Attendees at the session “Managing Hospitalized Elders,” presented by Robert Palmer, MD, MPH, head of the section of Geriatric Medicine at Cleveland Clinic in Ohio, gained insights into the unique dangers hospitalization presents to their oldest patients.
“As every hospital-based physician knows, increasingly, hospital care is geriatric care,” said Dr. Palmer. “We’re seeing not only more people over 65, we’re seeing more people over age 85—the most complex and challenging cases. The question is, how do we work our way through the chronic diseases, the acute on top of chronic disease, deal with the psychosocial issues and family issues of the frail elderly person during hospitalization.”
The problem is that simply being hospitalized may trigger or exacerbate a functional decline in an elderly patient. Hospitalization itself can lead to delirium, undernutrition, immobility, pressure ulcers, incontinence, and ultimately placement in a nursing home.
“The process of care, a hostile environment, bed rest, starvation, medications—especially those that are inappropriate for use with older people—and depression all conspire to create a dysfunctional older person,” stressed Dr. Palmer. Common co-morbid conditions in the elderly include dehydration, chronic obstructive pulmonary disease (COPD), hypertension, chronic heart failure, diabetes, and anemia.
“We rarely treat these patients for just one condition,” Dr. Palmer pointed out.
Common Geriatric Syndromes
Common clinical presentations in elderly hospitalized patients include dysfunction, delirium, depression, and dementia.
“Some well-designed cohort studies show that 20% to 32% of these patients lose independent performance of one or more basic activities of daily living [ADL] at discharge,” said Dr. Palmer. Basic ADLs include bathing, dressing, moving from bed to chair, using the toilet, and eating. Why is this important? Patients admitted who were dependent in all six basic ADLs were at greater risk for in-hospital mortality or one-year mortality, 90-day nursing home use, and up to 50% higher DRG hospital costs.
“Not all older patients are at risk,” Dr. Palmer assured his audience. Risk factors for functional decline to watch for include patients over 75, those who are cognitively impaired, those dependent in two or more instrumental ADLs (shopping, housekeeping, taking medications), depression, and pressure ulcers.
—Robert Palmer, MD, MPH, head of the section of Geriatric Medicine at Cleveland Clinic in Ohio
Focus on Delirium
Dr. Palmer paid special attention to delirium.
“This is the most risky syndrome during hospitalization,” he warned. Delirium, or the acute decline of attention and cognition, can be called several things: acute confusional state, acute change in mental state, metabolic encephalopathy, toxic encephalopathy, acute brain syndrome, or acute toxic psychosis.
However it is categorized, delirium is found in 10% to 15% of hospitalized elders upon admission, and 10% to 15% of elderly patients develop it after admission. In ICUs, 70% to 84% of elderly patients suffer from delirium.
What causes delirium during hospitalization? Risk factors include severe illness, dementia, dehydration, sensory impairments (trouble hearing or seeing), and psychoactive medications. Identifiable precipitants of delirium are the use of physical restraints, malnutrition, the addition of three or more new medications, use of a bladder catheter, and any iatrogenic event.
“The major concern with delirium is the increased risk of mortality,” said Dr. Palmer. “But it also leads to prolonged length of stay, increased costs, and potential nursing home placement upon discharge.”
Diagnosing delirium versus dementia is based on four factors:
- The onset of confusion is abrupt with delirium and gradual for the early stages of dementia;
- Consciousness is fluctuating and clouded with delirium; with dementia it’s not affected;
- Attention span will be reduced with delirium but not with dementia; and
- A delirious patient will show hyperactive or hypoactive psychomotor changes, whereas this change will not show in early stages of dementia.
When evaluating for delirium, search for the cause and any possible precipitating factors, advised Dr. Palmer: “Consider multiple etiologies, and remember that fluctuation in the course is the rule.” Eliminating precipitating factors can help. Evaluation should include a targeted history and physical, and lab work to check things like drug levels and neuroimaging.
You may be able to manage delirium with nonpharmacologic changes in environment such as adding orienting stimuli of clocks, TV, and personal items; minimizing abrupt relocations; and sitting the patient in an upright position. You can also increase sensory input, said Dr. Palmer. You may also try a short course of meds: For severe agitation, haloperidol (0.5 to 1 mg every four hours as needed) or for anxiety symptoms use lorazepam (0.5 to 1 mg every four to six hours as needed).
Dr. Palmer offered a partial list of medications to avoid for elderly patients. “These patients are very vulnerable to bad outcomes,” he warned. His list included:
- Trimethobenzamide; and
- Famotidine (high dose).
Additionally, you should be aware that the following classes of drugs could cause delirium in the elderly:
- Antianxiety medications;
- Antipsychotics; and
- Anti-inflammatory medications.
“Basically, any pharmacological class that begins with ‘anti’ should be avoided with elderly patients,” said Dr. Palmer.
Assess and Manage Undernutrition
An astonishing 40% to 60% of hospitalized, ill elderly patients suffer from malnutrition.
“This is often not diagnosed or adequately treated,” said Dr. Palmer. “It’s associated with terrible outcomes of hospital care, including length of stay, mortality, and affected ADL activities.”
There is no single blood test for malnutrition, Dr. Palmer continued, but indicators include a body mass index of less than 19, reduced muscle mass, reduced skin fold thickness, and biochemical measures including serum albumin of less than three and low hemoglobin and serum cholesterol.
To guard against dehydration and undernutrition in your elderly patients, Dr. Palmer advised assessing nutritional status at admission, prescribing and monitoring daily calorie and fluid intake for high-risk patients, giving priority to providing calories over restricted diet, and including consultation with a dietitian.
Take off the Restraints
“Why do we order bed rest for the weak and sick?” asked Dr. Palmer. He urged hospitalists to avoid bed-rest orders and instead encourage elderly patients to get out of bed and get physical activity or even physical therapy for transfer-dependent and gait-impaired patients.
Most of all, he said, “Avoid physical restraints.” These limit mobility, obviously, and can lead to pressure ulcers, deconditioning, falls, constipation, and incontinence.
Where to Send the Patient
Plan for discharging an independent elderly patient back home, not to a nursing home if you can, urged Dr. Palmer.
“Comprehensive discharge planning almost always requires an interdisciplinary team,” he said. “Goals of care and advanced directives should be discussed with the patient and family members, and post acute care needs should be considered.”
Following a “functional trajectory” from admission to discharge begins the first day. Dr. Palmer recommends the hospitalist, a nurse, and the case manager all interview the patient and family, establish a baseline and outline the expected hospital course including estimated length of stay and discharge site—nursing home, skilled nursing facility, or home.
“Work with physical or occupational therapy early to mobilize the patient and improve their functioning,” advised Dr. Palmer.
This type of comprehensive discharge planning, along with home follow-up, has reduced readmission rates. TH