically significant… Emory Reynolds Program Emory Hospital Medicine Service

  28. How is Aging Clinically Significant?Most Elderly Are Different from the Young 1) At the individual level, variability decreases with age Individual Variability Narrows Organ function deteriorates (~1% per year, starting ~30yo) and dynamic range of organ/system performance narrows over time e.g. stride length: less nimble (others: HR, FVC, Temp, Na handling, etc) Clinical Implication: detectable extremes tend to be associated with significant underlying illness (or iatrogenesis). Emory Reynolds Program Emory Hospital Medicine Service

  29. How is Aging Clinically Significant?Most Elderly Are Different From One Another How is Aging Clinically Significant?Most Elderly Are Different From One Another 2) Across the geriatric population, variability increases c age: Population Variability Widens Time“Normal aging” + DiseaseGenes/Environment = Wide Variability Clinical Implication: Your next elderly patient is likely to manifest the ravages of time and disease in ways that are totally unlike your previous 20 elderly inpatients. Emory Reynolds Program Emory Hospital Medicine Service

  30. How is Aging Clinically Significant?Many Elderly Are Running on Fumes 3) To maintain baseline performance, many elderly already have drawn upon physiologic reserves Homeostenosis the diminished capacity to maintain homeostasis when stressed (limited physiologic reserve + blunted compensatory mechanisms) Clinical Implication: next 3 slides Emory Reynolds Program Emory Hospital Medicine Service

  31. The Frail Elderly susceptibility to disease+  ability to compensate(homeostenosis)

  32. Homeostasis You stress Physiologic Reserve Compensatory Mechanisms You, Compensated Emory Reynolds Program Emory Hospital Medicine Service

  33. Homeostenosis Frail Elderly stress Limited Blunted Physiologic Reserve Compensatory Mechanisms “Tapped Out” Clinically Decompensated Emory Reynolds Program Emory Hospital Medicine Service

  34. Age-Related Changes Relevant to Inpatient Care Clinical Implication: The acutely ill elderly patient frequently presents with non-specific signs or symptoms. The absence of “classic” findings places greater value on the hospitalist’s diagnostic evaluation.

  35. Body Composition  lean body mass total and visceral body fat higher concentration of water soluble drugs longer T1/2 fat-soluble medications risk of excessive medication dose risk of excessive medication schedule propensity to DM, HTN, hyperlipidemia risk of under-diagnosis or treatment risk of over-treatment c polypharmacy/ADEs Renal  GFR  RAAS and ADH response to hypovolemia  natriuresis (Na excretion in hypervolemia) delayed clearance of water-soluble medications risk of excessive medication dose risk of excessive medication schedule blunted ability to return to euvolemia in face of volume depletion or overload risk of excessive IV fluid administration (type/amount/rate) risk of over-diuresis (or insuff. monitoring) risk of under-diuresis Age-Related Changes Relevant to Inpatient Care Emory Reynolds Program Emory Hospital Medicine Service

  36. Cardiovascular Medial sclerosis (stiffening of LV/arteries) ß-receptor responsiveness maximum HR and CO Diastolic dysfunction risk of under-recognized HF risk of underestimated impact from a.fib on CO (loss of atrial kick) on tolerance of HR (rate control) blunted HR response to stress risk of overlooking enormous significance of sinus tachycardia (work-up sinus tachycardia) Pulmonary  chest wall compliance elastic recoil of lungs strength diaphragm mucocilliary clearance  P02 and A-a gradient* Higher risk pulmonary infections risk of not vaccinating (PVX and flu shot) risk of overlooking smoking cessation advice Lower threshold for hypoxemia risk of occult hypoxemia risk of iatrogenic respiratory depression * Normal A-a gradient: [(age/4)+4] Normal PO2: [110-(0.4 x age)] Lower TVs, more atelectasis Weaker, less effective cough Age-Related Changes Especially Relevant to Hospital Medicine Emory Reynolds Program Emory Hospital Medicine Service

  37. Gastrointestinal  swallow coordination/esophageal motility  lactase levels colonic motility Dysphagia aspiration risk malnutrition risk Lactose Intolerance occult diarrhea risk Tendency to constipation risk of remaining occult risk of being exacerbated Immunological barrier integrity (skin, mucous membranes) Altered cytokine response to infection humoral Ab response to infection Susceptibility to skin, urinary, pulmonary infxns decubitus ulcer risk urosepsis risk aspiration risk Blunted febrile response to infection occult infection risk: (work-up T > 99ºF (37.2ºC)) (work-up new ↑WBC/bandemia) Age-Related Changes Relevant to Inpatient Care (Up to 25% of septic elders can be afebrile. Using T > 99ºF [37.2ºC] increases sensitivity for detecting fever to 80% and maintains specificity=90%) Emory Reynolds Program Emory Hospital Medicine Service

  38. Patient Cases

  39. Case #1: Inappropriate 75 yo woman being admitted after falling at home. She hit her head. She lives alone and this is her 2nd ER visit in 2 weeks (last treated for a facial laceration): • Fell in middle of the night on way to bathroom (she felt dizzy) • Has fallen two other times in last month: 1) Tripped over the edge of a rug 2) Lost balance when her cat stepped in her path Emory Reynolds Program Emory Hospital Medicine Service

  40. Case #1: Inappropriate PMH: 1. HTN. HCTZ 25mg qd. 2. Depression. Zoloft 100mg qhs and Ativan 1mg bid prn. 3. OA. Ibuprofen prn. Social Hx: lives alone; no tob/ETOH Emory Reynolds Program Emory Hospital Medicine Service

  41. Case #1: Inappropriate PE: supine HR 64, BP 132/70 standing HR 70, BP 122/68 HEENT: vision 20/40 (mildly impaired) Neuro: LE strength 5/5 B, gait stable Get-Up-and-Go test = 10 seconds Emory Reynolds Program Emory Hospital Medicine Service

  42. Case #1: Inappropriate Which of the following is the most appropriate next step in managing this patient’s recurring falls? • Refer to ophthalmology • Discontinue ativan • Discontinue HCTZ • Refer to physical therapy • Substitute buspirone for zoloft Emory Reynolds Program Emory Hospital Medicine Service

  43. Case #1: Inappropriate Which of the following is the most appropriate next step in managing this patient’s recurring falls? • Refer to ophthalmology • Discontinue ativan • Discontinue HCTZ • Refer to physical therapy • Substitute buspirone for zoloft Emory Reynolds Program Emory Hospital Medicine Service

  44. Case #1: Inappropriate Observational studies show medications are the most readily modifiable risk factors for falls • Especially psychotropics (bdz, neuroleptics, TCAs) Emory Reynolds Program Emory Hospital Medicine Service

  45. Case #1: Inappropriate RCTs show specific single interventions to reduce falls: • removal of psychotropic medications • home hazard assessment and modification • exercise programs Emory Reynolds Program Emory Hospital Medicine Service

  46. Case #1: Inappropriate Falls in elderly: usually multifactorial (so address all potential contributing factors) Emory Reynolds Program Emory Hospital Medicine Service

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  50. Case #2: Adverse Hospital Environment? 78 yo woman with DM 2 admitted with cellulitis, top of R foot, which seemed to start spontaneously. No improvement after one week outpatient Keflex. • 3 days of increased pain and redness. Unchanged localized swelling. No fever, chills. No open wound. • She is not able to give you an estimate of the highest/lowest BG in the last 2 weeks. Emory Reynolds Program Emory Hospital Medicine Service