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.