Transcript View slides on - Curriculum for the Hospitalized Aging Medical

CHAMP:
Care of the Hospitalized Aging Medical Patient
For Medical Students
Shellie Williams, M.D.
University of Chicago
Objectives
• Understand current trends in
hospitalization of the elderly.
• Identify issues to address at admission to
limit functional decline.
• Increase recognition of delirium in elderly.
• Devise overall plan for addressing
hospital care of elderly.
Hospitalization of the Elderly:
Hospital Focus
• 45-50% discharges US hospitals >65yo
• Hospital focus: managing illness, not
improved function.
• Diminishing LOS 8.7 days5.7 days
(1990-2000)
• Increased procedures iatrogenic events
Geriatric Focus of Hospitalization
• Improving/Maintaining functional status
• Facilitating safe transition to community
• Identifying and addressing geriatric
syndromes
4 “D” Physical
Delirium
Psycho
Dementia
social
Depression
FUNCTION
Diet
Geriatric Review of Systems: Daily
• Sensory function
• Bowels/bladder
• Appetite/Nutrition
• Sleep
• Cognition
• Mobility
• Pain
Key Risks of Hospitalizing Elderly:
• Functional Decline (Adl, IAdl)
• Institutionalization (Dispo Card)
• Cognitive Decline (CAM)
• Mortality (Walter Index)
Function and the Hospitalized Elder:
• Activities of Daily
Living (ADLs): Assess
self care capability
Bathing
Dressing
Toileting
Continence
Transfers
Gait
Feeding
• Instrumental ADLs
(iADLs): Assess living
independence
Telephone use
Travel
Shopping
Meal Preparation
Housekeeping
Medication management
Financial management
Functional Decline and the Hospitalized
Elder
• 1279 pts >70yo
• ADL measure at DC and 3mo post-DC
• 31% decline baseline-adl at DC
• 59% unchanged; 10% better at DC
• 3 months:
• 11% died
• 40% further adl deficits
Sager, M. Arch In Med 1996; 156: 645-2
Etiology of Functional Decline
Constipation
Medications
*BZD
Malnutrition *Antihypertensives
Insomnia
Fatigue
Incontinence
Pain
Sensory deficits
Iatrogenic
Atelactasis
DVT
Ulcers
Functional
Decline/
Deconditioning
Immobility
Depression/frustration
General Weakness
Restraint
Confusion (Physical,
Behavioral,
Conceptual-foley, iv)
Acute medical illness
Hospitalization and Bed-rest:
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Table 1. Effects of Bed Rest
System
Effect
Cardiovascular
↓ Stroke volume, ↓ cardiac output, ^ pvr,
orthostatic hypotension, < plasma
volume
Respiratory
↓ Respiratory excursion, ↓ oxygen uptake, ↑
potential for atelectasis
Muscles
↓ Muscle strength, ↓ muscle blood flow
Bone
↑ Bone loss, ↓ bone density
GI
Malnutrition, anorexia, constipation
GU
Incontinence
Skin
Sheering force, potential for skin breakdown
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Psychological
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Social isolation, anxiety, depression,
disorientation
Functional Decline
Other Geriatric Syndromes:
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Pressure Ulcers
Delirium
Dehydration
Malnutrition
Falls 13x increased
Incontinence
Insomnia
Pain
Creditor, M. Ann In Med 1993; 118:219-23.
Restraint devices: IV,
Foley, PEG, wrist
Walter Prognostic Index
1 year prognostic index patient >/= 70
Factor
Points
Male
ADL dependence dispo
1-4
All
CHF
Cancer solitary/mets
Createnine >3.0
Albumin 3-3.4/<3.0
1
2
5
2
3/8
2
1/2
Walter Prognostic Index
1 year prognostic index patient >/= 70
• 1 year mortality:
• 1-4 points 4%
• 2-3 points 19%
• 4-6 points 34%
• >6 points 64%
• >6 consider hospice or EOL focused care.
Appropriate for prognostic consideration in pts
with cancer, chf, dementia, copd, acute
irreversible process.
Diagnosis: Confusion Assessment
Method (CAM)
Inouye SK et al. Ann Intern Med. 1990; 113: 941-948
• (1) Acute change in
mental status with a
fluctuating course
• (2) Inattention
AND
• (3) Disorganized
thinking
OR
• (4) Altered level of
consciousness
Sensitivity: 94-100%, Specificity: 90-95%
How to Distinguish
Delirium from Dementia
• Features seen in both:
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Disorientation
Memory impairment
Paranoia
Hallucinations
Emotional lability
Sleep-wake cycle
reversal
• Key features of
delirium:
– Acute onset
– Impaired attention
– Altered level of
consciousness
Assume it is Delirium
until Proven Otherwise
Delirium may be the only
manifestation of life-threatening
illness in the elderly patient
Predisposing Factors
i.e. baseline underlying vulnerability
• Baseline Dementia
– 2.5 fold increased risk
of delirium in
dementia patients
– 25-31% of delirious
patients have
underlying dementia
• Medical comorbidities:
– Acute medical illness
• Visual impairment
• Hearing impairment
• Functional
impairment
• Advanced age
• History of ETOH
abuse
• Male gender
Precipitating Factors
i.e. noxious insults
• Medications
• Bedrest
• Indwelling bladder
catheters
• Physical restraints
• Iatrogenic events
• Uncontrolled pain
• Fluid/electrolyte
abnormalities
• Infections
• Medical illnesses
• Urinary retention
and fecal impaction
• ETOH/drug
withdrawal
• Environmental
influences
Some drug classes that are
associated with delirium
• Medications with psychoactive effects:
– 3.9-fold increased risk
– 2 or more meds: 4.5-fold
• Sedative-hypnotics: 3.0 to 11.7-fold
• Narcotics: 2.5 to 2.7-fold
• Anticholinergic drugs: 4.5 to 11.7-fold
Prevention of Delirium:
It can be done!
• Find patients with 1-4 of the following
predisposing characteristics:
– Visual impairment (worse than 20/70
corrected)
– Severe illness
– Cognitive impairment (MMSE<24/30)
– High BUN/Cr ratio (>18)
• (Inouye SK et al. Ann Intern Med. 1993; 119:474-481)
Take Home Points:
Delirium in the Elderly
• A multi-factorial syndrome: predisposing
vulnerability and precipitating insults
• Delirium can be diagnosed with high sensitivity
and specificity using the CAM
• Prevention should be our goal
• If delirium occurs, treat the underlying causes
• Always try non-pharmacologic approaches
• Use low dose anti-psychotics in severe cases
Targeted Interventions for
Prevention of Decline:
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Fall precautions/PT: hx dementia, confusion, fall
in prior 12 months
Dysphagia diet/speech eval: stroke, difficulty
swallowing, aspiration
Bowels: prunes, mobility, home foods
Social work/case manager: limited community
support, self neglect, cog deficits
Nutrition/supplements, 1:1 Feeding: Hx weight
loss, low albumin, advanced dementia, liberal
diet
Geriatric Complications and Screens for
Assessing:
GERIATRIC HOSPITAL
COMPLICATION:
SCREENING METHOD:
Delirium: CAM review with nurse or
Confusion Assessment Method; Mini Cog
family?
Deconditioning: What was your function 2
weeks prior to hospital and now?
ADL/IADL; mobility status
Poly-pharmacy: What are potential
Geriatric priniciples: start low go slow, ½1/3 dose abx, bp meds; Beers list
hazards with the medications?
Pressure ulcers: Assess patient’s perineum,
See Stage, assess with Braeden system
heels, elbows
Environmental Assessment: What aides
does the patient use, what is present?
Gait device, glasses, hearing aide,
dentures
Pain: PQRST step pain review
Type pain, location, duration, intensity,
exac/relieving
Restraint Review: How many restraints
?foley, PICC< drains, SCDs,
catheter/drains need and
discontinuation plan
are present on this patient?
Nutrition: How is your appetite?
Observe patient eating, desired foods,
dentures, last BM
Medical decision making: What have the
doctors told you about why you’re in
the hospital?
Applebaum review of decision making
Geriatric Screens Web Access:
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CAM: http://www.healthcare.uiowa.edu/igec/tools/cognitive/CAM.pdf
Mini-Cog
http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/clock_drawing_test.
pdf
ADL: http://www.healthcare.uiowa.edu/igec/tools/function/katzADLs.pdf
Options for assisting with ADLs: http://www.family-friendlyfun.com/disabilities/adaptive-equipment.htm
IADL: http://www.annalsoflongtermcare.com/article/7453
Braden scale:
http://www.ruralfamilymedicine.org/educationalstrategies/braden_scale_for_pred
icting_pres.htm
Pressure Ulcer Staging: http://woundconsultant.com/sitebuilder/staging.pdf
Decisional Capacity: See next slide +
http://www.nejm.org/doi/full/10.1056/NEJMcp074045
Appelbaum,P. NEJM 2007; 357:1834-1840