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The Hazards of Hospitalization

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  1. The Hazards of Hospitalization Geriatric medicine and care of the older patient George Heckman MD FRCPC August 9, 2004

  2. 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

  3. Frailty Why some older persons are more susceptible than others

  4. 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

  5. Aging and hospitalization • With age, changes affect • Muscles • Blood pressure control • Lung function • Bone strength • Bladder control • Skin • Nutrition • Cognition

  6. 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

  7. 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

  8. 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

  9. 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)

  10. 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

  11. 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

  12. 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

  13. Hospitalization and Cognition Delirium as a reflection of poor hospital care

  14. 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

  15. Delirium is NOT Dementia … Delirium Dementia Time

  16. …but more likely if demented Delirium Dementia Time

  17. The delirium syndrome Prevalence, features, risk factors, outcome

  18. 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

  19. 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

  20. 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

  21. 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

  22. Fluctuation • Symptoms wax and wane during day • May even have lucid intervals • Some patients may actually remember being delirious • Sundown: worse in evening, night

  23. Risk factors Predisposing and precipitating

  24. Impaired vision , hearing Severe illness Impaired cognition Dehydration Advanced age Number of other illnesses Frailty Alcoholism Depression Certain medications Sleep deprivation Immobility Predisposing factors

  25. Restraints Malnutrition > 3 new drugs Bladder catheter Complications of treatment Surgery Anaesthetic Trauma Medication withdrawal Environmental changes Metabolic disturbance Any acute illness Precipitating factors

  26. Model of delirium

  27. 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

  28. Delirium can be prevented HELP is on the way!

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

  30. 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

  31. 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

  32. 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

  33. Where do geriatricians fit in? For that matter, what IS a geriatrician?

  34. 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

  35. 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

  36. 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

  37. What do we do? • Clinical care • Outpatient Clinics • Hospital • Retirement and nursing homes • Usually over 65, but not exclusively • Research: Dr. Inouye • Education • Advocacy

  38. Who do we see?Geriatric Syndromes • Confusion • Falls • Loss of independence • Incontinence • Depression • Multiple medical problemsand medications • Elder abuse • Caregiver burden • Some or all of the above in the same person

  39. 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

  40. 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+

  41. 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

  42. Geriatric medicine sounds good … … but there’s a problem …

  43. The geriatrician shortage • British and Canadian standards suggest that 180 to 200 geriatricians are needed for Ontario • There are approximately 75 • Why?

  44. 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

  45. Funding for Geriatric Medicine • Fee-for-service funding does not recognize that • Comprehensive Geriatric Assessment takes time • Counseling and educating patients and health care workerstakes time • Coordinating services and agenciesby phones takes time • Team meetings are intrinsic to the practise • Take time

  46. 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

  47. 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

  48. 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

  49. Closing thoughts What can you do …

  50. 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