by Matt Rosenberg August 24th, 2011
SUMMARY: Doctors are seeing a growing percentage of elderly hospitalized patients, who often have special and potentially costly needs. The risks to elderly patients from hospitalization and related procedures are significant: surgical complications, surgical site and urinary tract infections, adverse drug reactions, pressure ulcers, fractures and falls. But most groups of “hospitalists” – typically internists, who care for hospitalized patients – don’t have programs or procedures addressing the special needs of elderly patients. In a paper recently published in The Journal of Hospital Medicine, three doctors from the University of Washington in Seattle reviewed 80 papers in the current literature and make recommendations for better, more attuned in-hospital care of the elderly.
Their recommendations include creating safer physical environments in the hospital rooms of elderly patients; using “Acute Care of The Elderly” unit strategies such as physical and occupational therapy, early mobility, regular exercise and early discharge planning; decreasing reliance on prescription drugs, where feasible; using a more thorough and holistic approach to screening and treating risk of falls; and screening patients for delirium and dementia and factoring those conditions into therapies and interventions.
KEY LINK: “Ten Ways To Improve The Care of Elderly Patients In The Hospital,” Journal of Hospital Medicine, July 2011. Authors: Susan Eva Merel, MD and Angelena Maria Labella MD – University of Washington Department of Medicine, Division of General internal Medicine; Elizabeth Anne Phelan, MD, MS, University of Washington Department of Medicine, Division of Gerontology and Geriatric Medicine, and School of Public Health, Department of Health Services.
Selected highlights follow.
“Acute Care of The Elderly” approaches recommended. Along with medical risks, hospitalization for elderly patients with a poor prognosis can accelerate decline in abilities to handle basic tasks such as bathing, feeding, using the toilet and physical mobility, and in independent skills such as cooking, shopping, personal finance and public transportation. More hospitals should adopt at least the basic strategies of so-called “Acute Care of the Elderly” units, including physical and occupational therapy, early mobility, regular exercise and early discharge planning. Discharge planning for hospitalized elderly patients must routinely include written instructions, involvement of family, and follow-up calls and visits by “transition coaches” or advanced practice nurses.
Re-evaluate prescription drug regimens. An estimated 30 percent of hospital admissions of elderly patients result from adverse drug reactions. Hospitalists should make sure to review prescriptions of all new elderly patients, and discuss with the primary care provider what if any drugs should be dropped or reduced in dosage. Hospitalists should also find out whether the patient has previously been taking all medications as prescribed. There are at least 11 medications identified as to be avoided or prescribed with caution for elderly patients, because they can, variously, increase the risk of delirium, falls, kidney problems, gastrointestinal bleeding, severe constipation, agitation and sleep disturbance.
Treat pain promptly and aggressively. Too often, pain of hospitalized elderly patients is under-treated and this can heighten the risk of delirium, delay rehabilitation, and increase health care costs. Non-steroidal anti-inflammatry drugs often used for pain carry significant risks of adverse reactions. To treat pain hospitalists generally should use acetaminophen first and then if needed, consider low-dosages of opioids such as oxycodone.
Smart screening for risk factors related to falls. Often, screening for risk of falls focuses on physiological factors and uses costlier diagnostic procedures such as echocardiogram and neurologic workup. A geriatric approach looks at risk factors such as leg weakness, recency of falls, prevalence of falls when moving from one resting place to another, and poor lighting at home; and prescribes interventions such as strength training, assistive devices when transferring, and home safety assessment and installation of additional lights.
Safer environments for elderly hospital patients. Other important interventions to reduce the risk of falls by hospitalized elderly patients are environmental changes including low beds, cushioned floor mats, bedside posters and educational materials, and exercise. In addition, Vitamin D supplements of 700 to 1,000 I.U. per day can reduce risk of falls in the elderly, as can reduction in psychoactive medications, diuretics and blood pressure agents.
Know delirium risk factors, and accent screening, prevention and proper treatment. Delirium can occur in up to 60 percent of elderly hospital patients with multiple risk factors. It often is triggered by an acute illness such as an infection or heart attack, manifests itself with confusion, and can heighten the risks of injury in a hospital, such as a patient deciding suddenly to get out of bed and slipping and falling. Multiple drug prescriptions, pre-existing cognitive impairment over age 65, inability to take care of one’s self, and loss of some sensory capabilities increase risk of delirium. While usually acute, delirium can often be reversed. Hospitalists need to be attuned to prevention strategies such as regular sleep-wake cycles, frequent reorientation, movement from early on, adequate nutrition and liquids, and regular use of glasses and hearing aids. Delirium can often require patient discharge to a more closely supervised setting such as a nursing home.
Recognize dementia and factor it in to decisions on other medical interventions. Dementia is a chronic, progressive, fatal disease including Alzheimer’s dementia, Parkinson’s dementia and vascular dementia. Significant memory deficits are one manifestation, as are impaired judgement or language. Hospitalists need to recognize dementia in its early or mild forms, and learn from family “how the patient is managing at home so that appropriate discharge plans can be made.” Surgery or invasive procedures should be evaluated very carefully for patients with dementia, factoring in their remaining life expectancy, heightened risk for post-operative delirium, and possible challenges complying with directions for after surgery and rehabilitation. A short screening test developed by a University of Washington doctor called the “Mini-Cog” can help hospitalists determine whether a cognitively impaired new elderly hospital patient has dementia or not.
RELATED: Information on delirium, for older adults and caregivers, Hospital Elder Life Program.
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