Title: The Hazards of Hospitalization
1The Hazards of Hospitalization
- Geriatric medicine and care of the older patient
- George Heckman MD FRCPC
- August 9, 2004
2Objectives
- 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 arent there enough?
- What can you do?
- Reading list
3Frailty
- Why some older persons are more susceptible than
others
4Frailty 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 DrugsAging2000 Rockwood CMAJ 1994
5Aging and hospitalization
- With age, changes affect
- Muscles
- Blood pressure control
- Lung function
- Bone strength
- Bladder control
- Skin
- Nutrition
- Cognition
6Muscles
- 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
7Blood 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
8Lung 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
9Bone 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)
10Bladder 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
11Skin 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
12Nutrition
- 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
13Hospitalization and Cognition
- Delirium as a reflection of poor hospital care
14What 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
15Delirium is NOT Dementia
Delirium
Dementia
Time
16but more likely if demented
Delirium
Dementia
Time
17The delirium syndrome
- Prevalence, features, risk factors, outcome
18Epidemiology
- 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
19Clinical features
- The bodys delicate the tempest in my mind
doth from my senses take all feeling - Shakespeare, King Lear, Act III, Scene IV
20The 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
21Full-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
22Fluctuation
- Symptoms wax and wane during day
- May even have lucid intervals
- Some patients may actually remember being
delirious - Sundown worse in evening, night
23Risk factors
- Predisposing and precipitating
24Predisposing factors
- Impaired vision , hearing
- Severe illness
- Impaired cognition
- Dehydration
- Advanced age
- Number of other illnesses
- Frailty
- Alcoholism
- Depression
- Certain medications
- Sleep deprivation
- Immobility
25Precipitating factors
- Restraints
- Malnutrition
- 3 new drugs
- Bladder catheter
- Complications of treatment
- Surgery
- Anaesthetic
- Trauma
- Medication withdrawal
- Environmental changes
- Metabolic disturbance
- Any acute illness
26Model of delirium
27Duration 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
28Delirium can be prevented
29Hospitalized Elder Life Program Dr. Sharon
Inouye, Geriatrician from Yale University
30Effectiveness 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
31Preventing 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
32Delirium 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
33Where do geriatricians fit in?
- For that matter, what IS a geriatrician?
34What is a geriatrician?
- Â 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
35The 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
36Geriatrician 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
37What do we do?
- Clinical care
- Outpatient Clinics
- Hospital
- Retirement and nursing homes
- Usually over 65, but not exclusively
- Research Dr. Inouye
- Education
- Advocacy
38Who 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
39Why 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
40How?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
41Goals 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
42Geriatric medicine sounds good
43The geriatrician shortage
- British and Canadian standards suggest that 180
to 200 geriatricians are needed for Ontario - There are approximately 75
- Why?
44Current 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
45Funding 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
46A 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
47Case 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 nurses living room
- Worked 6 days a week
- Had to quit no take-home pay
- Temporary salary support has been found
48Geriatrician 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
49Closing thoughts
50Summary
- 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
51 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
52If an elderly relative is hospitalized
- Insist on early mobilization and physiotherapy
- If they cant 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 - Dont 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
53 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
54 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
55 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
56Reading list
- Prescription for Excellence How Innovation is
saving Canadas 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 1999106565. - John A. Rizzo et al. Multicomponent targeted
intervention to prevent delirium in hospitalized
older patients What is the economic value?
Medical Care 200139740.
57Stay well!