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How many octogenarians do you treat in a year? Nonagenarians? Centenarians? How much have their numbers increased over the last two decades? In the wake of the fabled “silver tsunami,” more than 40% of adult inpatients are aged 65 years or older. By 2030, more than 70 million Americans will have joined the ranks of senior citizens.
Members of this group often have multiple chronic conditions that may require hospitalization as many as 10 times per year.1 Others appear in the ED after falls or suffering from cardiovascular conditions or infection.2
The Hospitalist surveyed seasoned geriatricians for their advice on treating this highly specialized and rapidly growing population, and compiled a list of 10 things these specialists believe hospitalists should know.
1 All physicians should be educated in the basics of geriatric care.
Wayne McCormick, MD, MPH, a geriatrician on the Inpatient Palliative and Supportive Care Consultation Team at Harborview Medical Center, Seattle, notes that with the explosion of the aging population in the U.S., it is impossible to train enough geriatricians to care for every elderly hospital inpatient, so hospitalists need to increase their knowledge base of geriatric issues.
“To ensure that elderly patients receive good care suited to their specific needs, there need to be 10 times as many geriatrics-savvy internal medicine physicians as board-certified geriatricians,”Dr. McCormick says. “That way, elderly patients can find good primary, if not specialized, geriatric care.”
Dr. McCormick recommends the resources of the American Geriatrics Society, which includes fellowships on geriatric issues, conferences, and educational material on its website.
2 Sometimes the disease is not the most important focus—maintaining the patient’s function is.
Kenneth Covinsky, MD, MPH, division of geriatrics, University of California, San Francisco, says that, many times, geriatric patients are “admitted for pneumonia or heart failure, and, during their stay, the condition improves; however, the person who came in walking and able to perform activities of daily living on their own leaves unable to function.”
Dr. Mattison
It is easy to see how hospital stays work against maintaining function in the elderly. An important part of maintaining function is encouraging mobility, but, according to Melissa Mattison, MD, SFHM, FACP, assistant professor of medicine at Harvard University and associate chief of hospital medicine at Beth Israel Deaconess Medical Center in Boston, this does not happen enough.
“Most older adults spend the majority of their days in the hospital in bed, even when they are able to walk independently,” she says. “This is a major risk factor for functional decline.”
Ethan Cumbler, MD, FACP, a hospitalist and director of the Acute Care for the Elderly Service of The University of Colorado Hospital in Denver, explains that his institution has addressed this issue using a dedicated order set for geriatric patients admitted anywhere in the hospital. The order set guides clinicians toward encouraging mobility.
“The order set defaults to ambulation three times a day with nursing supervision,” he says. “In fact, it does not include an option for bed rest. Therefore, a physician would have to manually enter a bed rest order, making supervised exercise the path of least resistance.”
3 Follow the Choosing Wisely guidelines set forth by the American Geriatrics Society.
Susan Parks, MD, associate professor and director, division of geriatric medicine and palliative care, Thomas Jefferson University Hospital, Philadelphia, points to the 10 recommendations developed by the American Geriatrics Society for the care of geriatric patients as an excellent reference for hospitalists treating the elderly.
Is it common for geriatricians not to make rounds on their elderly hospitalized patients and to leave their care to the hospitalist? Wouldn’t this create panic in the patient to be cared for face-to-face by a doctor who is unknown to the patient and whom the hospitalist does not know?