the hospitalized elderly: general principles jason stein, md emory reynolds faculty scholar emory...

The Hospitalized Elderly: General Principles

The Hospitalized Elderly: General Principles

Jason Stein, MDEmory Reynolds Faculty ScholarEmory Hospital Medicine Service

Jason Stein, MDEmory Reynolds Faculty ScholarEmory Hospital Medicine Service

Highest Quality Care for the Hospitalized ElderlyHighest Quality Care for the Hospitalized Elderly

Emory Reynolds Program

Emory Hospital Medicine ServiceEmory Reynolds Program

Emory Hospital Medicine Service

Highest Quality Care in the HospitalGoals for this Module

Highest Quality Care in the HospitalGoals for this Module

1) Identify the significance of elderly patients to hospitalists 2) Identify the significance of hospitalizations to elderly

patients3) Appraise the extent of your hospital’s specific approach

to its geriatric population 4) 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

1) Identify the significance of elderly patients to hospitalists 2) Identify the significance of hospitalizations to elderly

patients3) Appraise the extent of your hospital’s specific approach

to its geriatric population 4) 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




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)

What do half your patients have in common?(whether you’re at EUH, ECLH, Cartersville,

Dunwoody, Northlake, or Eastside)






What is the median age on your census? What is the median age on your 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)

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.




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…

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%)





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

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

Your patient’s age is clinically significant.Your patient’s age is clinically significant.






Hospitalization Facts: Older patients have: More frequent hospitalizations

Longer HospitalizationsHigher Mortality

Hospitalization Facts: Older patients have: More frequent hospitalizations

Longer HospitalizationsHigher Mortality






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)


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)







Longer hospitalizations Patients > 85 years old average = 6.2 days Patients 45-64 years old average = 4.8 days


Longer hospitalizations Patients > 85 years old average = 6.2 days Patients 45-64 years old average = 4.8 days







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


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




Beaufort Scale: 1 - 12

(scale of wind velocity)

Hurricane = 12 (74 mph)

Light breeze = 1 (1 mph)

Beaufort Scale: 1 - 12

(scale of wind velocity)

Hurricane = 12 (74 mph)

Light breeze = 1 (1 mph)

Gill TM. JAMA. 2004; 292: 2115-24Gill TM. JAMA. 2004; 292: 2115-24

Factors Associated With Development of DisabilityFactors Associated With Development of Disability




Defining A Key Geriatric TermWhat is Functional Decline?Functional Decline?Defining A Key Geriatric TermWhat is Functional Decline?Functional Decline?

Functional Decline = New DisabilityLoss of ADLs (basic self-care activities)

Transfer out of bed to chair independentlyToileting yourselfBathing yourselfDressing yourselfFeeding yourself

Functional Decline = New DisabilityLoss of ADLs (basic self-care activities)

Transfer out of bed to chair independentlyToileting yourselfBathing yourselfDressing yourselfFeeding yourself




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

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








Functional Decline = Higher Mortality

# basic ADLs absent at discharge strong independent predictor of mortality 4,5

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.

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.


Until it does, your elderly inpatients rely on you alone to deliver all – and only – the care they need.

Highest Quality Care in the HospitalHighest Quality Care in the Hospital


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?


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

Guided Prescription of Psychotropic Medications for Geriatric Inpatients.Josh F. Peterson, et al. Arch Intern Med Volume 165:802-807 April 11, 2005





Processes Processes Outcomes Outcomes

Every system is perfectly designed to achieve exactly the results it gets.






What’s the difference?






What do you care more about?




Processes:

influence outcomes

more amenable to measurement

must be tightly associated to outcomes

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

Outcomes:

what you really care about ultimately

can be difficult to measure in real time





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)

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)

¥ iADLs = instrumental ADLs: tasks necessary to run a household (telephone, managing money, shopping, preparing meals, light housework, getting around the community)






Risk Factors After Admission:

“Adverse” Hospital environment Iatrogenic illness Sensory Deprivation Altered sleep-wake cycles Disorientation Deconditioning Malnutrition

Risk Factors After Admission:

“Adverse” Hospital environment Iatrogenic illness Sensory Deprivation Altered sleep-wake cycles Disorientation Deconditioning Malnutrition

Acts of Omission

Jurisdiction = Hospital Services (Physical Space, Workplace

Culture, Multidisciplinary Team skill and availability)

(but you still play a role)

Acts of Commission Jurisdiction = You




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

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

Example:

Deconditioning from… Illness-induced immobility

your usual good careyour 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 insist on handrails and 24/7 PThandrails 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 patientun-tie” your patient

Example:

Deconditioning from… Illness-induced immobility

your usual good careyour 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 insist on handrails and 24/7 PThandrails 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 patientun-tie” your patient




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)

“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)






Three Key Geriatric Principles for the Hospital1) At the individual level, variability decreases with age2) 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…

Three Key Geriatric Principles for the Hospital1) At the individual level, variability decreases with age2) 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…




How is Aging Clinically Significant?Most Elderly Are Different from the Young

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)

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).

Clinical Implication: detectable extremes tend to be associated with significant underlying illness (or iatrogenesis).




How is Aging Clinically Significant?Most Elderly Are Different From One Another


2) Across the geriatric population, variability increases c age:

Population Variability Widens TimeTime “Normal aging” + DiseaseDisease Genes/Environment = Wide Variability

2) Across the geriatric population, variability increases c age:

Population Variability Widens TimeTime “Normal aging” + DiseaseDisease 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.

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.




How is Aging Clinically Significant?Many Elderly Are Running on FumesHow 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)

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 slidesClinical Implication: next 3 slides

susceptibility to disease+

ability to compensate(homeostenosis)

susceptibility to disease+

ability to compensate(homeostenosis)

The Frail ElderlyThe Frail Elderly




HomeostasisHomeostasis

You

Compensatory MechanismsCompensatory Mechanisms

You, Compensated

Physiologic ReservePhysiologic Reserve

stress




HomeostenosisHomeostenosis

Frail Elderly

Compensatory MechanismsCompensatory MechanismsLimited Blunted

“Tapped Out”

Clinically Decompensated

Physiologic ReservePhysiologic Reserve

stress

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.

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.






Body CompositionBody 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 doserisk of excessive medication schedule

propensity to DM, HTN, hyperlipidemiarisk of under-diagnosis or treatmentrisk of over-treatment c polypharmacy/ADEs

Body CompositionBody 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 doserisk of excessive medication schedule

propensity to DM, HTN, hyperlipidemiarisk of under-diagnosis or treatmentrisk of over-treatment c polypharmacy/ADEs

RenalRenal GFR RAAS and ADH response to hypovolemia natriuresis (Na excretion in hypervolemia)

delayed clearance of water-soluble medicationsrisk of excessive medication doserisk 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

RenalRenal GFR RAAS and ADH response to hypovolemia natriuresis (Na excretion in hypervolemia)

delayed clearance of water-soluble medicationsrisk of excessive medication doserisk 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




Age-Related Changes Especially Relevant to Hospital Medicine

Age-Related Changes Especially Relevant to Hospital Medicine

CardiovascularCardiovascularMedial 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 stressrisk of overlooking enormous

significance of sinus tachycardia (work-up sinus tachycardia)

CardiovascularCardiovascularMedial 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 stressrisk of overlooking enormous

significance of sinus tachycardia (work-up sinus tachycardia)

PulmonaryPulmonary chest wall compliance elastic recoil of lungs strength diaphragm mucocilliary clearance P02 and A-a gradient*

Higher risk pulmonary infectionsrisk of not vaccinating (PVX and flu shot)risk of overlooking smoking cessation

advice

Lower threshold for hypoxemiarisk of occult hypoxemiarisk of iatrogenic respiratory depression

* Normal A-a gradient: [(age/4)+4] Normal PO2: [110-(0.4 x age)]

PulmonaryPulmonary chest wall compliance elastic recoil of lungs strength diaphragm mucocilliary clearance P02 and A-a gradient*

Higher risk pulmonary infectionsrisk of not vaccinating (PVX and flu shot)risk of overlooking smoking cessation

advice

Lower threshold for hypoxemiarisk of occult hypoxemiarisk of iatrogenic respiratory depression

* Normal A-a gradient: [(age/4)+4] Normal PO2: [110-(0.4 x age)]

Lower TVs, more atelectasis

Weaker, less effective cough






GastrointestinalGastrointestinal swallow coordination/esophageal motility lactase levels colonic motility

Dysphagiaaspiration riskmalnutrition risk

Lactose Intoleranceoccult diarrhea risk

Tendency to constipationrisk of remaining occultrisk of being exacerbated

GastrointestinalGastrointestinal swallow coordination/esophageal motility lactase levels colonic motility

Dysphagiaaspiration riskmalnutrition risk

Lactose Intoleranceoccult diarrhea risk

Tendency to constipationrisk of remaining occultrisk of being exacerbated

Immunological Immunological barrier integrity (skin, mucous membranes)Altered cytokine response to infection humoral Ab response to infection

Susceptibility to skin, urinary, pulmonary infxns

decubitus ulcer riskurosepsis riskaspiration risk

Blunted febrile response to infection occult infection risk:

(work-up T > 99ºF (37.2ºC)) (work-up new ↑WBC/bandemia)

Immunological Immunological barrier integrity (skin, mucous membranes)Altered cytokine response to infection humoral Ab response to infection

Susceptibility to skin, urinary, pulmonary infxns

decubitus ulcer riskurosepsis riskaspiration risk

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%)

(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%)

Patient CasesPatient Cases




Case #1: InappropriateCase #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

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





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

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





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

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





Which of the following is the most appropriate next step in managing this patient’s recurring falls?

A) Refer to ophthalmologyB) Discontinue ativanC) Discontinue HCTZD) Refer to physical therapyE) Substitute buspirone for zoloft

Which of the following is the most appropriate next step in managing this patient’s recurring falls?

A) Refer to ophthalmologyB) Discontinue ativanC) Discontinue HCTZD) Refer to physical therapyE) Substitute buspirone for zoloft





Observational studies show medications are the most readily modifiable risk factors for falls– Especially psychotropics (bdz,

neuroleptics, TCAs)

Observational studies show medications are the most readily modifiable risk factors for falls– Especially psychotropics (bdz,

neuroleptics, TCAs)





RCTs show specific single interventions to reduce falls:

– removal of psychotropic medications– home hazard assessment and modification– exercise programs

RCTs show specific single interventions to reduce falls:

– removal of psychotropic medications– home hazard assessment and modification– exercise programs





Falls in elderly:

usually multifactorial (so address all potential contributing factors)

Falls in elderly:

usually multifactorial (so address all potential contributing factors)




Case #2: Adverse Hospital Environment?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.

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.





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

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





PE: T 37.4°C HR 90 BP 154/85 RR 12Gen: non-toxic appearingLungs/CV/abd: normalExt: 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, 90Rad: non-diagnostic for OM

PE: T 37.4°C HR 90 BP 154/85 RR 12Gen: non-toxic appearingLungs/CV/abd: normalExt: 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, 90Rad: non-diagnostic for OM





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.

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.


On night of first hospital stay, she can’t sleep. X-cover writes for ambien 5mg qhs.





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?

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?





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?

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?





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 hydroxyzineC) Surreptitious ETOH use and withdrawal following

hospitalizationD) Forced adherence with adverse effects from

outpatient medications glyburide and synthroid




hospitalizationD) Forced adherence with adverse effects from









hospitalizationD) Enforced adherence with adverse effects from





hospitalizationD) Enforced adherence with adverse effects from





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 oncee.g. in hospital…new confusion, hypoglycemia, low BP, atrial fibrillation

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 oncee.g. in hospital…new confusion, hypoglycemia, low BP, atrial fibrillation






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)

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)




Case #3: Non-specificCase #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.

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.





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.

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.





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 CA2) they’ve been to another hospital ER twice in the last month

to try to get this explained

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 CA2) they’ve been to another hospital ER twice in the last month

to try to get this explained





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.

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.





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

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





Allergies: NKDAMeds:

1. Risperdal 0.5mg bid2. MVI c iron daily3. Bextra qd4. Darvocet prn5. Flexeril prn

Allergies: NKDAMeds:

1. Risperdal 0.5mg bid2. MVI c iron daily3. Bextra qd4. Darvocet prn5. 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. ROS: no fever, chills, malaise. No abd pain, N/V/D. No SOB/cough.

No focal weakness but poor balance. No CP/LH/syncope.




Case #3: Non-specificCase #3: Non-specificPE: T 100.8°F HR 102 BP 120/72 RR 16Gen: non-toxic appearing, well-nourishedHEENT: OP very dry; neck supple; NL visionCV: No JVD, RRR, II/VI systolic murmur at RUS borderLungs/abd: normalExt: No synovitis. No lesions. 2+ peripheral pulses.Skin: Warm and dry. No rash.Neuro: A&O to time, place, and situation, and o/w NLLab: 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

PE: T 100.8°F HR 102 BP 120/72 RR 16Gen: non-toxic appearing, well-nourishedHEENT: OP very dry; neck supple; NL visionCV: No JVD, RRR, II/VI systolic murmur at RUS borderLungs/abd: normalExt: No synovitis. No lesions. 2+ peripheral pulses.Skin: Warm and dry. No rash.Neuro: A&O to time, place, and situation, and o/w NLLab: 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





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.


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.






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

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





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.

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.




Especially if Your Hospital Lacks Specific Geriatric Processes…

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

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

the hospitalized elderly: general principles jason stein, md emory reynolds faculty scholar emory...

Documents

geriatric patients

patients age

hospital deaths

hospital goals

median age of patients

care of elderly inpatients

adverse hospital environment

national hospital survey