Care of the Hospitalized Geriatric PatientEthan Cumbler MD, FACPAssociate Professor of MedicineDirector UCH Acute Care For Elderly ServiceUniversity of Colorado Denver2010

ObjectivesRecognize patients at highest risk for hazards of hospitalization such as delirium and falls using simple evidence based screening tools

Be able to implement elements of an evidence based prevention protocol for common hazards of hospitalization

Understand treatment options for deliriumDisclosures: The speaker has no conflicts of interest to disclose

Changing DemographicsIn 2000 about 1 in 8 Americans was over age 65.

By 2030 it will be 1 in 5

Hospitalization is a time of critical risk for the elderly

We can do better

Current State of AffairsMajority of inpatient geriatric care is provided by physicians without specific training in geriatrics.Only 7,000 Geriatricians30,000 Hospitalists

Hospital communications silos inhibit recognition and treatment of new geriatric syndromes

Physician often the last to know about barriersPhysicalSocialFinancial

Outpatient caregivers not involved

What Explains the Status Quo?Barriers to ChangeVulnerable elderly dispersed across teams and within hospitals

Traditional closed ACE units proven successful but not widely implemented due to increased resource commitments

Geriatric issues considered less vital than admit diagnosis

Solutions require interdisciplinary approach Team infrastructure inadequate

Focus can be on more rather than making it easy to do right

Jayadevappa R. Dissemination and Characteristics of Acute Care for Elders Units in the United States. In J Tech Assess in Health Care 2003;19:220-227

Hazards of HospitalizationHigh Risk PatientHigh Risk SituationHigh Risk EnvironmentHAZARDFallsDeliriumPressureulcersAdversedrug eventsFunctional declineTransitionFailure

There are Some Who Think the Hospital Is a Fancy Hotel

A Modest ProposalSystem change is required

Geographic concentration

Standardized assessment

Standardized care protocols

Interdisciplinary care

Acute Care for the Elderly Service

Brief Geriatric AssessmentIdeal Geriatric Assessment FastTolerated by patientsProvide new informationLeads to new actionConfusion Assessment Method (CAM)Mini-CogVulnerable Elders Survey

2 Q Depression ScreenSensory Aid AssessmentFalls ScreenGet-Up-and-Go Test

Clinical CaseGertrudes Tragic Tale88 y/o woman admitted for back pain after a fall stepping off a curb outside her assisted living

Xray demonstrates thoracic compression fracture.

Admit for pain control, inability to ambulate.

PMHMild Alzheimer's DementiaInsomniaHTNUrge incontinenceDepression

MedicationsLisinopril 10mg dailyAspirin 81 mg dailyAmitryptiline 50mg qhsOxybutinin 5mg bid

When Hospitalization is Over.Will Gertrude be going home?How do you predict discharge location on admission?

Assessing Need for PlacementVulnerable Elders Survey-13Originally developed to identify community dwelling elders at risk for functional decline or death.

10 point score based on:AgeSelf reported health statusAbility to perform six physical tasks and five activities of daily living. Saliba D. The Vulnerable Elders Survey: A tool for Identifying Vulnerable Older People in the Community. J Am Geriatr Soc 2001;49:1691-1699Min LC. Higher Vulnerable Elders Survey Scores Predict Death and Functional Decline in Vulnerable Older People. J Am Geriatr Soc 2006;54:507-511

VES-13Cumbler E. Vulnerability Assessment on Hospital Admission Predicts Need for Placement upon Discharge for Elderly Patients. Journal of the American Geriatrics Society 2009; 57:944-946Now validated to predict need for SNF in elderly admissions

Take Home PointFunction PRIOR to admission predicts need for placement

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Gertrudes Tragic TaleGertrude is confused about the timeline of events

Does not remember her home medications

Honey, I dont have to know that at my age when asked for the year, Can spell WORLD backwards

Tells you a bright and animated story about her dog and how funny it was when he ate peanut butter

Is Gertrude Delirious?

Delirium Acute onset of disturbance in consciousness in which cognition or perception is altered 17%-74% cases unrecognized by nursesPhysicians may do worse

Over reliance on disorientation/inappropriate behavior

More likely to be missedHypoactiveAge >80 yrsVision impairmentDementiaAre Nurses Recognizing Delirium? A systematic review. JOGN 2008;34:40-48Occurrence of Delirium is Severely Underestimated in the ICU during Daily Care. Intensive Care Med 2009

DIAGNOSING DELIRIUM: The Confusion Assessment Method (CAM)Patient must demonstrate the following:

Sensitivity 94-100%, Specificity 90-95%Positive LR 9.6 , Negative LR 0.16Inouye SK et al. Ann Intern Med 1990;113:941-948Wong CL. JAMA.2010;304:779-786 OR

ASSESSING DELIRIUM RISKInouye, S. Ann Intern Med. 1993;119:474-481Medical Inpatient Prediction Rule--Cognitive impairment--Severe Illness--High BUN/Cr--Vision impairment

Low Risk (0) 10% riskInt. Risk (1-2) 25% riskHigh Risk (3-4) 80% risk

Assessing Delirium RiskMini-Cog3 item recall (ball, justice, tree) (up to 3 pts)Clock Draw (10 minutes after 11)All or nothing-- 0 or 2 pts

On Admission:Scores of 0, 1, or 2 carries a 4-5X increased risk for deliriumTrue regardless of whether the patient has dementia or notAlagiakrishnan K et al. Simple Cognitive Testing (Mini-Cog) Predicts In-Hospital Delirium in the Elderly. JAGS 2007;55:314-316 0 points

DELIRIUM IS COMMONAffects 20% of hospitalized patients over age 65Up to 70-80% of older patients in intensive careUp to 83% of older patients at the end-of-life

Affects 36.8% of postoperative patientsCataract Surgery 1-3%General Surgery 10-15%Orthopedic Surgery 28-61%

Miller MO. Evaluation and Management of Delirium in Hospitalized Older Patients. AAFP 2008;78:1265-1270

Mechanism of DeliriumImbalance of NeurotransmittersAcetylcholine Dopamine Others ??

Hypothalamic-pituitary-adrenal axis

InflammationCytokines (TNF, Interleukins)

Occult diffuse brain injuryEspecially following sepsis (ischemic insult)

WHY DO WE CARE Increased Length of StayBy 8 days

Increased MortalityDouble the mortality in pts with delirium

Functional Decline/NH placement

Prolonged Cognitive Defects

NEW RESEARCH1/3 of pts d/c to SNF delirious will still be delirious 6 months laterKiely DK, et al. Persistent Delirium Predicts Greater Mortality. JAGS 2009;57:55-61Miller MO. Evaluation and Management of Delirium in Hospitalized Older Patients. AAFP 2008;78:1265-1270

Delirium Prevention Modifiable risk factorCognitive impairment Immobility Visual Impairment Hearing Impairment Dehydration Sleep deprivation Prospective InterventionOrienting communicationEarly mobilization, reduce restraintsVisual aides, adaptive equipAmplifiers, adaptive equipPrevent and correct dehydrationUninterrupted sleep, nonpharmacologic aides

Inouye SK et al. A multicomponent Intervention to Prevent Delirium in Hospitalized Geriatric Patients. NEJM 1999;340:669-676Vidan MT et al. An Intervention Integrated into Daily Clinical Practice Reduces Incidence of Delirium During Hospitalization in Elderly Patients. JAGS 2009;57:2029-203640% Relative Risk Reduction

One of Hebb's sensory deprivation subjects at McGill. Sensory Deprivation

Declassified 1983 CIA Training ManualDeprivation of sensory stimuli induces stress and anxiety

Some subjects progressively lose touch with reality, focus inwardly, and produce hallucinations, delusions, and other pathological effects.

1984 revision states:Deliberately causing these symptoms is a serious impropriety.Accessed 2/28/09 at http://www.gwu.edu/~nsarchiv/NSAEBB/NSAEBB27/02-02.htm from National Security Archive Database

One of Hebb's sensory deprivation subjects at McGill. Sensory Deprivation

Sleep DeprivationConsequences of lack of sleep in healthy volunteers include impaired attention and irritability

Record for sleep deprivation is approximately 11 days

No longer accepts submissions in this category due to deleterious health effectsNoiseLightIllnessPainPhlebotomyVital signsSkin careCould you sleep?Drouot X. Sleep in the ICU. Sleep Medicine Reviews 2008;12:391-403

Practical Application

Order set as:

-QI tool

-Psychological manipulation

-Establishment of culture

-Time saving device

Gertrudes Tragic Tale

Diphenhydramine prn for insomnia

An indwelling catheter is placedHer personal possessions are safely stored in the closet ClothingGlassesDenturesHearing aids.

Maintenance IV fluids, telemetry, and SCDs

Clinical CaseGertrudes Tragic TaleThe following morning Gertrude is still sleepy when:The intern assesses her at 6:00amThe nurse assesses her at 8:00amThe attending assesses her at 10:00am

She sleeps through lunchDisoriented and inattentive-- not following instructions

She becomes confused Trying to get out of bed Pulling at her IVs

Is she delirious..Who knows?

Silos of CareHave you ever heard the phrase:

It seemed like the right hand didnt know what the left hand was doing

Effective Interdisciplinary Communication15 Minute Daily Team HuddleAttendings

Residents

Interns

Nursing

Physical Therapy

Occupational Therapy

Pharmacy

Case Management

Social Work

VolunteersGeographic Concentration

We want you to participate in your care and be as active as possible while staying safe

Let your team know about any problems or questions.If you use glasses, hearing aids, or dentures- use them in the hospital just as you do at home.Your activity care plan will be based on your abilities and illness.If possible, walk in the hall multiple times each day to keep your strength up. Eat meals while sitting up, preferably in a chair.

Your physicians will usually come in to see you and discuss your plan for the day between 9:00am and 11:00 am

feel free to invite family or other people in your life to be part of the care discussion

Your team includes an attending physician responsible for your overall care planEthan Cumbler M.D. Heidi Wald M.D. Jeannette Guerrasio M.D. Jeanie Youngwerth M.D. Judy Zerzan M.D.

We are interested in your thoughts about your care on the ACE serviceAfter your discharge we welcome you to write your physician atACE Servicec/o Hospitalist SectionAnschutz Inpatient Pavilion12605 E. 16th AveP.O. Box 6510. Aurora, CO. 80045 ENCOURAGING PATIENT INVOLVEMENT

Response to DeliriumTESTINGChem7, CBC, U/ATroponin, EKGCXR

TSH, Ammonia, B12, ABG?

LP if fever or neck stiffnessCT/MRI brain if focal neurologic signs or head traumaEEG if clinical evidence of seizuresDrug levels (Digoxin, anticonvulsants)

Extensive testing of limited value unless driven by a specific clinical suspicion

Practical ApproachRemove Problem MedicationsParticularly Anticholinergics, BNZ, and minimize Narcotics

Treat WithdrawalAlcohol or benzodiazepines

Correct Metabolic DisturbancesElectrolytes, glucose, hydration, ammonia

Reduce Level of InvasionIndwelling urinary catheters and lines

Assess and Treat Infection

Adequately Treat Pain Scheduled may be better than prn. Non-narcotic if possible

Improve Environment and Mobility?

Medical Therapy for DeliriumNo good evidence that Cholinesterase Inhibitors (dopepezil) are effective

No good evidence that Benzodiazepines are effective EXCEPT in alcohol withdrawal

Antipsychotics decrease the degree and duration of delirium (typical just as good as atypical)Cholinesterase Inhibitors for Delirium. Cochrane Database of Systematic Reviews 2008Benzodiazepines for Delirium. Cochrane Database of Systematic Reviews 2009Antipsychotics for Delirium. Cochrane Database of Systematic Reviews 2007

When All Else Fails.. ANTIPSYCHOTICSTypical Antipsychotics (Haloperidol)Does not prevent delirium when given prophylacticallyExtrapyramidal side effects with high dosesHaloperidol 0.25 0.5mg PO BID or prn q 4h.

Atypical Antipsychotics (Risperidone, Olanzapine, Quetiapine)Less QTc prolongation compared to haloperidolAntipsychotics associated with increased mortality in dementia--Prolonged QTc--Lowers seizure threshold

What About Restraints?Restraint chains used to control mentally ill patients, and documentation regarding Pennsylvania Hospital's purchase of such restraints in 1751 and 1752.

RESTRAINT USERestraints ARE appropriate for behavior that is a risk to life or to necessary medical care

Restraints associated with significant injuries

Restraints associated with 4 fold increased risk of delirium

Distraction VestDunn KS. Et al. The effect of physical restraints on fall rates in older adults who are institutionalized. Journal of Gerentol Nurs 2001:27:40-48Evaluation and Management of the Elderly Postoperative Patient at Risk for Postoperative Delirium. Clin Geriatr Med 2008;24:667-686

Gertrudes Tragic TaleShe gets out of bed to use bathroom at 2 a.m. and is found by staff on the floor.Urinary catheter still attached to the bed

Her scalp laceration requires staples.

Inpatient Falls2-12% of patients will have a fall in the hospital30% with minor injury, 4% with major injuryAssociated increased hospital charges ($4233) Associated increased LOS (12 days)

Injuries from falls in the hospital are Never EventsMedicare will no longer pay for them

Hospital falls with significant injury are JCAHO reportable sentinel events

Falls with injury in the hospital pose malpractice risk

Coussement J, et al. Interventions for Preventing Falls in Acute and Chronic Care Hospitals: A systematic review and meta-analysis. JAGS 2007;56:29-36

Fall Risk AssessmentHow do we as physicians assess a patients risk for this hazard of hospitalization?

A simple falls screen:Have you fallen in the last month or are you afraid of falling?Get-Up-And-Go testYou learn a lot about strength, balance, and gait in 30 seconds.

Identifying the High Risk PatientRisk FactorsPrior fall historyGait instabilityLower limb weaknessConfusionDrugsSedative/hypnoticsUrinary incontinenceOliver D, et al. Risk Factors and Risk Assessment Tools for Falls in Hospital In-patients: A Systematic Review. Age and Ageing 2004;33:122-130

The High Risk EnvironmentIV dripsTelemetrySequential compression devices

Indwelling urinary catheters

Modifying the High Risk EnvironmentPhysicians unaware of catheter21% for Medical Students22% for Interns27% for Residents38% for Attendings

This is not just about fallsIatrogenic infection is a potent hazard of hospitalizationCMS no longer pays for catheter-associated UTIsSaint S, et al. Are Physicians Aware of Which of Their Patients Have Indwelling Urinary Catheters. Am J Med 2000;109:476-480Jain P, et al. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med 1995;155:1425-1429

Modifying High Risk TherapyPsychoactive MedicationsAntidepressants and neurolepticsBenzodiazepinesLorazepam, Diazepam

NarcoticsMeperidine

Cardiac medications Clonidine, short acting Nifedipine, Doxazosin, Digoxin

Anticholinergic medications Diphenhydramine, Amitryptiline, Promethazine, Cyclobenzaprine

Combinations of medications with partial anticholinergic activityPrednisoloneTheophylineDigoxinFurosemideRanitidine

Woolcott JC et al. Metaanalysis of the Impact of 9 Medication Classes on Falls in Elderly Persons. Arch Int Med 2009;169:1952-1960Fick, D, et al. Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Arch Int Med 2003;163:2716-24Tune L, et al. Anticholinergic Effects of Drugs Commonly Prescribed to the Elderly. Am J Psych 1992;149:1393-1394

Use of Sleepers in The Elderly15% of elderly inpatients were on a sleep aid prior to admission

25% received pharmacotherapy for insomnia in the hospital

Non-benzodiazepine hypnotics (zolpidem)Most commonly chosen by hospitalistsCumbler E. Use of Medications for Insomnia in the Hospitalized Geriatric Population. JAGS 2008; 56:579-581

ResultsUCH ExperienceRandomized patients for 1st 6 months ACE vs usual careResource UtilizationDocumented severity of illness slightly higher for ACECase mix index for ACE patients was 1.15 vs 1.05 in usual care

Length of stay 3.4 days

Mean Patient Charges $24,617

30 Day readmission rate 12.3%

ACE service model did not significantly change resource utilization

3600 EvaluationHouse staff 100% feel better medical care of the elderly

Patient Satisfaction

Staff-- improved:Care coordinationCommunicationJob satisfactionOverall I received very good care

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Clinician Behavior Mirrors the System in Which They Practice!

Recognition and Treatment of Geriatric Conditions

p < 0.0001

p < 0.01

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ACE ModelWhat Does The Literature Show?Less Functional Decline at Discharge13% risk reduction

Lower rate of Institutionalization22% risk reduction at 1 year

No influence on LOS

Trend towards reducedReadmission (15% risk reduction but not statistically significant)Mortality (22% risk reduction at 3 months but not statistically significant)

Van Craen K. The Effectiveness of Inpatient Geriatric Evaluation and Management Units:A Systematic Review and Meta-Analysis. J Am Geriatr Soc 2010;58:83-92Baztan JJ. Effectiveness of Acute Geriatric Units on Functional Decline, Living at Home, and Case Fatality Among Older PatientsBMJ 2009;338

Geriatric Syndromes Have Profound ImpactMiller MO. Evaluation and Management of Delirium in Hospitalized Older Patients. AAFP 2008;78:1265-1270Kiely DK, et al. Persistent Delirium Predicts Greater Mortality. JAGS 2009;57:55-61Hazards

Delirium

Deconditioning

Falls

Harmed

The Patient

The Hospital

The Provider

The Insurer

Keys to Care of the Hospitalized ElderSimple Risk Assessments

Avoidance of Problematic InterventionsAnti-cholinergic and Sedative MedicationsTethersRestraints

Interdisciplinary Team Communication

Standardized Care Protocols

***Hospitalist as force multiplier for geriatrics in the hospital

*ACE Units first described in 1984-85. First RCT of an ACE unit was done in Case Western in 1994. As of 2000 there were 16 ACE units in the country and none at all in the West*ACOVE QI measures include Discharge planning should begin within 48 hours of admission**The acetylcholine deficit hypothesis is born out by delirium induced by anticholihnergic drugs such as diphenhydramine. The Dopamine excess hypothesis is supported by response of delirium to haldol. Abnormal tryptophan metabolism may also play a role.Elevated level of CRP in hip fracture patients correlates with delirium (Beloosesky Y Gerontology 2004;50:216-222)

*NOTE: COG. IMPAIRMENT (MMSE < 24); VISION IMPAIRMENT > 20/70; BUN/CR > 18/1; SEVERE ILLNESS= APACHE II > 16 OR CHARLSON ORDINAL CLINICAL = RATED AS SEVERE

*ACOVE Quality Measures include evaluation of cognitive status should occur within 24 hours of admission*ACOVE Quality Measures include evaluation for potentially precipitating factors must be undertaken and identified causes treated.*ACOVE quality measures include justifying use of restraints and methods other than restraints in the care plan.**2-12% of patients will have a fall in the hospital. From Coussement J, et al. Interventions for Preventing Falls in Acute and Chronic Care Hospitals: A systematic review and meta-analysis. JAGS 2007;56:29-36Inpatient fall cost and LOS from Bates DW et al. Serious Falls in Hospitalized Patients: Correlates and Resource Ulilization. AJM 1995;99:137-143*ACOVE Quality measures include assessment of functional status AND patients with problems of gait, strength, or endurance should be offered an exercise program*Risk Factors from Oliver D, et al. Risk Factors and Risk Assessment Tools for Falls in Hospital In-patients: A Systematic Review. Age and Ageing 2004;33:122-130Psychotropics are most associated with falls with a pooled odds ratio of 1.73- From Leipzig RM et al. Drugs and Falls in Older People: A systematic review and Meta-analysis I. Psychotrophic Drugs. JAGS 1999;47:30*Saint S, et al. Are Physicians Aware of Which of Their Patients Have Indwelling Urinary Catheters. Am J Med 2000;109:476-480- In this study catheters were deemed to be unnecessary in 31% of cases.Urinary Catheter Use was judged always inappropriate in 21% of all cases and approximately half of all patient days.Jain P, et al. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med 1995;155:1425-1429**All of these medications are on the Beers list although Lorazepam and Digoxin only at certain doses.*25% of patients over the age of 65 in the care of a hospitalist are treated with a medication for insomnia during hospitalization-Cumbler E, Guerrasio J, Kim J, Glasheen J. Use of Medications for Insomnia in the Hospitalized Geriatric Population. JAGS 2008; 56:579-581Dementia present in 23% and 15% were previously on an outpatient sleep aid, of which 30% were non-benzodiazepine hypnotics. Insomnia medication was prescribed during hospitalization in 27% of patients. Patients with dementia were prescribed a medication for insomnia in only 7% of cases compared to 32% for patients without dementia. Of patients who had medication ordered for insomnia, Non-benzodiazepine hypnotics were lone therapy for insomnia in 55%, benzodiazepines in 19%, antidepressants in 15% and antihistamines in 2%. 9% of patients were prescribed more than one class. Use of outpatient sleep medication was positively associated (p < 0.001) with ordering of medication for sleep in the hospital, and dementia was a negatively associated (p < 0.001). Age, race, sex, or housestaff involvement was not significant. Logistic regression models revealed the presence of dementia significantly decreased likelihood of a sleep medication order with unadjusted OR of 0.15 and adjusted OR of 0.22 (p = 0.04, 95% CI 0.05-0.96). *Total cost of treatment full thickness ulcer up to $70,000