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Care of the Hospitalized Geriatric Patient. Ethan Cumbler MD, FACP Associate Professor of Medicine Director UCH Acute Care For Elderly Service University of Colorado Denver 2010. Objectives.
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Care of the Hospitalized Geriatric Patient Ethan Cumbler MD, FACP Associate Professor of Medicine Director UCH Acute Care For Elderly Service University of Colorado Denver 2010
Objectives Recognize patients at highest risk for hazards of hospitalization such as delirium and falls using simple evidence based screening tools Be able to implement elements of an evidence based prevention protocol for common hazards of hospitalization Understand treatment options for delirium Disclosures: The speaker has no conflicts of interest to disclose
Changing Demographics In 2000 about 1 in 8 Americans was over age 65. By 2030 it will be 1 in 5 Hospitalization is a time of critical risk for the elderly We can do better
Current State of Affairs • Majority of inpatient geriatric care is provided by physicians without specific training in geriatrics. • Only 7,000 Geriatricians • 30,000 Hospitalists • Hospital communications silos inhibit recognition and treatment of new geriatric syndromes • Physician often the last to know about barriers • Physical • Social • Financial • Outpatient caregivers not involved
What Explains the Status Quo?Barriers to Change • Vulnerable elderly dispersed across teams and within hospitals • Traditional closed ACE units proven successful but not widely implemented due to increased resource commitments • Geriatric issues considered less vital than “admit diagnosis” • Solutions require interdisciplinary approach • Team infrastructure inadequate • Focus can be on “more” rather than making it easy to do “right” Jayadevappa R. Dissemination and Characteristics of Acute Care for Elders Units in the United States. In J Tech Assess in Health Care 2003;19:220-227
Hazards of Hospitalization High Risk Patient Transition Failure Falls Pressure ulcers Delirium Adverse drug events HAZARD Functional decline High Risk Environment High Risk Situation
A Modest Proposal • System change is required • Geographic concentration • Standardized assessment • Standardized care protocols • Interdisciplinary care Acute Care for the Elderly Service
Brief Geriatric Assessment Ideal Geriatric Assessment Fast Tolerated by patients Provide new information Leads to new action Confusion Assessment Method (CAM) Mini-Cog Vulnerable Elders Survey 2 Q Depression Screen Sensory Aid Assessment Falls Screen Get-Up-and-Go Test
Clinical CaseGertrude’s Tragic Tale 88 y/o woman admitted for back pain after a fall stepping off a curb outside her assisted living Xray demonstrates thoracic compression fracture. Admit for pain control, inability to ambulate. PMH Mild Alzheimer's Dementia Insomnia HTN Urge incontinence Depression Medications Lisinopril 10mg daily Aspirin 81 mg daily Amitryptiline 50mg qhs Oxybutinin 5mg bid
When Hospitalization is Over….Will Gertrude be going home? How do you predict discharge location on admission?
Assessing Need for PlacementVulnerable Elders Survey-13 • Originally developed to identify community dwelling elders at risk for functional decline or death. • 10 point score based on: • Age • Self reported health status • Ability to perform six physical tasks and five activities of daily living. Saliba D. The Vulnerable Elders Survey: A tool for Identifying Vulnerable Older People in the Community. J Am Geriatr Soc 2001;49:1691-1699 Min LC. Higher Vulnerable Elders Survey Scores Predict Death and Functional Decline in Vulnerable Older People. J Am Geriatr Soc 2006;54:507-511
VES-13 Now validated to predict need for SNF in elderly admissions Take Home Point Function PRIOR to admission predicts need for placement Cumbler E. Vulnerability Assessment on Hospital Admission Predicts Need for Placement upon Discharge for Elderly Patients. Journal of the American Geriatrics Society 2009; 57:944-946
Gertrude’s Tragic Tale • Gertrude is confused about the timeline of events • Does not remember her home medications • “Honey, I don’t have to know that at my age” when asked for the year, • Can spell “WORLD” backwards • Tells you a bright and animated story about her dog and how funny it was when he ate peanut butter Is Gertrude Delirious?
Delirium“Acute onset of disturbance in consciousness in which cognition or perception is altered” • 17%-74% cases unrecognized by nurses • Physicians may do worse • Over reliance on disorientation/inappropriate behavior • More likely to be missed • Hypoactive • Age >80 yrs • Vision impairment • Dementia Are Nurses Recognizing Delirium? A systematic review. JOGN 2008;34:40-48 Occurrence of Delirium is Severely Underestimated in the ICU during Daily Care. Intensive Care Med 2009
DIAGNOSING DELIRIUM:The Confusion Assessment Method (CAM) Patient must demonstrate the following: Sensitivity 94-100%, Specificity 90-95% Positive LR 9.6 , Negative LR 0.16 OR Inouye SK et al. Ann Intern Med 1990;113:941-948 Wong CL. JAMA. 2010;304:779-786
ASSESSING DELIRIUM RISK Medical Inpatient Prediction Rule • Low Risk (0) 10% risk • Int. Risk (1-2) 25% risk • High Risk (3-4) 80% risk • --Cognitive impairment • --Severe Illness • --High BUN/Cr • --Vision impairment Inouye, S. Ann Intern Med. 1993;119:474-481
Assessing Delirium Risk • Mini-Cog • 3 item recall (ball, justice, tree) (up to 3 pts) • Clock Draw (10 minutes after 11) • All or nothing-- 0 or 2 pts • On Admission: • Scores of 0, 1, or 2 carries a 4-5X increased risk for delirium • True regardless of whether the patient has dementia or not 0 points Alagiakrishnan K et al. Simple Cognitive Testing (Mini-Cog) Predicts In-Hospital Delirium in the Elderly. JAGS 2007;55:314-316
DELIRIUM IS COMMON • Affects 20% of hospitalized patients over age 65 • Up to 70-80% of older patients in intensive care • Up to 83% of older patients at the end-of-life • Affects 36.8% of postoperative patients • Cataract Surgery 1-3% • General Surgery 10-15% • Orthopedic Surgery 28-61% Miller MO. Evaluation and Management of Delirium in Hospitalized Older Patients. AAFP 2008;78:1265-1270
Mechanism of Delirium • Imbalance of Neurotransmitters • Acetylcholine • Dopamine • Others ?? • Hypothalamic-pituitary-adrenal axis • Inflammation • Cytokines (TNF, Interleukins) • Occult diffuse brain injury • Especially following sepsis (ischemic insult)
WHY DO WE CARE • Increased Length of Stay • By 8 days • Increased Mortality • Double the mortality in pts with delirium • Functional Decline/NH placement • Prolonged Cognitive Defects • NEW RESEARCH • 1/3 of pts d/c to SNF delirious… will still be delirious 6 months later Kiely DK, et al. Persistent Delirium Predicts Greater Mortality. JAGS 2009;57:55-61 Miller MO. Evaluation and Management of Delirium in Hospitalized Older Patients. AAFP 2008;78:1265-1270
Delirium Prevention Modifiable risk factor Prospective Intervention • Cognitive impairment • Immobility • Visual Impairment • Hearing Impairment • Dehydration • Sleep deprivation Orienting communication Early mobilization, reduce restraints • Visual aides, adaptive equip Amplifiers, adaptive equip • Prevent and correct dehydration Uninterrupted sleep, nonpharmacologic aides 40% Relative Risk Reduction Inouye SK et al. A multicomponent Intervention to Prevent Delirium in Hospitalized Geriatric Patients. NEJM 1999;340:669-676 Vidan MT et al. An Intervention Integrated into Daily Clinical Practice Reduces Incidence of Delirium During Hospitalization in Elderly Patients. JAGS 2009;57:2029-2036
Sensory Deprivation One of Hebb's sensory deprivation subjects at McGill.
Declassified 1983 CIA Training Manual “Deprivation of sensory stimuli induces stress and anxiety” “Some subjects progressively lose touch with reality, focus inwardly, and produce hallucinations, delusions, and other pathological effects”. 1984 revision states: “Deliberately causing these symptoms is a serious impropriety”. Accessed 2/28/09 at http://www.gwu.edu/~nsarchiv/NSAEBB/NSAEBB27/02-02.htm from National Security Archive Database
Sensory Deprivation One of Hebb's sensory deprivation subjects at McGill.
Sleep Deprivation Consequences of lack of sleep in healthy volunteers include impaired attention and irritability Record for sleep deprivation is approximately 11 days No longer accepts submissions in this category due to deleterious health effects Vital signs Light Noise Could you sleep? Illness Pain Phlebotomy Skin care Drouot X. Sleep in the ICU. Sleep Medicine Reviews 2008;12:391-403
Practical Application Order set as: -QI tool -Psychological manipulation -Establishment of culture -Time saving device
Gertrude’s Tragic Tale • Diphenhydramine prn for insomnia • An indwelling catheter is placed • Her personal possessions are safely stored in the closet • Clothing • Glasses • Dentures • Hearing aids. • Maintenance IV fluids, telemetry, and SCDs
Clinical CaseGertrude’s Tragic Tale The following morning Gertrude is still sleepy when: The intern assesses her at 6:00am The nurse assesses her at 8:00am The attending assesses her at 10:00am She sleeps through lunch Disoriented and inattentive-- not following instructions She becomes confused Trying to get out of bed Pulling at her IVs Is she delirious…..Who knows?
Silos of Care Have you ever heard the phrase: “It seemed like the right hand didn’t know what the left hand was doing”
Attendings Residents Interns Nursing Physical Therapy Occupational Therapy Pharmacy Case Management Social Work Volunteers Effective Interdisciplinary Communication15 Minute Daily Team “Huddle” Geographic Concentration
ENCOURAGING PATIENT INVOLVEMENT • We want you to participate in your care • and be as active as possible while staying safe • Let your team know about any problems or questions. • If you use glasses, hearing aids, or dentures- use them in the hospital just as you do at home. • Your activity care plan will be based on your abilities and illness. • If possible, walk in the hall multiple times each day to keep your strength up. • Eat meals while sitting up, preferably in a chair. • Your physicians will usually come in to see you and discuss • your plan for the day between 9:00am and 11:00 am • feel free to invite family or other people in your life to be part of the care discussion • Your team includes an attending physician responsible for your overall care plan • Ethan Cumbler M.D. Heidi Wald M.D. Jeannette Guerrasio M.D. Jeanie Youngwerth M.D. Judy Zerzan M.D. • We are interested in your thoughts about your care on the ACE service • After your discharge we welcome you to write your physician at • ACE Service • c/o Hospitalist Section • Anschutz Inpatient Pavilion • 12605 E. 16th Ave • P.O. Box 6510. Aurora, CO. 80045
Response to Delirium TESTING Chem7, CBC, U/A Troponin, EKG CXR TSH, Ammonia, B12, ABG? LP if fever or neck stiffness CT/MRI brain if focal neurologic signs or head trauma EEG if clinical evidence of seizures Drug levels (Digoxin, anticonvulsants) Extensive testing of limited value unless driven by a specific clinical suspicion
Practical Approach • Remove Problem Medications • Particularly Anticholinergics, BNZ, and minimize Narcotics • Treat Withdrawal • Alcohol or benzodiazepines • Correct Metabolic Disturbances • Electrolytes, glucose, hydration, ammonia • Reduce Level of Invasion • Indwelling urinary catheters and lines • Assess and Treat Infection • Adequately Treat Pain • Scheduled may be better than prn. Non-narcotic if possible • Improve Environment and Mobility?
Medical Therapy for Delirium No good evidence that Cholinesterase Inhibitors (dopepezil) are effective No good evidence that Benzodiazepines are effective EXCEPT in alcohol withdrawal Antipsychotics decrease the degree and duration of delirium (typical just as good as atypical) Cholinesterase Inhibitors for Delirium. Cochrane Database of Systematic Reviews 2008 Benzodiazepines for Delirium. Cochrane Database of Systematic Reviews 2009 Antipsychotics for Delirium. Cochrane Database of Systematic Reviews 2007
When All Else Fails…..ANTIPSYCHOTICS Typical Antipsychotics (Haloperidol) • Does not prevent delirium when given prophylactically • Extrapyramidal side effects with high doses • Haloperidol 0.25 – 0.5mg PO BID or prn q 4h. Atypical Antipsychotics(Risperidone, Olanzapine, Quetiapine) • Less QTc prolongation compared to haloperidol Antipsychotics associated with increased mortality in dementia --Prolonged QTc --Lowers seizure threshold
What About Restraints? Restraint chains used to control mentally ill patients, and documentation regarding Pennsylvania Hospital's purchase of such restraints in 1751 and 1752.
RESTRAINT USE Restraints ARE appropriate for behavior that is a risk to life or to necessary medical care Restraints associated with significant injuries Restraints associated with 4 fold increased risk of delirium Distraction Vest Dunn KS. Et al. The effect of physical restraints on fall rates in older adults who are institutionalized. Journal of Gerentol Nurs 2001:27:40-48 Evaluation and Management of the Elderly Postoperative Patient at Risk for Postoperative Delirium. Clin Geriatr Med 2008;24:667-686
Gertrude’s Tragic Tale She gets out of bed to use bathroom at 2 a.m. and is found by staff on the floor. Urinary catheter still attached to the bed Her scalp laceration requires staples.
Inpatient Falls • 2-12% of patients will have a fall in the hospital • 30% with minor injury, 4% with major injury • Associated increased hospital charges ($4233) • Associated increased LOS (12 days) • Injuries from falls in the hospital are “Never Events” • Medicare will no longer pay for them • Hospital falls with significant injury are JCAHO reportable • sentinel events • Falls with injury in the hospital pose malpractice risk Coussement J, et al. Interventions for Preventing Falls in Acute and Chronic Care Hospitals: A systematic review and meta-analysis. JAGS 2007;56:29-36
Fall Risk Assessment • How do we as physicians assess a patient’s risk for this hazard of hospitalization? • A simple falls screen: • Have you fallen in the last month or are you afraid of falling? • Get-Up-And-Go test • You learn a lot about strength, balance, and gait in 30 seconds.
Identifying the High Risk PatientRisk Factors • Prior fall history • Gait instability • Lower limb weakness • Confusion • Drugs • Sedative/hypnotics • Urinary incontinence Oliver D, et al. Risk Factors and Risk Assessment Tools for Falls in Hospital In-patients: A Systematic Review. Age and Ageing 2004;33:122-130
The High Risk Environment • IV drips • Telemetry • Sequential compression devices • Indwelling urinary catheters
Modifying the High Risk Environment • Physicians unaware of catheter • 21% for Medical Students • 22% for Interns • 27% for Residents • 38% for Attendings • This is not just about falls • Iatrogenic infection is a potent hazard of hospitalization • CMS no longer pays for catheter-associated UTIs Saint S, et al. Are Physicians Aware of Which of Their Patients Have Indwelling Urinary Catheters. Am J Med 2000;109:476-480 Jain P, et al. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med 1995;155:1425-1429
Modifying High Risk Therapy Psychoactive Medications Antidepressants and neuroleptics Benzodiazepines Lorazepam, Diazepam Narcotics Meperidine Cardiac medications Clonidine, short acting Nifedipine, Doxazosin, Digoxin Anticholinergic medications Diphenhydramine, Amitryptiline, Promethazine, Cyclobenzaprine Combinations of medications with partial anticholinergic activity Prednisolone Theophyline Digoxin Furosemide Ranitidine Woolcott JC et al. Metaanalysis of the Impact of 9 Medication Classes on Falls in Elderly Persons. Arch Int Med 2009;169:1952-1960 Fick, D, et al. Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Arch Int Med 2003;163:2716-24 Tune L, et al. Anticholinergic Effects of Drugs Commonly Prescribed to the Elderly. Am J Psych 1992;149:1393-1394
Use of “Sleepers” in The Elderly • 15% of elderly inpatients were on a sleep aid prior to admission • 25% received pharmacotherapy for insomnia in the hospital • Non-benzodiazepine hypnotics (zolpidem) • Most commonly chosen by hospitalists Cumbler E. Use of Medications for Insomnia in the Hospitalized Geriatric Population. JAGS 2008; 56:579-581
ResultsUCH ExperienceRandomized patients for 1st 6 months ACE vs usual care • Resource Utilization • Documented severity of illness slightly higher for ACE • Case mix index for ACE patients was 1.15 vs 1.05 in usual care • Length of stay 3.4 days • Mean Patient Charges $24,617 • 30 Day readmission rate 12.3% • ACE service model did not significantly change resource utilization
3600 Evaluation • House staff • 100% feel better medical care of the elderly • Patient Satisfaction • Staff-- improved: • Care coordination • Communication • Job satisfaction “Overall I received very good care”