Care of the Hospitalized
Geriatric Patient
Ethan Cumbler MD, FACP
Associate Professor of Medicine
Director UCH Acute Care For Elderly Service
University of Colorado Denver
2010
Disclosures: The speaker has no conflicts of interest to disclose
Objectives
Recognize patients at highest risk for hazards of
hospitalization such as delirium and falls using
simple evidence based screening tools
Be able to implement elements of an evidence
based prevention protocol for common hazards
of hospitalization
Understand treatment options for delirium
Changing Demographics
In 2000 about 1 in 8 Americans was over age 65.
By 2030 it will be 1 in 5
Hospitalization is a time of critical risk for the
elderly
We can do better
Current State of Affairs
Majority of inpatient geriatric care is provided by
physicians without specific training in geriatrics.
Only 7,000 Geriatricians
30,000 Hospitalists
Hospital communications silos inhibit recognition
and treatment of new geriatric syndromes
Physician often the last to know about barriers
Physical
Social
Financial
Outpatient caregivers not involved
What Explains the Status Quo?
Barriers to Change
Vulnerable elderly dispersed across teams and within hospitals
Traditional closed ACE units proven successful but not widely
implemented due to increased resource commitments
Geriatric issues considered less vital than “admit diagnosis”
Solutions require interdisciplinary approach
– Team infrastructure inadequate
Focus can be on “more” rather than making it easy to do “right”
Hazards of Hospitalization
High Risk
Patient
Transition
Failure
Falls
Pressure
ulcers
Delirium
HAZARD
Functional
decline
High Risk
Environment
Adverse
drug
events
High Risk
Situation
There are Some Who
Think the Hospital Is a
Fancy Hotel
A Modest Proposal
System change is required
– Geographic concentration
– Standardized assessment
– Standardized care protocols
– Interdisciplinary care
Acute Care for the Elderly Service
Brief Geriatric Assessment
Ideal Geriatric
Assessment
–
–
–
–
Fast
Tolerated by patients
Provide new information
Leads to new action
Confusion Assessment
Method (CAM)
Mini-Cog
Vulnerable Elders Survey
2 Q Depression Screen
Sensory Aid Assessment
Falls Screen
Get-Up-and-Go Test
Clinical Case
Gertrude’s Tragic Tale
88 y/o woman admitted
for back pain after a fall
stepping off a curb
outside her assisted living
Xray demonstrates
thoracic compression
fracture.
PMH
– Mild Alzheimer's
Dementia
– Insomnia
– HTN
– Urge incontinence
– Depression
Medications
Admit for pain control,
inability to ambulate.
–
–
–
–
Lisinopril 10mg daily
Aspirin 81 mg daily
Amitryptiline 50mg qhs
Oxybutinin 5mg bid
When Hospitalization is Over….
Will Gertrude be going home?
How do you predict discharge location
on admission?
Assessing Need for Placement
Vulnerable Elders Survey-13
Originally developed to identify
community dwelling elders at risk for
functional decline or death.
10 point score based on:
– Age
– Self reported health status
– Ability to perform six physical tasks and five
activities of daily living.
Saliba D. The Vulnerable Elders Survey: A tool for Identifying Vulnerable Older People in the Community. J Am Geriatr Soc 2001;49:1691-1699
Min LC. Higher Vulnerable Elders Survey Scores Predict Death and Functional Decline in Vulnerable Older People. J Am Geriatr Soc 2006;54:507-511
VES-13
100%
90%
80%
70%
60%
Percent
50%
requiring SNF
40%
30%
20%
10%
0%
80.0%
62.5%
40.0%
30.8%
31.8%
25.0%
16.7%
11.1%
4.1% 0.0%
0
1
0.0%
2
3
4
5
6
7
8
9
10
VES-13 Score
Now validated to predict need for SNF in elderly admissions
Take Home Point
Function PRIOR to admission predicts need for placement
Cumbler E. Vulnerability Assessment on Hospital Admission Predicts Need for Placement upon Discharge for Elderly Patients.
Journal of the American Geriatrics Society 2009; 57:944-946
Gertrude’s Tragic Tale
Gertrude is confused about the timeline of events
Does not remember her home medications
“Honey, I don’t have to know that at my age” when
asked for the year,
– Can spell “WORLD” backwards
Tells you a bright and animated story about her dog
and how funny it was when he ate peanut butter
Is Gertrude Delirious?
Delirium
“Acute onset of disturbance in consciousness
in which cognition or perception is altered”
17%-74% cases unrecognized by nurses
Physicians may do worse
Over reliance on disorientation/inappropriate behavior
More likely to be missed
Hypoactive
Age >80 yrs
Vision impairment
Dementia
Are Nurses Recognizing Delirium? A systematic review. JOGN 2008;34:40-48
Occurrence of Delirium is Severely Underestimated in the ICU during Daily Care. Intensive Care Med 2009
DIAGNOSING DELIRIUM:
The Confusion Assessment Method (CAM)
Patient must demonstrate the following:
Disturbance in Cognition
Acute/Fluctuating
Altered Level of Consciousness
AND
OR
Inattention
Disorganized Thinking
Sensitivity 94-100%, Specificity 90-95%
Positive LR 9.6 , Negative LR 0.16
Inouye SK et al. Ann Intern Med 1990;113:941-948
Wong CL. JAMA. 2010;304:779-786
ASSESSING DELIRIUM RISK
Medical Inpatient Prediction Rule
--Cognitive impairment
--Severe Illness
--High BUN/Cr
--Vision impairment
Inouye, S. Ann Intern Med. 1993;119:474-481
1. Low Risk (0)
10% risk
2. Int. Risk (1-2)
25% risk
3. High Risk (3-4)
80% risk
Assessing Delirium Risk
Mini-Cog
– 3 item recall (ball, justice, tree) (up to 3 pts)
– Clock Draw (10 minutes after 11)
All or nothing-- 0 or 2 pts
0 points
On Admission:
Scores of 0, 1, or 2 carries a 4-5X increased risk for delirium
True regardless of whether the patient has dementia or not
Alagiakrishnan K et al. Simple Cognitive Testing (Mini-Cog) Predicts In-Hospital Delirium in the Elderly. JAGS 2007;55:314-316
DELIRIUM IS COMMON
Affects 20% of hospitalized patients over age 65
– Up to 70-80% of older patients in intensive care
– Up to 83% of older patients at the end-of-life
Affects 36.8% of postoperative patients
– Cataract Surgery 1-3%
– General Surgery 10-15%
– Orthopedic Surgery 28-61%
Miller MO. Evaluation and Management of Delirium in Hospitalized Older Patients. AAFP 2008;78:1265-1270
Mechanism of Delirium
Imbalance of Neurotransmitters
– Acetylcholine 
– Dopamine 
– Others ??
Hypothalamic-pituitary-adrenal axis
Inflammation
– Cytokines (TNF, Interleukins)
Occult diffuse brain injury
Especially following sepsis (ischemic insult)
WHY DO WE CARE
Increased Length of Stay
– By 8 days
Increased Mortality
– Double the mortality in pts with delirium
Functional Decline/NH placement
Prolonged Cognitive Defects
– NEW RESEARCH
1/3 of pts d/c to SNF delirious… will still be delirious 6 months later
Kiely DK, et al. Persistent Delirium Predicts Greater Mortality. JAGS 2009;57:55-61
Miller MO. Evaluation and Management of Delirium in Hospitalized Older Patients. AAFP 2008;78:1265-1270
Delirium Prevention
Modifiable risk factor
Cognitive impairment
Immobility
Visual Impairment
Hearing Impairment
Dehydration
Sleep deprivation
Prospective Intervention






Orienting communication
Early mobilization, reduce restraints
Visual aides, adaptive equip
Amplifiers, adaptive equip
Prevent and correct dehydration
Uninterrupted sleep,
nonpharmacologic aides
40% Relative Risk Reduction
Inouye SK et al. A multicomponent Intervention to Prevent Delirium in Hospitalized Geriatric Patients. NEJM 1999;340:669-676
Vidan MT et al. An Intervention Integrated into Daily Clinical Practice Reduces Incidence of Delirium During Hospitalization in Elderly Patients.
JAGS 2009;57:2029-2036
Sensory Deprivation
One of Hebb's sensory deprivation subjects at McGill.
Declassified 1983 CIA Training Manual
“Deprivation of sensory
stimuli induces stress
and anxiety”
“Some subjects
progressively lose touch
with reality, focus
inwardly, and produce
hallucinations, delusions,
and other pathological
effects”.
1984 revision states:
“Deliberately causing these symptoms is
a serious impropriety”.
Accessed 2/28/09 at http://www.gwu.edu/~nsarchiv/NSAEBB/NSAEBB27/02-02.htm from National Security Archive Database
Sensory Deprivation
One of Hebb's sensory deprivation subjects at McGill.
Sleep Deprivation
Consequences of lack of sleep in healthy volunteers
include impaired attention and irritability
Record for sleep deprivation is approximately 11 days
No longer accepts submissions in this category due
to deleterious health effects
Vital signs
Noise
Illness
Light
Could you sleep?
Pain
Phlebotomy
Drouot X. Sleep in the ICU. Sleep Medicine Reviews 2008;12:391-403
Skin care
Practical Application
Order set as:
-QI tool
-Psychological manipulation
-Establishment of culture
-Time saving device
Gertrude’s Tragic Tale
Diphenhydramine prn for insomnia
An indwelling catheter is placed
Her personal possessions are safely stored in the
closet
Clothing
Glasses
Dentures
Hearing aids.
Maintenance IV fluids, telemetry, and SCDs
Clinical Case
Gertrude’s Tragic Tale
The following morning Gertrude is still sleepy when:
– The intern assesses her at 6:00am
– The nurse assesses her at 8:00am
– The attending assesses her at 10:00am
She sleeps through lunch
Disoriented and inattentive-- not following instructions
She becomes confused
– Trying to get out of bed
– Pulling at her IVs
Is she delirious…..Who knows?
Silos of Care
Have you ever heard
the phrase:
“It seemed like the right
hand didn’t know what
the left hand was doing”
Effective Interdisciplinary
Communication
15 Minute Daily Team “Huddle”
Attendings
Nursing
Physical Therapy
Residents
Occupational Therapy
Interns
Pharmacy
Case Management
Geographic Concentration
Social Work
Volunteers
ENCOURAGING PATIENT INVOLVEMENT
We want you to participate in your care
and be as active as possible while staying safe
Let your team know about any problems or questions.
If you use glasses, hearing aids, or dentures- use them in the hospital just as you do at home.
Your activity care plan will be based on your abilities and illness.
If possible, walk in the hall multiple times each day to keep your strength up.
Eat meals while sitting up, preferably in a chair.
Your physicians will usually come in to see you and discuss
your plan for the day between 9:00am and 11:00 am
feel free to invite family or other people in your life to be part of the care discussion
Your team includes an attending physician responsible for your overall care plan
Ethan Cumbler M.D.
Heidi Wald M.D.
Jeannette Guerrasio M.D.
Jeanie Youngwerth M.D.
Judy Zerzan M.D.
We are interested in your thoughts about your care on the ACE service
After your discharge we welcome you to write your physician at
ACE Service
c/o Hospitalist Section
Anschutz Inpatient Pavilion
12605 E. 16th Ave
Response to Delirium
TESTING
Chem7, CBC, U/A
Troponin, EKG
CXR
TSH, Ammonia, B12, ABG?
LP if fever or neck stiffness
CT/MRI brain if focal neurologic signs or head trauma
EEG if clinical evidence of seizures
Drug levels (Digoxin, anticonvulsants)
Extensive testing of limited value unless driven by a
specific clinical suspicion
Practical Approach
1. Remove Problem Medications
Particularly Anticholinergics, BNZ, and minimize Narcotics
2.
Treat Withdrawal
Alcohol or benzodiazepines
3.
Correct Metabolic Disturbances
Electrolytes, glucose, hydration, ammonia
4.
Reduce Level of Invasion
Indwelling urinary catheters and lines
5.
Assess and Treat Infection
6.
Adequately Treat Pain
Scheduled may be better than prn. Non-narcotic if possible
7.
Improve Environment and Mobility?
Medical Therapy for Delirium
No good evidence that Cholinesterase
Inhibitors (dopepezil) are effective
No good evidence that Benzodiazepines
are effective EXCEPT in alcohol withdrawal
Antipsychotics decrease the degree and
duration of delirium (typical just as good as atypical)
Cholinesterase Inhibitors for Delirium. Cochrane Database of Systematic Reviews 2008
Benzodiazepines for Delirium. Cochrane Database of Systematic Reviews 2009
Antipsychotics for Delirium. Cochrane Database of Systematic Reviews 2007
When All Else Fails…..
ANTIPSYCHOTICS
Typical Antipsychotics (Haloperidol)
Does not prevent delirium when given prophylactically
Extrapyramidal side effects with high doses
Haloperidol 0.25 – 0.5mg PO BID or prn q 4h.
Atypical Antipsychotics (Risperidone, Olanzapine, Quetiapine)
Less QTc prolongation compared to haloperidol
Antipsychotics associated with increased mortality in dementia
--Prolonged QTc
--Lowers seizure threshold
What About Restraints?
Restraint chains used to control mentally ill patients, and documentation
regarding Pennsylvania Hospital's purchase of such restraints in 1751 and 1752.
RESTRAINT USE
Restraints ARE appropriate for behavior that is a
risk to life or to necessary medical care
Restraints associated with significant injuries
Restraints associated with 4 fold increased risk
of delirium
Distraction Vest
Dunn KS. Et al. The effect of physical restraints on fall rates in older adults who are institutionalized. Journal of Gerentol Nurs 2001:27:40-48
Evaluation and Management of the Elderly Postoperative Patient at Risk for Postoperative Delirium. Clin Geriatr Med 2008;24:667-686
Gertrude’s Tragic Tale
She gets out of bed to use bathroom at 2 a.m.
and is found by staff on the floor.
– Urinary catheter still attached to the bed
Her scalp laceration requires staples.
Inpatient Falls
2-12% of patients will have a fall in the hospital
– 30% with minor injury, 4% with major injury
– Associated increased hospital charges ($4233)
– Associated increased LOS (12 days)
Injuries from falls in the hospital are “Never Events”
– Medicare will no longer pay for them
Hospital falls with significant injury are JCAHO reportable
– sentinel events
Falls with injury in the hospital pose malpractice risk
Coussement J, et al. Interventions for Preventing Falls in Acute and Chronic Care Hospitals: A systematic review and meta-analysis.
JAGS 2007;56:29-36
Fall Risk Assessment
How do we as physicians assess a patient’s risk
for this hazard of hospitalization?
A simple falls screen:
– Have you fallen in the last month or are you
afraid of falling?
– Get-Up-And-Go test
You learn a lot about strength, balance, and gait in
30 seconds.
Identifying the High Risk Patient
Risk Factors
Prior fall history
Gait instability
Lower limb weakness
Confusion
Drugs
– Sedative/hypnotics
Urinary incontinence
Oliver D, et al. Risk Factors and Risk Assessment Tools for Falls in Hospital In-patients: A Systematic Review. Age and Ageing 2004;33:122-130
The High Risk Environment
IV drips
Telemetry
Sequential compression devices
Indwelling urinary catheters
Modifying the High Risk
Environment
Physicians unaware of catheter
–
–
–
–
21% for Medical Students
22% for Interns
27% for Residents
38% for Attendings
This is not just about falls
– Iatrogenic infection is a potent hazard of hospitalization
– CMS no longer pays for catheter-associated UTIs
Saint S, et al. Are Physicians Aware of Which of Their Patients Have Indwelling Urinary Catheters. Am J Med 2000;109:476-480
Jain P, et al. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med 1995;155:1425-1429
Modifying High Risk Therapy
Psychoactive Medications
– Antidepressants and neuroleptics
– Benzodiazepines
Lorazepam, Diazepam
Narcotics
– Meperidine
Cardiac medications
– Clonidine, short acting Nifedipine, Doxazosin, Digoxin
Anticholinergic medications
– Diphenhydramine, Amitryptiline, Promethazine, Cyclobenzaprine
– Combinations of medications with partial anticholinergic activity
Prednisolone
Theophyline
Digoxin
Furosemide
Ranitidine
Woolcott JC et al. Metaanalysis of the Impact of 9 Medication Classes on Falls in Elderly Persons. Arch Int Med 2009;169:1952-1960
Fick, D, et al. Updating the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Arch Int Med 2003;163:2716-24
Tune L, et al. Anticholinergic Effects of Drugs Commonly Prescribed to the Elderly. Am J Psych 1992;149:1393-1394
Use of “Sleepers” in The Elderly
15% of elderly inpatients were on a sleep
aid prior to admission
25% received pharmacotherapy for
insomnia in the hospital
Non-benzodiazepine hypnotics (zolpidem)
– Most commonly chosen by hospitalists
Cumbler E. Use of Medications for Insomnia in the Hospitalized Geriatric Population. JAGS 2008; 56:579-581
Results
UCH Experience
Randomized patients for 1st 6 months ACE vs usual care
Resource Utilization
– Documented severity of illness slightly higher for ACE
Case mix index for ACE patients was 1.15 vs 1.05 in usual care
– Length of stay 3.4 days
– Mean Patient Charges $24,617
– 30 Day readmission rate 12.3%
ACE service model did not significantly change
resource utilization
3600 Evaluation
House staff
5
4.5
4
– 100% feel better
medical care of the
elderly
Patient Satisfaction
3.5
3
2.5
2
1.5
1
0.5
0
Prepared for interdisciplinary teamwork
2.95
3.2
Post-rotation
4.45
4.75
“Overall I received very good care”
ACE
Non-ACE
6%
29%
71%
Staff-- improved:
– Care coordination
– Communication
– Job satisfaction
Prepared to care for elderly patients
Pre-rotation
94%
Recognition and Treatment of
Geriatric Conditions
70
60
p < 0.0001
p < 0.01
50
40
p < 0.05
30
ACE
non-ACE
20
10
0
Abnormal
Functional
Status
Abnormal
Cognitive Status
Delirium
Clinician Behavior Mirrors the System in Which They Practice!
ACE Model
What Does The Literature Show?
Less Functional Decline at Discharge
– 13% risk reduction
Lower rate of Institutionalization
– 22% risk reduction at 1 year
No influence on LOS
Trend towards reduced
– Readmission (15% risk reduction but not statistically significant)
– Mortality (22% risk reduction at 3 months but not statistically
significant)
Van Craen K. The Effectiveness of Inpatient Geriatric Evaluation and Management Units:A Systematic Review and Meta-Analysis. J Am Geriatr Soc 2010;58:83-92
Geriatric Syndromes Have
Profound Impact
Hazards
Harmed
Delirium
The Patient
Deconditioning
The Hospital
Falls
The Provider
The Insurer
Miller MO. Evaluation and Management of Delirium in Hospitalized Older Patients. AAFP 2008;78:1265-1270
Kiely DK, et al. Persistent Delirium Predicts Greater Mortality. JAGS 2009;57:55-61
Keys to Care of the Hospitalized Elder
Simple Risk Assessments
Avoidance of Problematic Interventions
– Anti-cholinergic and Sedative Medications
– Tethers
– Restraints
Interdisciplinary Team Communication
Standardized Care Protocols