Transcript First Do No Harm

Highest Quality Care for the Hospitalized Elderly
The Hospitalized Elderly:
General Principles
Jason Stein, MD
Emory Reynolds Faculty Scholar
Emory Hospital Medicine Service
Highest Quality Care in the Hospital
Goals for this Module
1)
2)
3)
4)
Identify the significance of elderly patients to hospitalists
Identify the significance of hospitalizations to elderly
patients
Appraise the extent of your hospital’s specific approach
to its geriatric population
Describe how the adverse hospital environment
combines with physiologic aging and pathophysiologic
changes from disease to impact the hospitalist’s
approach to the care of elderly inpatients
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Highest Quality Care in the Hospital:
Look at Your Inpatient Census
What do half your patients have in common?
(whether you’re at EUH, ECLH, Cartersville,
Dunwoody, Northlake, or Eastside)
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Highest Quality Care in the Hospital:
Look at Your Inpatient Census
What is the median age on your census?
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Highest Quality Care in the Hospital:
Look at Your Inpatient Census
What is the median age of patients on your census?
About half your patients are geriatric patients (> 65 years
old):
 patients >65 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 Patient’s Age Clinically Significant?
 Why geriatric patients are important to hospitalists…
Summary:
Half your admission H&Ps
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 patient’s age is clinically significant.
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Highest Quality Care in the Hospital:
Is Your Patient’s 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 Patient’s Age Clinically Significant?
 Hospitalization Facts:
Older patients have:
More frequent hospitalizations
 Patients > 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 Patient’s Age Clinically Significant?
 Hospitalization Facts:
Older patients have:
Longer hospitalizations
 Patients > 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 Patient’s Age Clinically Significant?
Hospitalization Facts:
Older patients have:
Higher mortality
 Patients > 85 years old:
– 4x the mortality rate of middle aged patients (45-64 year olds)
– 75% of in-hospital deaths occur in patients > 65 years old
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Highest Quality Care in the Hospital:
Is Your Patient’s 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 Term
What 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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Hospitalization:
A 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. 2002;13(153).
3 Gill TM. JAMA. 2004; 292: 2115-24
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Hospitalization:
A 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
5 Walter
SK et al. JAMA. 1998; 279: 1187-93.
LC et al. JAMA. 2001; 85: 2987-94.
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Highest Quality Care in the Hospital
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
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?
Guided Prescription of Psychotropic Medications for Geriatric Inpatients.Josh F. Peterson, et al. Arch Intern Med
Volume 165:802-807 April 11, 2005
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
What’s 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 Process
Who 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 Process
Who Will Get Functional Decline?
Risk Factors After Admission:
“Adverse” Hospital environment






Acts of Commission
Iatrogenic illness
Jurisdiction = You
Sensory Deprivation
Acts of Omission
Altered sleep-wake cycles
Jurisdiction = Hospital Services
Disorientation
(Physical Space, Workplace
Deconditioning
Culture, Multidisciplinary Team
Malnutrition
skill and availability)
(but you still play a role)
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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
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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The Frail Elderly
susceptibility to disease
+
 ability to compensate
(homeostenosis)
Homeostasis
You
stress
Physiologic Reserve
Compensatory Mechanisms
You, Compensated
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Homeostenosis
Frail Elderly
stress
Limited
Blunted
Physiologic Reserve
Compensatory Mechanisms
“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 hospitalist’s
diagnostic evaluation.
Age-Related Changes
Relevant to Inpatient Care


Body Composition
Renal
 lean body mass
 total and visceral body fat
 GFR
 RAAS and ADH response to hypovolemia
 natriuresis (Na excretion in hypervolemia)
higher concentration of water soluble drugs
longer T1/2 fat-soluble medications
risk of excessive medication dose
risk of excessive medication schedule
delayed clearance of water-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
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
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Age-Related Changes
Especially Relevant to Hospital Medicine


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
Pulmonary
 chest wall compliance
 elastic recoil of lungs
 strength diaphragm
 mucocilliary clearance
 P02 and A-a gradient*
Lower TVs, more atelectasis
Weaker, less effective
cough
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
(work-up sinus tachycardia)
* Normal A-a gradient: [(age/4)+4]
Normal PO2: [110-(0.4 x age)]
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Age-Related Changes
Relevant to Inpatient Care
 Gastrointestinal
 Immunological
 swallow coordination/esophageal motility
 lactase levels
 colonic motility
Dysphagia
aspiration risk
malnutrition risk
 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
Lactose Intolerance
occult diarrhea risk
Tendency to constipation
risk of remaining occult
risk of being exacerbated
Blunted febrile response to infection
occult infection risk:
(work-up T > 99ºF (37.2ºC))
(work-up new ↑WBC/bandemia)
(Up to 25% of septic elders can be afebrile. Using T > 99ºF [37.2ºC] increases
sensitivity for detecting fever to 80% and maintains specificity=90%)
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Patient Cases
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
patient’s recurring falls?
A)
B)
C)
D)
E)
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
patient’s recurring falls?
A)
B)
C)
D)
E)
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:
1. DM 2. Recent HgA1C 8.5%. No h/o
microvascular disease.
Metformin 500mg bid
Glyburide 10mg qd
2. 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 37.4°C 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: A&O 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 can’t 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.
What’s going on?
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Case #2: Adverse Hospital Environment?
The most likely cause of this patient’s hospital
complications is:
A)
Polypharmacy with adverse effects from
hydrocodone and ambien
B) Adverse drug event from hydroxyzine
C) Surreptitious ETOH use and withdrawal following
hospitalization
D) 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 patient’s hospital
complications is:
A)
Polypharmacy with adverse effects from
hydrocodone and ambien
B) Adverse drug event from hydroxyzine
C) Surreptitious ETOH use and withdrawal following
hospitalization
D) 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 HPI…patient not responding to appropriate or increasing
doses of medications
Suspect when you see different problems evolving at once
e.g. in hospital…new 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 you’re 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 Alzheimer’s. 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 couldn’t 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 he’s seeing “little women” and “little tigers.”
Patient corroborates and goes on to say he’s very much aware
that they can’t 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
he’d been getting as an outpatient for bladder CA
2) they’ve 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 she’d given him an
hour ago. Patient and wife acknowledge that he’s had difficulty
swallowing his food.
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Case #3: Non-specific
PMH:
1. Bladder CA. Currently receiving outpatient
chemotherapy.
2. H/O Prostate CA. S/p prostatectomy.
3. H/O Tobacco Abuse. Quit 20 yrs ago after
25 pack-years.
PSH:
1. S/p cholecystectomy
2. S/p prostatectomy
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Case #3: Non-specific
Allergies: NKDA
Meds:
1.
2.
3.
4.
5.
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 100.8°F 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: A&O 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…
1)
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 > 99, and leukocytosis
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