hospital care of the elderly resident’s thursday school 12/03/09 j rush pierce jr, md, mph...
TRANSCRIPT
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Hospital Care of the Elderly
Resident’s Thursday School12/03/09
J Rush Pierce Jr, MD, MPHHospitalist Section, UNM
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Outline• Resources• Epidemiology, costs, and outcomes• Functional Assessment• Falls prevention• Strategies to prevent delirium• Avoiding inappropriate drugs• Transitioning care• Making rounds on elderly patients
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Resources
UNM Hospitalist Wiki Site
www.unmhospitalist.pbworks.com
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Epidemiology, costs and outcome of hospitalization of elderly
Jencks SF, Williams MV, Coleman EA. Rehospitalization among persons in the Medicare Fee-for-service program. NEJM 2009;360:1418-1428
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Hospitalization of the elderly
• 1/4 elderly hospitalized each year• 1/5 of hospitalized are re-hospitalized within
30 days – only 10% planned• Half of those re-hospitalized within 30 days
had not had any office visit in between• Most common dxs = CHF, psychoses, COPD• Unplanned re-hospitalizations cost $17.4B in
2004
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Functional Assessment
• Importance of function in the elderly
• Functional assessment instruments
• Functional assessment in the hospital– Why should I do it?– When should I do it?– How do I do it?– What are implications?
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Functional Impairments in Elderly Associated with Hospitalization
• 15% event discharged to nursing home• Another 20% discharged without ever
recovering pre-hospital level of activity• Another 15% elderly lose ability to perform
basic self-care activities; but regain before going home
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Functional Loss during Hospitalization: Targeted Interventions
• Falls prevention• Strategies to prevent delirium• Avoiding inappropriate drugs• Transitioning care---------------------------------------------------------------------• Optimizing nutrition• Improving sensory impairments• Screening/treating depression• Screening/treating cognitive impairment
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Falls in the hospital - epidemiology
• 5 – 10% of hospitalized elderly fall during hospital stay
• 30% occur within first 48 hours• 1/2 occur at bedside during transfer• 1/2 unwitnessed
Vass CD, Sahota O, Drummond A, et al. REFINE (Reducing Falls in In-patient Elderly)--a randomised controlled trial. Trials. 2009 Sep 10;10:83.
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Falls prevention in the hospital: strategies
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Epidemiology of delirium in hospitalized elderly
• Present of admission in 10%• Develops in another 30% during hospital stay• Increased rate of in-hospital mortality• Increased rate of nursing home placement• Risk factors: pre-existing cognitive
impairment; sleep deprivation; immobility; visual impairment; hearing impairment; dehydration
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Recognizing delirium in hospitalized patients: CAM
Both 1 & 2, plus either 3 or 4
Inouye SK. Delirium in older persons. NEJM 2006; 354:1157-1165
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Strategies to prevent delirium
• Avoid certain medications (sedatives, narcotics, anticholinergics)
• Treat infection and fever• Detect and correct electrolyte abnormalities• Frequently re-orient the patient (family, sitter)• Get out of bed• Avoid room changes, Foley, restraints
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Delirium: principles of pharmacologic treatment
• Reserve this approach for patients with severe agitation at risk for interruption of essential medical care for patients who pose safety hazard
• Start low doses and adjust until effect achieved
• Maintain effective dose for 2–3 days
Inouye SK. Delirium in older persons. NEJM 2006; 354:1157-1165
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Delirium: pharmacologic agents
Inouye SK. Delirium in older persons. NEJM 2006; 354:1157-1165
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Epidemiology of medication use in hospitalized elderly
• 40% outpt drugs discontinued on admission• 45% of discharge meds started during hospital
stay• 22% of hospitalized elderly have at least one
serious or life-threatening drug problem
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The Beers list
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Avoiding inappropriate drug use in hospitalized elderly: principles
• Avoid anticholinergics, sedative/hypnotics, drugs with CNS side effects
• Pick drugs with shorter half-lives• Try to simplify the regimen that your patient is
going home on (frequency of dosing, grouping of drugs, expense)
• Use your pharmacists!
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Transitions from hospital care: epidemiology
• 1/4 hospitalized elderly are discharged to another facility
• 50% experience a medical error at discharge• 1/5 experience an adverse event at discharge
(more than half are preventable)• 1/5 of hospitalized are re-hospitalized within
30 days – only 10% planned
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Transitioning care: where?
http://champ.bsd.uchicago.edu/idealDischarge/index.html
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Transitions from hospital care: strategies to improve success
• Involve multi-disciplinary team • Anticipate discharge needs early during stay• Involve the patient and family• Review and reconcile meds• Dictate an accurate and timely discharge
summary• If going home, schedule f/u outpt visit in 2 weeks• Coordinate care with next provider• Do a discharge “Time out”
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Discharge summary• Only 30% d/c summ available to PCP at first visit (JAMA
2007; 297:834)
• In pts referred to SNF’s medication discrepancy between DCs and transfer form identified in 52% of admissions. CV drugs, opiates, psych meds, hypoglycemics, antibiotics, and anticoags accounted for 50% of descrepancies (JGIM 2009;24:630)
• In pts with outstanding tests, only 25% DS recorded any outstanding test, and only 13% recorded all outstanding tests. 10% outstanding test were actionable
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Draft of “Model” Discharge Summary
• Dates of Admission and Discharge • Final Primary and All Secondary Diagnoses • Brief HPI: Presenting problem that precipitated hospitalization• Brief Hospital Course by Problem - Include procedure results, and abnormal test
results• Sub-Specialist Recommendations • Reconciled Discharge Medication - New or Changed Dose Medications, Continued
Meds from Admission, Stopped Meds • Functional Status at Discharge and Discharge Destination • Follow-up Plan - Follow up Appointments• Suggested Management Plan• Pending Labs or Test • Any Anticipated Problems and Suggested Interventions with documentation of
patient education (smoking cessation) and understanding
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The Discharge “Time – out”
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Hospitalized elderly: Daily Rounds
• Review all meds• What is the functional capacity? • Is the patient eating?• Is the patient getting out of bed?• Does the patient need all these attachments?• What is the discharge plan and destination?• Is the family aware?
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General principles in caring for hospitalized elderly
• Add FUNCTION to your dx/rx paradigm
• Consider medication regimen as well as meds
• Think early about the destination