Highest Quality Care for the Hospitalized Elderly The

1
The Hospitalized Elderly General Principles
Highest Quality Care for the Hospitalized Elderly

• 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 hospitals specific
  approach to its geriatric population
• Describe how the adverse hospital environment
  combines with physiologic aging and
  pathophysiologic changes from disease to impact
  the hospitalists approach to the care of elderly
  inpatients

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Highest Quality Care in the HospitalLook at
Your Inpatient Census

• What do half your patients have in common?
• (whether youre at EUH, ECLH, Cartersville,
• Dunwoody, Northlake, or Eastside)

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Highest Quality Care in the HospitalLook at
Your Inpatient Census

• What is the median age on your census?

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Highest Quality Care in the HospitalLook at
Your Inpatient Census

• What is the median age of patients on your
  census?
• About half your patients are geriatric patients
  (gt 65 years old)
• patients gt65 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.
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Highest Quality Care in the Hospital Is Your
Patients Age Clinically Significant?

• Why geriatric patients are important to
  hospitalists
• Summary
• Half your admission HPs
• 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

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Highest Quality Care in the Hospital Why
Hospitalizations Are Important to Your Geriatric
Patient

• Your patients age is clinically significant.

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Highest Quality Care in the Hospital Is Your
Patients Age Clinically Significant?

• Hospitalization Facts
• Older patients have More frequent
  hospitalizations
• Longer Hospitalizations
• Higher Mortality

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Highest Quality Care in the Hospital Is Your
Patients Age Clinically Significant?

• Hospitalization Facts
• Older patients have
• More frequent hospitalizations
• Patients gt 85 years old
• 2x the rate of 65-74 year olds
• 5x the rate of middle aged patients (45-64 year
  olds)

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Highest Quality Care in the Hospital Is Your
Patients Age Clinically Significant?

• Hospitalization Facts
• Older patients have
• Longer hospitalizations
• Patients gt 85 years old average 6.2 days
• Patients 45-64 years old average 4.8 days

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Highest Quality Care in the Hospital Is Your
Patients Age Clinically Significant?

• Hospitalization Facts
• Older patients have
• Higher mortality
• Patients gt 85 years old
• 4x the mortality rate of middle aged patients
  (45-64 year olds)
• 75 of in-hospital deaths occur in patients gt 65
  years old

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Highest Quality Care in the Hospital Is Your
Patients Age Clinically Significant?

• Why hospitalizations are important to your
  geriatric patient

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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
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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

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HospitalizationA Threat of Its Own
Hospitalization 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. 200213(153). 3 Gill TM. JAMA. 2004
292 2115-24
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HospitalizationA Threat of Its Own
Hospitalization 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.
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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.
Highest Quality Care in the Hospital
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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?
Highest Quality Care in the Hospital
Guided Prescription of Psychotropic Medications
for Geriatric Inpatients.Josh F. Peterson, et al.
Arch Intern Med Volume 165802-807 April 11, 2005
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Highest Quality Care in the Hospital

• Processes

• Outcomes

Every system is perfectly designed to achieve
exactly the results it gets.
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Highest Quality Care in the Hospital

• Processes

• Outcomes

Whats the difference?
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Highest Quality Care in the Hospital

• Processes

• Outcomes

What do you care more about?
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Highest Quality Care in the Hospital

• 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

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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)
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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

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Apart From Preventing Iatrogenic Illness,You Can
Dampen the Adverse Hospital Environment

• Example
• Deconditioning from
• 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

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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)

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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

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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).
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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 Disease Genes/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.
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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
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?susceptibility to disease ? ability to
compensate(homeostenosis)
The Frail Elderly
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Homeostasis
You
stress
Compensatory Mechanisms
Physiologic Reserve
You, Compensated
33
Homeostenosis
Frail Elderly
stress
Limited
Blunted
Compensatory Mechanisms
Physiologic Reserve
Tapped Out
Clinically Decompensated
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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
  hospitalists diagnostic evaluation.

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Age-Related Changes Relevant to Inpatient Care

• 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

36
Age-Related Changes Especially Relevant to
Hospital Medicine

• 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

• 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)

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Age-Related Changes Relevant to Inpatient Care

• 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 gt 99ºF (37.2ºC))
• (work-up new ?WBC/bandemia)

(Up to 25 of septic elders can be afebrile.
Using T gt 99ºF 37.2ºC increases sensitivity for
detecting fever to 80 and maintains
specificity90)
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Patient Cases
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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

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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

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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

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Case 1 Inappropriate

• Which of the following is the most appropriate
  next step in managing this patients recurring
  falls?
• Refer to ophthalmology
• Discontinue ativan
• Discontinue HCTZ
• Refer to physical therapy
• Substitute buspirone for zoloft

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Case 1 Inappropriate

• Which of the following is the most appropriate
  next step in managing this patients recurring
  falls?
• Refer to ophthalmology
• Discontinue ativan
• Discontinue HCTZ
• Refer to physical therapy
• Substitute buspirone for zoloft

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Case 1 Inappropriate

• Observational studies show medications are the
  most readily modifiable risk factors for falls
• Especially psychotropics (bdz, neuroleptics,
  TCAs)

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Case 1 Inappropriate

• RCTs show specific single interventions to reduce
  falls
• removal of psychotropic medications
• home hazard assessment and modification
• exercise programs

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Case 1 Inappropriate

• Falls in elderly
• usually multifactorial (so address all potential
  contributing factors)

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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.

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Case 2 Adverse Hospital Environment?

• PMH/Meds
• DM 2. Recent HgA1C 8.5. No h/o microvascular
  disease.
• Metformin 500mg bid
• Glyburide 10mg qd
• Hypothyroidism. Synthroid increased by PCP 2
  months ago when TSH 8.
• Synthroid 150 mcg qd
• 3. HTN.
• Lisinopril 40mg qd

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Case 2 Adverse Hospital Environment?

• PE
• T 37.4C HR 90 BP 154/85 RR 12
• Gen non-toxic appearing
• Lungs/CV/abd normal
• Ext well-demarcated area of tender erythema
  dorsum of R foot. No ulcer. No fluctuance in
  surrounding soft tissue palpation of adjacent
  bone shows no point tenderness peripheral pulses
  1 B
• Neuro AO to time, place, situation. Light touch
  intact.
• Lab BG 188, WBC 9K (70 neutrophils, no bands)
• EKG NSR, 90
• Rad non-diagnostic for OM

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Case 2 Adverse Hospital Environment?

• Hospital Day 1
• 1) Cellulitis. Start Vancomycin. Serial exams.
• 2) Pain. Hydrocodone and acetaminophen.
  Laxative.
• 3) DM2. Continue home medications. Target good
  glycemic control.
• 4) DVT prophylaxis. Age and anticipated
  immobility. ?Lovenox 40mg SQ QD.
• On night of first hospital stay, she cant sleep.
  X-cover writes for ambien 5mg qhs.

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Case 2 Adverse Hospital Environment?

• Hospital Day 2
• Not oriented to month or year. Correctly
  identifies place.
• NL vitals and O2 sat. NL PE
• Bedside BG 54. Other labs NL.
• You start D50W and halve glyburide to 5mg qd.
• Check back in on her 45 minutes later fully
  oriented to time and place, NL BG.
• On night of 2nd hospital stay, she complains of
  itching and so cross cover writes for hydroxyzine
  10mg q6hrs prn.
• Any thoughts, commentary?

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Case 2 Adverse Hospital Environment?

• Hospital Day 3
• On rounds again not oriented to month or year.
• VS review normal except for a single HR
  recorded at 100 at 5am. O2 sat NL.
• On PE you note an irregular rhythm, rate 90s.
  
• BG 55. EKG ? afib, rate 98.
• CBC NL, Trop negative, CMP NL except BG 64.
• Whats going on?

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Case 2 Adverse Hospital Environment?

• The most likely cause of this patients hospital
  complications is
• Polypharmacy with adverse effects from
  hydrocodone and ambien
• Adverse drug event from hydroxyzine
• Surreptitious ETOH use and withdrawal following
  hospitalization
• Forced adherence with adverse effects from
  outpatient medications glyburide and synthroid

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Case 2 Adverse Hospital Environment?

• The most likely cause of this patients hospital
  complications is
• Polypharmacy with adverse effects from
  hydrocodone and ambien
• Adverse drug event from hydroxyzine
• Surreptitious ETOH use and withdrawal following
  hospitalization
• Enforced adherence with adverse effects from
  outpatient medications glyburide and synthroid

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Case 2 Adverse Hospital Environment?Enforced
Adherence in the Hospitalized Elderly

• Anticipate likelihood of poor compliance before
  hospitalization
• e.g. from HPIpatient not responding to
  appropriate or increasing doses of medications
• Suspect when you see different problems evolving
  at once
• e.g. in hospitalnew confusion, hypoglycemia,
  low BP, atrial fibrillation

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Case 2 Adverse Hospital Environment?Enforced
Adherence in the Hospitalized Elderly

• Why Enforced Adherence is Particularly Relevant
  to Your Elderly Patient
• High Incidence Polypharmacy - non-compliance
  due to
• multiple medications
• cost
• complexity
• unwanted side effects, or
• just lack of support
• Identifiable and Correctable Homeostenosis -
  effects of medications dosed too high tend to
  reveal themselves (if youre looking)

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Case 3 Non-specific

• 81 yo male admitted with altered mental status,
  poor po intake, and involuntary weight loss over
  the last 5 weeks.
• Baseline Historically very active. Until two
  months ago he was collaborating with his wife on
  writing and distributing a bi-monthly newsletter
  to the WWII vets from his military battalion.
  Until 1 month ago was driving and doing own yard
  work.

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Case 3 Non-specific

• Four weeks ago went to PCP with fatigue, rising
  agitation, and with R shoulder pain. Told he
  probably had early Alzheimers. Given Rx for
  Bextra for OA of shoulder.
• Two weeks ago went back to PCP reporting same
  symptoms and now poor appetite. PCP note
  describes focal point tenderness over
  trapezius. Given Rx for Flexeril and Darvocet
  for muscle spasms, referral to outpatient
  geriatric-psychiatrist.
• Today he agreed to let his wife to drive him to
  the ER b/c he felt like he couldnt get out of
  bed. He ate almost nothing yesterday. The
  geriatric-psychiatry appointment is four days
  away.

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Case 3 Non-specific

• Collateral history
• Wife tells you hes seeing little women and
  little tigers. Patient corroborates and goes on
  to say hes very much aware that they cant be
  real and that he knows nobody else sees them.
• Wife also points out that
• 1) this 5-week illness interrupted a course of
  chemotherapy hed been getting as an outpatient
  for bladder CA
• 2) theyve been to another hospital ER twice in
  the last month to try to get this explained

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Case 3 Non-specific

• Other collateral history
• You talk to the nurse taking care of him in the
  ER. She tells you he seemed to choke a bit on the
  sandwich shed given him an hour ago. Patient and
  wife acknowledge that hes had difficulty
  swallowing his food.

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Case 3 Non-specific

• PMH
• Bladder CA. Currently receiving outpatient
  chemotherapy.
• H/O Prostate CA. S/p prostatectomy.
• H/O Tobacco Abuse. Quit 20 yrs ago after 25
  pack-years.
• PSH
• S/p cholecystectomy
• S/p prostatectomy

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Case 3 Non-specific

• Allergies NKDA
• Meds
• Risperdal 0.5mg bid
• MVI c iron daily
• Bextra qd
• Darvocet prn
• Flexeril prn

ROS no fever, chills, malaise. No abd pain,
N/V/D. No SOB/cough. No focal weakness but poor
balance. No CP/LH/syncope.
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Case 3 Non-specific

• PE
• T 100.8F HR 102 BP 120/72 RR 16
• Gen non-toxic appearing, well-nourished
• HEENT OP very dry neck supple NL vision
• CV No JVD, RRR, II/VI systolic murmur at RUS
  border
• Lungs/abd normal
• Ext No synovitis. No lesions. 2 peripheral
  pulses.
• Skin Warm and dry. No rash.
• Neuro AO to time, place, and situation, and o/w
  NL
• Lab Na 130, Cl 96, Cr 1.4, WBC 12K (85
  neutrophils), UA ketones, 10-25 RBCs and WBCs. No
  leuk est or nitrite.
• EKG NSR, 96.
• Micro urine culture growing gram cocci

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Case 3 Non-specific

• Hospital Day 1
• 1) Hyponatremia. Appears hypovolemic. NS at
  150cc/hr for 2L and re-evaluate.
• 2) Fever/leukocytosis. 3 sets of blood
  cultures over next 24 hrs. No antibiotic until
  infection confirmed. TEE if blood cultures c/w
  SBE.
• 3) Dysphagia. Observe at bedside. Formal swallow
  evaluation. Nutritional assessment and support.
  Aspiration precautions.
• 4) DVT prophylaxis. Age and anticipated
  immobility. ?Lovenox 40mg SQ QD.

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Case 3 Non-specific

• Hospital Day 2
• In AM, urine cultures growing Enterococcus.
• In PM, blood cultures also growing Enterococcus.
• Start Ampicillin and Gentamicin
• Follow Cr closely
• Order TEE

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Case 3 Non-specific

• Hospital Day 3
• TEE aortic leaflet vegetation, 1cm
  moderate-severe AI, NL LV
• Subsequent Hospital Course
• Hallucinations, anorexia, fatigue, and dysphagia
  resolved.
• Started ace-inhibitor.
• Follow Up
• Completed 2 weeks Amp/Gent, another 4 weeks
  Ampicillin. Returned completely to previous
  baseline.
• Echo 3 months later with no changes in LV.

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Especially if Your Hospital Lacks Specific
Geriatric Processes

• Your elderly inpatients need you to minimize the
  impact of hospitalization, with special emphasis
  on appropriate prescribing
• 2) Your elderly inpatients need you to decipher
  the root cause of their non-specific signs
  symptoms
• 3) Your elderly inpatients need you to be able to
  explain and address their sinus tachycardia, T gt
  99, and leukocytosis