The Hazards of Hospitalization Geriatric medicine and care of the older patient George Heckman MD...
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Transcript of The Hazards of Hospitalization Geriatric medicine and care of the older patient George Heckman MD...
The Hazards of Hospitalization
Geriatric medicine and care of the older patient
George Heckman MD FRCPC
August 9, 2004
Objectives
How can hospitalization be bad for older persons? The interaction between Frailty and Hospital care
Delirium: How hospital care fails the elderly Geriatric medicine
What is Geriatric Medicine? What is a Geriatrician? Why aren’t there enough?
What can you do? Reading list
Frailty
Why some older persons are more susceptible than others
Frailty: Not just advanced age
Susceptibility to adverse health outcomes Death Hospitalization Functional decline Falls Caregiver burden Atypical or unusual symptoms
Frailty more common with age
Rockwood Drugs&Aging2000; Rockwood CMAJ 1994
Aging and hospitalization
With age, changes affect Muscles Blood pressure control Lung function Bone strength Bladder control Skin Nutrition Cognition
Muscles Aging: loss of muscle mass, strength, and
energy efficiency Hospital: Bed rest, restraints, tethers Effect
5% loss of strength per day Joints tighten up
Consequences Loss of independence in daily tasks, e.g. bathing Falls and related injuries Need 3+ rehab days for 1 day immobility
Blood Pressure Control Aging
Impaired sensing of postural changes Less thirst drive Less water retention by kidneys
Hospital: bed rest makes this worse Effect: Dizziness when standing Consequences
Falls and related injuries
Lung function Aging: Stiffer rib cage reducing
ventilation Hospital: Bed rest further reduces
ventilation Effect: Reduced oxygen levels in blood Consequences: especially if lungs
already diseased Dizziness (leading to falls and injuries) Oxygen supplements (leading to bed rest) Confusion
Bone Strength
Aging: Osteoporosis common Hospital:
Bed rest Poor nutrition
Effect: Accelerated bone loss (up to 50-fold) begins within 10 days
Consequences Increased fracture risk (hip, spine)
Bladder Control Aging:
Reduced bladder capacity, “Twitchy” bladder Prostate enlargement Pelvis floor relaxation, menopause
Hospital: Bed rest, bed rails, restraints, tethers, unfamiliar environment
Effect: Loss of muscle strength Inability to get to or find bathroom
Consequence: Up to 50% incontinence rate within one day
Skin integrity Aging:
Thinner skin, less fat “padding” Poorer blood supply Slower rate of skin cell replacement
Hospital: Bed rest, Shearing, Incontinence
Effect: Increased pressure on buttocks, heals cuts off blood flow
Consequences: Skin ulcers Infection
Nutrition Aging:
Loss of taste, smell, thirst Dentition: dependence on dentures
Hospital: Food may be less appealing Access: bedrails, restraints Illness reduces appetite, increases calorie needs
Effect: Malnutrition, dehydration Consequences:
Loss of muscle strength, bone strength Dizziness, confusion Slower healing
Hospitalization and Cognition
Delirium as a reflection of poor hospital care
What is delirium?
Acquired disorder of cognition Rapid onset Fluctuates Clouding of consciousness Inability to pay attention and
concentrate Triggered by illness, medications, drugs Usually reversible
Dementia
Delirium
Time
Delirium is NOT Dementia …
DementiaDelirium
Time
…but more likely if demented
The delirium syndrome
Prevalence, features, risk factors, outcome
Epidemiology Elderly hospitalized medical patients
15-25% at presentation 5-20% develop in hospital
Surgical patients: 10-60% Terminal illness: 80% Community, nursing home ???
Rockwood Oxford Textbook of Geriatrics 2000; Fisher JAGS 1995;
Massie Am J Psychiatry 1983
Clinical features
… The body’s delicate; the tempest in my mind doth from my senses take all feeling …
Shakespeare, King Lear, Act III, Scene IV
The Early Phases
Develops over hours to days Restlessness Trouble sleeping Anxiety Irritability Person may complain of confusion
Working group on delirium Am J Psychiatry 1998
Full-blown delirium Cannot concentrate
Disorganized, rambling, irrelevant conversation
Altered level of consciousness Agitated (25%) Lethargic, sedated (25%) Mixed, fluctuating (50%)
Psychosis: up to 90% Hallucinations, paranoia
Sandberg J Am Geriatr Soc 1999
Fluctuation
Symptoms wax and wane during day May even have lucid intervals
Some patients may actually remember being delirious
Sundown: worse in evening, night
Risk factors
Predisposing and precipitating
Predisposing factors
Impaired vision , hearing
Severe illness Impaired cognition Dehydration Advanced age Number of other
illnesses
Frailty Alcoholism Depression Certain medications Sleep deprivation Immobility
Precipitating factors
Restraints Malnutrition > 3 new drugs Bladder catheter Complications of
treatment Surgery
Anaesthetic Trauma Medication
withdrawal Environmental
changes Metabolic
disturbance Any acute illness
Model of deliriumPredisposing factors Precipitating factors High vulnerability Noxious insult
Low vulnerability Less noxious insult
Adapted from Inouye JAMA 1996
Duration and consequences Average 10-12 days
May frequently persist beyond one month Short term consequences
Prolonged hospital stay Loss of independence, nursing home placement Death
Long-term consequences Loss of independence, nursing home placement Death Dementia?
Care providers spend less time with the elderly, especially when confused
Delirium can be prevented
HELP is on the way!
Hospitalized Elder Life Program Dr. Sharon Inouye, Geriatrician from Yale University
Risk factor Intervention Outcome
Impaired cognition Orientation protocol Orientation score
Sleep deprivation Sleep protocol Sedative use
Immobility Early mobilization, least restraints
Activities of daily living score
Visual impairment Visual aids, adaptive equipment
Vision correction
Hearing impairment Wax disimpaction, amplifying devices
Whisper in the ear test
Dehydration Screening and repletion
Blood tests of kidney function
Effectiveness of the HELP Program in older hospitalized medical patients
Reduced risk of delirium by 40% days of delirium by 35% sedative use by 24%
Cost-effective for moderate risk group Significant contamination:
Intervention likely more powerful in typical hospital
Geriatrician back-up for complex patients
Preventing bad outcomes from hospitalization of the frail elderly
Intimately related to quality of hospital care Nutrition Dehydration Immobilization
Insufficient physiotherapy resources, restraints, bladder catheters, bed rest
Sleep deprivation Unnecessary medications
Delirium prevention: Summary
HELP demonstrates that simple, low-tech attention to hospital care can have a tremendous impact on patient outcomes
Keys to a successful program Heavy volunteer commitment Modifications to the hospital environment
ACTIVE LOBBYING BY STAKEHOLDERS As family members of hospitalized persons As potentially hospitalized persons who have a
vote
Where do geriatricians fit in?
For that matter, what IS a geriatrician?
What is a geriatrician?
A physician specialized in the care of the frail elderly who are at risk for Institutionalization Loss of independence Caregiver stress and burn-out Hospitalization Death
The Epidemic of Frailty
Our population is aging In the community, disability reported by
>50 % of adults over 65 >70% of adults over 75
Lifetime risk of needing a nursing home is 40-50%
Geriatricians can improve patient outcomes at all levels of frailty
Geriatrician training
3 to 4 years of undergraduate studies 3 to 4 years of medical school Care of the Elderly Family doctors
3 years of residency Specialist geriatricians
3 years of General Internal Medicine 2 years of Geriatric Medicine
9 to13 years of training
What do we do?
Clinical care Outpatient Clinics Hospital Retirement and nursing homes Usually over 65, but not exclusively
Research: Dr. Inouye Education Advocacy
Who do we see?Geriatric Syndromes
Confusion Falls Loss of independence Incontinence Depression Multiple medical problems and medications Elder abuse Caregiver burden Some or all of the above in the same person
Why are geriatricians needed?
Such syndromes are too often dismissed as normal aging By doctors By nurses By patients and families By the community at large
Often there are one or more correctable causes
How?Comprehensive Geriatric Assessment
A thorough and holistic assessment that aims to reverse and optimize medical, psychological, environmental, and social factors that contribute to Geriatric Syndromes
Requires 75 to 90 minutes+
Goals and outcomes
Reduce caregiver stress Improve and maintain function Improve and maintain cognition Reduce falls Prevent or delay (or facilitate) nursing
home placement Improve quality of life
Geriatric medicine sounds good …
… but there’s a problem …
The geriatrician shortage
British and Canadian standards suggest that 180 to 200 geriatricians are needed for Ontario
There are approximately 75 Why?
Current GeriatriciansPractice Patterns
Recent survey (38 replies) 12 (32%) graduated before 1980 30 (79%) urban University affiliated
20 (53%) do not practice full-time geriatrics 15 unable to financially sustain full-time geriatrics
42% of Care of the Elderly family physicians are unable to sustain full-time geriatrics
Geriatric nurses 71% of geriatricians have one Facilitates seeing more patients 90% of geriatricians cannot afford his/her salary
Funding for Geriatric Medicine
Fee-for-service funding does not recognize that Comprehensive Geriatric Assessment
takes time Counseling and educating patients and
health care workers takes time Coordinating services and agencies by
phones takes time Team meetings are intrinsic to the practise
Take time
A Specialty at risk
Many geriatricians approaching retirement age
Recruitment dwindling 3 in Canada this year Rising student debts OHIP insufficient to sustain practice Recent decision limited salaries to
University centers (70% of geriatricians) 70% of Ontario Seniors live elsewhere
Case study
Dr. K. Specialist Geriatrician in South Central Ontario Pure fee-for-service Practise expenses Has to pay for nurse and part-time clerical Worked out of nurse’s living room Worked 6 days a week Had to quit: no take-home pay
Temporary salary support has been found
Geriatrician shortage
Geriatricians are the core of specialized geriatric services Directly provide care Educate others
Shortage creates barrier to access, especially for Seniors living away from University Centres
Closing thoughts
What can you do …
Summary
Hospitals are designed to deal with acute illness, not frailty
There are things you can expect and do With now have strong evidence that
“back to basics” nursing care works Geriatricians can help the frail elderly
But more are needed
… if an elderly relative is hospitalized? Get involved and be pro-active
Expect to be at the bed-side, especially if delirious
Make sure they are getting Fluids, Food Glasses and hearing aids
Ask to look at medications Why gravol? Why sleeping pills? Why sedatives? Ask for alternative sleep aids
If an elderly relative is hospitalized … Insist on early mobilization and physiotherapy
If they can’t walk, use massage or in-bed stretches Avoid restraints unless absolutely necessary
Talk to them, read the paper, play cards Make sure you also get clear discharge
instructions regarding follow-up, treatments Don’t let them be discharged if you are not
comfortable or unable to look after them Ask for referral to a geriatrician if you are
concerned
… as a tax-paying voter
Get informed (see reading list) Lobby
Individually, or as a group
Need more Geriatricians Gerontological nurses and nurse practitioners Physiotherapists Home care
Lobby for elderly-friendly programs like HELP
… as a concerned Senior
Lobby for mandatory geriatric medicine rotations Medical school Royal College of Physicians and Surgeons
of Canada
Consider forming a Canadian Seniors Lobby group
… as a potentially frail Senior
Eat well Stay active
Exercise your body Exercise your mind Remain socially engaged
Get informed about your health Control your risk factors: heart, cancer Screening Immunizations
Reading list
Prescription for Excellence: How Innovation is saving Canada’s Health Care System, by Michael Rachlis MD, Harper Collins 2004.
Sharon K. Inouye et al. Delirium: A symptom of how hospital care is failing older persons and a window of opportunity to improve quality of hospital care. Am J Med 1999;106:565.
John A. Rizzo et al. Multicomponent targeted intervention to prevent delirium in hospitalized older patients: What is the economic value? Medical Care 2001;39:740.
Stay well!
Thank you