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The Hazards of Hospitalization

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Title: The Hazards of Hospitalization


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 arent 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 DrugsAging2000 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 bodys 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
Predisposing factors
  • Impaired vision , hearing
  • Severe illness
  • Impaired cognition
  • Dehydration
  • Advanced age
  • Number of other illnesses
  • Frailty
  • Alcoholism
  • Depression
  • Certain medications
  • Sleep deprivation
  • Immobility

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

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 problems and 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 theres 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
    workers takes time
  • Coordinating services and agencies by 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 nurses 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

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

52
If 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

56
Reading 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.

57
Stay well!
  • Thank you
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