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: