Hospitalization can be risky business for geriatric patients. Americans 65 and older make up 13% of the population but account for 48% of inpatient days of care and 78% of hospital deaths. While in the hospital, patients 75 and older are at high risk for deconditioning and functional decline, medication errors, delirium, and falls.1,2
For geriatric patients not closely monitored, notes geriatrician Don Murphy, MD, co-principal of Senior Care of Colorado, a large primary care geriatrics group in Denver, going to the hospital can be like disappearing into a black hole.
As the U.S. population ages, hospitalists will be caring for an increasing number of geriatric patients. They will have to address patients’ acute medical conditions without compromising their functional status.
The Hospitalist asked several leading geriatricians to identify valuable tools and strategies for delivering comprehensive geriatric care in the hospital. Even in the absence of formal geriatric care units, they say, hospitalists are positioned for adopting the principles of quality geriatric care. Many of those principles align with the central mission of hospital medicine: promoting high-quality, patient-centered care, working as a team, and developing clear lines of communication between the hospitalist and the primary care teams.
A Survey of Interventions
“There’s no question that it’s becoming extraordinarily difficult to do good care,” says John Morley, MD, professor of medicine and chief of the Division of Geriatrics and Endocrinology at Saint Louis University Health Sciences Center in Missouri. “Taking care of an older person in the hospital is a team sport—the physician can’t do it alone.”
It’s clear the team approach is a crucial foundation for interventions that target at-risk geriatric patients, agrees Edgar Pierluissi, MD, associate clinical professor of medicine and medical director of the recently established ACE unit at San Francisco General Hospital. Reducing the incidence of delirium, for instance, cannot be accomplished simply by utilizing a geriatric consultation. Once established, acute confusion can be intractable. “The idea is to try to prevent delirium, and research has shown that single-person types of interventions in these massively impervious-to-change facilities don’t work,” he says.
Clinical trials have demonstrated that interventions, including interdisciplinary and collaborative teams, targeted patient-centered therapies, and comprehensive geriatric assessment can improve outcomes of hospitalization in geriatric patients. Four major interventions include:
- Acute Care for Elders (ACE) units based on interdisciplinary team rounds, discharge planning, and medical review in a prepared environment to foster patient self-care and improve function. Randomized clinical trials have shown ACE units can reduce the length of stay, the risk of nursing home admissions, and the use of physical restraints while improving providers’ satisfaction with patient care.3,4
- The Hospital Elder Life Program (HELP), led by a geriatrics resource nurse, is an intervention designed to reduce the incidence of delirium by adjusting environmental elements, such as dimming lights and keeping the floor quiet at night. HELP also introduces non-pharmacologic interventions, including massages and warm tea at night and promotes mobility and hydration during the day.
- Incidence of delirium is reduced and cost savings are realized using the HELP.5 (Visit http://elderlife.med.yale.edu/public for more information.)
- Geriatric Evaluation and Management (GEM) units also emphasize a multidisciplinary comprehensive approach using geriatrician-led teams. The intervention can reduce long-term costs, while improving physical functioning and general health domains in the SF-36.6
- Use of advanced practice nurses in comprehensive discharge planning interventions, including nursing home visits for older patients with risk factors for poor outcomes post-discharge, has been shown to reduce readmissions.7
Assessment Is the Bottom Line
Robert Palmer, MD, head of the Section of Geriatric Medicine and professor of medicine at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University in Ohio, is known for his work with ACE units. He and his colleagues have tracked patients following discharge and have identified the highest priority issues that should be addressed to avoid deleterious geriatric syndromes in the hospital. Although he advocates what he calls a minimalist approach to conducting a geriatric assessment, Dr. Palmer underlines the idea that it must also be a deliberate and structured approach. Assessing and acting upon key indicators in four to five major domains, he notes, can make a big difference for patients’ hospital trajectories.8 Here are a few domains to consider:
1 Focus on activities of daily living (ADLs). Function and performance of ADLs can predict post-hospital outcome and help the physician prioritize elements of the patient’s trajectory and goals while in the hospital. “If a person was able to independently bathe, dress, toilet, walk, and transfer—from bed to chair, for instance—before the acute illness, then he or she should be able to get back to that point after the illness has been treated,” says Dr. Palmer. The ability to transfer independently is an important predictor of discharge status because if the patient requires assistance to transfer, he or she will need a different level of care upon discharge. The hospitalist should seek information —from the patient, family member or primary caregiver, or primary care physician—about the patient’s ADLs before he or she got sick. Again, recovery of ADLs may be possible if the patient was performing these independently before the acute episode.
2 Cognitive assessments are also key. Dr. Morley places assessment for delirium at the top of his list. Research shows that approximately one third of patients over 70 in the hospital will develop the condition. Delirium, or acute confusion, is also a predictor of decline in ADLs, notes Dr. Palmer. Dr. Morley recommends the use of the Confusion Assessment Method (CAM) because the Mini Mental State Exam can be time-consuming. (A CAM form is available free online as part of SHM’s “Clinical Toolbox for Geriatric Care.” Go to www.hospitalmedicine.org, click on “Resource Center” and then “Geriatric Special Interest Area” to find the Toolbox.) According to Dr. Palmer, the physician should also use common sense when initially examining the patient: Observe whether the patient is confused, distracted, or inappropriate in conversation. If so, the next step is to use the simple Digit Span test: Say a random set of four to five numbers, and ask the patient to repeat them. Inability to do this is consistent with delirium as a cause of cognitive impairment.
For assessing cognitive impairment, Dr. Morley prefers the St. Louis University Mental Status Exam (SLUMS) to the Mini Mental Status Exam. The SLUMS, developed in collaboration with the Department of Veterans Affairs (and available free online at: http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf) successfully picks up even mild cognitive impairment, according to Dr. Morley. This is important information not just for the hospital trajectory but also for discharge planning: Inability to follow discharge instructions due to cognitive impairment could result in a readmission.
3 Malnutrition is associated with mortality. Dr. Morley uses the four questions of the Simplified Nutrition Assessment Questionnaire (SNAQ), which correlate well with future weight loss and poor outcomes.9
If the SNAQ is positive, the use of a lengthier questionnaire may be warranted. Dr. Palmer suggests that a review of the patient’s comprehensive metabolic panel to judge kidney and liver function and a bedside evaluation using the Subjective Global Assessment (SGA) can yield results just as usable as the more complex and time-consuming textbook nutritional assessments.
4 Mood and affect also play a role in patients’ outcomes. Research has shown that depressed patients have poor outcomes, so physicians should always assess for depression. While the Geriatric Depression Scale (see “Clinical Toolbox for Geriatric Care” on the SHM Web site) can help quantify the extent of the patient’s symptoms, simply asking the patient, “Are you depressed, sad, or blue?” can often elicit enough information about the patient’s psychological status to direct interventions.
5 Mobility is sometimes classified as a stand-alone domain. However, walking and balance may be included in the assessment of ADLs. A patient who can walk independently—even with a cane or a walker—has a good chance to return home, says Dr. Palmer. Requiring another person to help with walking most likely indicates the patient will need short-term rehabilitation in a skilled nursing facility before returning home.
6 Social and living situation are important. The physician must identify the extent and quality of the patient’s support network. If, for instance, a patient has mild dementia but has a network of 10 extended family members who act as caregivers, discharge to home may be possible. If the patient was admitted to the hospital from a nursing home, however, it is most likely he or she will return there.
Revisit Daily Goals
Dr. Palmer advises hospitalists to follow the geriatric assessment with a translation of the information into what he calls a functional trajectory for the patient’s hospital stay. This includes an estimate of the patient’s anticipated length of stay and the expected discharge site. Interventions and consultations from allied health providers will be keyed to the patient’s individualized needs and to the goals of the functional trajectory.
To head off problems, Dr. Palmer advocates consultations from allied health professionals early in the hospital trajectory. For instance, if the patient is having trouble transferring from bed to chair upon admission, a consult with physical therapy may be warranted immediately rather than right before discharge, as is usually the case.
“We should not be depending on physical therapists at the end of hospitalization, when patients are already deconditioned and can’t get out of bed and need to go to a nursing home,” he explains. “The ideal time to bring in the physical therapist or technician is when you’ve identified—on day one—that the patient needs assistance with transfers, so that you can preserve mobility and shorten hospital stay.”
In the same vein, knowing the patient’s living situation will allow involvement of the discharge planner from day one of the hospitalization to plan with the patient or family for the patient’s return to home or to an alternate site. If the patient has been on a complex drug regimen, involving the pharmacist to help straighten out medications can head off potential drug-drug interactions. (SHM’s Geriatric Toolbox also has a list of medications to avoid in geriatric patients.)
It is important to review the functional trajectory on a daily basis. Input from other members of the health team will be invaluable. “Each day you identify barriers to that successful plan of the outcome, and you take care of them one at a time,” says Dr. Palmer. “If the patient is not on track with that daily goal, the team goes back to the drawing board and asks, ‘What are we missing here?’ Then you do a reassessment of ADLs, nutrition, and cognition.”
Hospitalists must also include the patient’s family members and primary caregivers as the patient moves toward discharge, asserts Dr. Morley. Clear, unambiguous written instructions must always be given to the patient or the primary caregiver when the patient leaves the hospital. (You can also find a discharge instruction sheet in SHM’s Toolbox.) If a patient appears to be facing the end of life, the hospitalist should schedule a conference with members of the primary care team, the hospitalist team, and all family stakeholders.
Some experts maintain that quality care for geriatric patients can be accomplished without a specialized geriatrics unit.
“I never conceived of the ACE intervention as being done exclusively on a unit,” says Dr. Palmer. “The idea was to develop the skills on a unit and then transport those skills to all units.” Although the protocols developed for ACE units are good for teaching, he says the team has been the key.
Dr. Morley agrees: “It’s not the physical part of the ACE unit that works. You must have team interactions. Finding a way to communicate between the different team members is absolutely key to good outcomes.”
Involving healthcare providers from different disciplines only enhances the care of geriatric patients. “Even though hospitalists may not have the depth of knowledge of geriatrics that a geriatrician has, they certainly have the knowledge of acute care medicine that we have, so they can manage the medical problems,” says Dr. Palmer. “What they need to do is think systematically, in a structured way, and to work collaboratively with key players. This only takes a few minutes each day, but more importantly, it saves time. You have fewer phone calls and fewer angry family members when you manage the care in a structured manner, working with a team of health professionals.”
Dr. Morley and his team have developed a form for their ACE unit that allows them to assess a patient’s status and goals in two to three minutes.
Dr. Pierluissi has experienced firsthand the benefits of working as a member of the interdisciplinary team. “Essentially,” he says, working in teams to treat the geriatric patient means there are “more heads in the game, more people trying to work in the patient’s best interest. You [the clinician] really do feel supported, and it makes your day more enjoyable and more productive.” TH
Gretchen Henkel is a medical journalist based in California.
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