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Acute Care for Elders (ACE):
Physical Therapy in an
Interdisciplinary ACE Consult
Team—Dementia, Delirium, and
Beyond
Objectives
• Understand components of ACE team
• Understand how an ACE team:
– Improves patient functional outcomes
– Decreases LOS & hospitalization cost
• Have framework for implementing a multi-factorial,
interdisciplinary program to prevent/treat delirium
• Understand best evidence for management of
• Jacque Pokorney, MSPT, GCS
• Amanda LaLonde, PT
• Combined Sections Meeting
• January 24, 2013
hospitalized older adults at risk for delirium
• Identify ways PT within an ACE team may decrease
Medicare/Medicaid “never events” and improve
discharge planning for observation patients
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
University of Wisconsin ACE
Team
Why are we all here?
• Gray Tsunami…
• Age 65+ predicted to
increase from 35
million (2010) to 71
million in (2030)
• Clinical Nurse Specialist (team leader), Geriatric Medicine,
Pharmacy, Physical Therapy, Social Work
• Consult-based service, discipline-specific rounding, daily
photo:unmc.edu/intmed/geriatrics
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Benefit of ACE Model
• Older adults only 13% of the population, but
36% of hospital admissions
• Nearly 50% of hospital spending
• Most clinicians not trained to manage older
adults correctly
• Increase LOS (and costs)
• Increased likelihood of SNF/institutionalization at
discharge, potentially long-term
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
interdisciplinary team meeting
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Benefit of ACE Model
• Potential adverse outcomes due to
hospitalization (avoidable)
– Delirium
– Restraint use
– Falls
– ADL/functional decline
– Infections
– Poor nutrition
– Improper medication use
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
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Comprehensive Geriatric
Assessment (CGA)
“Multidimensional interdisciplinary diagnostic
process focused on determining a frail older
person’s medical, psychological, and functional
capability in order to develop a coordinated and
integrated plan for treatment and long-term
follow-up.”
Comprehensive geriatric assessment for older adults admitted to the
hospital: meta-analysis of randomized controlled trials. BMJ 2011;
343:d6553
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
CGA: ACE Team Collaboration
CGA: Interdisciplinary Teams
• High likelihood of multiple overlapping
problems = need to assess multiple domains
• Multiple domains = include multiple disciplines
• Getting beyond compartmentalized care
• Increased need for teams
• Increased PT autonomy
• The diagnosis is just the tip of the iceberg…
• Need to start asking...
WHY?
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Research: Interdisciplinary
Models
• Meta-Analysis of CGA care versus usual care
• Significant improvement in odds of being alive,
in own home if received CGA
• Less cognitive decline
• Increased ability to perform ADLs
• Cost reduction (some studies)
• Decreased LOS
Effectiveness of acute geriatric units on functional decline, living at home,
and case fatality among older patients admitted to hospital for acute
medical disorders: meta-analysis. BMJ, 2009;338:b50.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Research: Interdisciplinary
Models
• Hospital admission alone is risk for
• Functional decline
• Frailty
• SNF admission
• BMJ 2009 Meta-analysis: Acute geriatric units
versus conventional care
• Units reduced ADL decline by 18%
• Lower risk of functional decline
• More likely to live at home at discharge
• No differences in case fatality
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Research: Interdisciplinary
Models
• ID model benefits are particularly true for
Wards versus Mobile Units via research
• UW ACE team IS a Mobile Service
• Have had success at UWHC—2011 data
showing decreased LOS and cost savings
• Per patient: $3,039 average
• Cost savings for years 2007-2011 is estimated to be
$3,622,488 total; $812,217 per year
• $600,000 per year after adjusting for staff salaries
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
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11/18/2012
Use of Interdisciplinary (ID) Model
Hip fx population
• 310, 000 (2003)
• Re-admission rates 20-30% in first 30 days
• Delirium, dehydration, underlying cardiopulmonary disease
• Medical ID consultation associated with
• Improved 1-yr mortality
• Decreased LOS
• Decreased incidence of delirium
•
•
61% non-ID treatment
48% ID treatment group
Medical consultation for patients with hip fracture. In: UpToDate, Schmader,
KE (Ed), UpToDate, Waltham, MA, 2012.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Types of ACE Models: Mobile
• Mobile ID teams that see patients on all
hospital floors
• Ability to provide CGA to anyone in hospital
• Similar members and roles
• PT/OT, Pharmacy, Social Worker, RN, MD,
Dietician, Facilitator
• Successful UW mobile ACE model
• Improved patient/family satisfaction,
medication compliance, increased team
communication and delivery of care
Types of ACE Models: Units/Wards
• Designated units or wards
• Home-like—carpeted, spacious rooms with
large windows, large clocks, and calendars
• Activities in hallways
• Puzzles, aquarium
• Music, art
• Specially trained staff
• Care of elders
• Patient satisfaction
• ID teams
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team
Mission Statement
• To offer patients 65 and older a proactive and comprehensive
interdisciplinary team geriatric evaluation directed toward
preserving function and independence and preventing the
hazards of hospitalization
Program Goals
• Improve quality of care of the hospitalized elderly
• Improve patient safety
• Prevent functional decline
• Prevent onset or worsening of delirium
• Reduce hospitalized length of stay
• Facilitate discharge to appropriate setting
• Assist with transitions of care settings
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team
• Clinical Nurse Specialist (Team Leader)
• Pharmacist
• Social Worker
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team
Role of Nursing
•Ensure that nurses recognize the uniqueness of
the geriatric hospitalized patients
• Respect for lived experience; at risk for iatrogenic
illnesses
• Physical Therapist
•Delirium: Education of family and staff regarding
• Geriatrician/Fellows
all areas related to delirium
• Students from all categories
• Risk factors, prevention, treatment, management
•Delirium: Increase awareness that a delirious
patient impacts the system at every level with an
increased need for collaboration
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
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Components of UW ACE team
Components of UW ACE team
Role of Nursing: Delirium Protocol
Role of Nursing: System-wide advocacy
•Appropriate levels of cognitive stimulation
•Formation of EBP nursing guidelines for:
•Day/night sleep cycle
•Mobility
•Visual/hearing issues
•Nutrition/elimination concerns
•Environmental awareness/ modifications
•Orientation methods
•Consistency of nurse/patient relationship
•Safety/Risk issues (falls, restraints, staff safety)
•Education of patient/family (risk factors/prevention,
treatment, resolution of symptoms)
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team
– Delirium (CAM, risk factors, prevention)
– Pain in the geriatric patient
– Fall prevention (early alert triggers)
– Restraints—low bed and restraint alternatives
•Sitters: Rounding team and metrics on judicious
personal safety assistant (PSA) use
•Recognition of staffing needs with delirious
patients
•Diversional activity carts
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team
Role of Pharmacy
Role of Nursing: System-wide advocacy
•Completes a secondary medication reconciliation
•Patient capacity issues/ HCPOA and decision
• Admission order omissions
making
•Discharge disposition issues related to SNF
placement (48 hour restraint and sitter free)
•Stressing nurse as patient advocate
•Involvement of other APNs/CNSs for consultation
• Medication & dosing discrepancies
• Health psych, Spiritual Care, Wound Care, Pain
team, Palliative Care
• Primary review done at admit by ward Pharmacist
•Considers age-related changes that may alter
medication pharmacokinetic/dynamic characteristics
• Ex: Creatinine clearance
•Evaluates medications that may impact a wide range
of geriatric syndromes
•Confers with the ward pharmacist and nursing staff
• Patient behavior
• Medication management
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team
Role of Pharmacy: Medication Issues
Common in the Elderly
•Inappropriate drug prescription
•Compliance
• Regimen complexity, cost, fear of side effects, cognitive
impairment, visual/hearing impairment, failure to thrive
•Over/under-dosage
• Renal function
• Hepatic function
•Drug interactions
•Polypharmacy
•Anti-cholinergic burden
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team
Pharmacy Role: Medications that may lead
to Delirium
• Antihistamines
• Anticonvulsants
• Opiates
• NSAIDs
• Corticosteriods
• Benzodiazepines
• H2 receptor antagonists
• Dopamine agonists (Parkinson’s meds)
• Antibiotics
•Cardiovascular drugs
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
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Components of UW ACE team
Components of UW ACE team
Delirium Pharmacotherapy
Pharmacy Role: Geriatric Syndromes
•
•
•
•
•
•
•
•
•
Mobility and self-care
Medication management and adherence
Safety and injury potential
Health promotion (primary/secondary prevention)
Nutrition and elimination issues: bowel/bladder
Disposition issues
Pain
Skin integrity
Depression, anxiety, delirium, dementia, altered
thought processes
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team
Pharmacy Role: System Changes
•
•
•
•
Delirium guidelines
Local, state and national poster presentations
Workshops on the interdisciplinary team model
Updated order sets for hospital admission
• Best practice alerts
• Pharmacist-targeted workshops
• Staff resource for medication-related issues and
questions
Haloperidol
Atypical Antipsychotic
Benzodiazepine
Advantages
No efficacy advantage over
other pheno- thiazines
Less sedation and
hypotension
Fewer EPSEs
Less sedation
When sedation needed,
refractory to haloperidol, for
withdrawal delirium, seizures,
intolerance to phenothiazines
Disadvantages
Can exacerbate
anticholinergic delirium.
Risk of EPSEs.
Oral route and higher cost
(rapidly disintegrating now
available). Black box
warnings.
Risk of paradoxical reaction
(esp. frail elderly with
dementia)
Administration
PO, IV, IM
PO
PO, IV, IM
Dosing
0.5-5 mg q 30-60 mins for
initial control. Maintenance
= ½ the daily dose for initial
control
Varies by agent
Lorazepam preferred;
0.5-2mg IV q 30-60 mins
(every 4-6 hrs)
Pharmacokinetics
Clearance decreased with
aging.
Clearance decreased with
aging
Clearance decreased for fat
soluble agents.
Onset
Parenteral (15-30 mins)
Oral (30-60 minutes)
Varies with agent
IV (1-5 mins)
Monitoring
EPSEs
Sedation
Sedation, respiration
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team
Social Work/Case Management Role
•Patient assessment
• Prior living situation
• Functional status PTA
• Prior admissions
• Admission reason
• Disposition outcome
•
Advanced Directives
•Code status
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team
Role of Social Work: Why is discharge planning
important?
• Hospital stay is a brief window in the life of the
patient
• What comes before and after is just as important
• Frail elders are especially at risk
• Poor planning results in failed care plans
• Poor handoffs result in unnecessary readmissions
• Delirium: Highly impacts disposition
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team
Role of Physical Therapy
•Primary roles of physical therapy
• Mobilization
• Discharge planning
•Mobilization is challenging with both hyper- and
hypo-active delirious patients
• Tendency for PT/Nursing to state “Hold PT
today” —because of this, patients will not be
mobilized
• Increases LOS
• Increases cost of care
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
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Components of UW ACE team
Components of UW ACE team
Role of Physical Therapy
Role of Physical Therapy: Problems Created by
Immobility
•Delirious patients often have delayed discharges
• Agitated behaviors
• Restraints
•Changes in the Cardiopulmonary System
• Sitters
•Changes in the Musculoskeletal System
•Key component of breaking delirium is early and
•Changes in the Integumentary System
aggressive mobilization
•
•Changes in Internal Organ Functions
Facilitates faster discharge planning
•Changes in the Neurosensory System…
•PT represents the entire therapy team
(DELIRIUM)
• PT, OT, Speech, Swallow
• Makes recommendations accordingly
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team
Components of UW ACE team
Role of Physical Therapy: Problems Created by
Immobility
Role of Physical Therapy: Problems Created by
Immobility
•Changes in the Neurosensory System
•Changes in the Neurosensory System
• Social isolation—feelings of loneliness
• Thermoregulation is altered
• Mood changes—increased anxiety, irritability and
• Balance decreases
depression
• Decreased performance on cognitive testing
• Perception of time intervals distorted
• Affects EEG pattern of sleep
• Coordination decreases
• Reaction time increases
• Increased mental lethargy during wake hours
• Decreased arousal when supine in bed
• Less time spent in deep sleep
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team
Components of UW ACE team
Role of Physical Therapy: Sleep Cycle and
Mobility
Standard
Phase:
Sleepy,
Go to Bed
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Role of Physical Therapy: How to Mobilize
•Mobilize
Wake Up
• As soon as possible
• Frequently during daytime hours (at least 3x/day)
•If ambulatory: Try 2 people with gait belt & hand hold
6:00 7:00 8:00 9:00 10:00 11:00 12:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 10:00
•If debilitated: Transfer to bedside chair or slide to
cardiac chair (instruct RN/CNA)
Midnight
• Educate and Document
Sleep Awake Sleep Awake Sleep Awake Sleep
Aperiodic Phase: Is common in dementia
•Collaborate with OT, RN/CNA, Geriatric CNS for
mobilization ideas/techniques
• Especially if the patient is agitated
Adapted from: Ancoli-Israel,S. All I Want Is a Good Night’s Sleep. Mosby; 1996.
35
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
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Components of UW ACE team
Components of UW ACE team
Role of Physical Therapy: How to Mobilize
Role of Physical Therapy: Rehabilitation
Interventions
•Ensure appropriate activity orders
•Patient out of bed within 6-8 hours of admission,
unless bed rest ordered (discontinue if inappropriate)
•Have patient out of bed for meals
•Reduce or eliminate barriers to mobility
•Encourage independence with ADLs
•Seat patient near nurses' station
• Give activities to engage patient and minimize restraints
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team
Role of Physical Therapy: Rehabilitation
Interventions
•Dysphagia— assess and monitor (can fluctuate)
•
DHT and NG tube can be source of agitation
•Social support—family, activities
•Careful monitoring and control of pain
•Orientation and memory aids
•Staff approaches—attitudes, demeanors
•Constant observation
•Consult family: Verify prior level of function and
cognition
•Early mobilization: Discontinue bed rest orders
•Fall prevention: Avoid restraints
• Increased stress = increased cortisol levels = can cause
increased agitation/delirium
• Implement alarms, low bed, and sitter as needed
•Reality orientation as appropriate
• Depends on underlying dementia and to what degree
•ADL retraining
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team
Role of Geriatric Medicine
•4-6 Geriatricians rotate by the week
• Monday through Friday mornings
•Billing for patients is submitted for the MD service
•ACE averages ~2.6 new patients and have 3 follow-
up patients each day
•47% of ACE consults are for a cognitive evaluation
•Patients usually have a mix of dementia and delirium
•The most common ACE discharge diagnostic related
group (DRG) is delirium—over 30% of the ACE consult
patients have this diagnosis
• Seat at nurses’ station, family members can be calming, use of
sitter
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team
Role of Geriatric Medicine: Objective
Outcomes
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Components of UW ACE team:
Reason for Consult
Reason for ACE Consult
N = 439
Delirium
•Shorter hospital LOS and lower costs
• Patients seen by ACE team within 4 days of admission
• Versus those seen later in the hospital stay
Overall Geriatric Evaluation
Dementia
Mobility Issues
Disposition/Social/Caregiver Concerns
Confusion
Medication Concerns
•Change in the culture of the hospital
•Venue for teaching all disciplines about the elderly
and team work
•Proving value to hospital administration
• Annual ACE Executive Summary
• Demonstrate ID model for the hospital
• Better management of aggression, pain, and reduced
hospital readmissions
Cognition Eval
Depression
Falls
Pain
Reason
Agitation
Failure to Thrive
Functional Evaluation
Elimination
Nutrition
Sleep issues
Skin/Ulcers
Competency
Home safety
Guardianship
0
10
20
30
40
50
60
70
80
# of Consults
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
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Components of UW ACE team:
Components of UW ACE team:
Discharge Diagnoses
ACE Recommendations
Top 15 ACE Recommendations
Top 15 ACE Discharge DRGs
N = 427
Medication Management
VASCULAR DEMENTIA UNCOMP
Disposition
OTHER CONVULSIONS
Elimination
MALAISE & FATIGUE NEC
Mobility/Self Care
DEMENTIA IN CCE W BEHAV
Labs
ANXIETY STATE NOS
Delirium
DYSTHYMIC DISORDER
Nutrition
ALTER CONSCIOUSNESS NEC
Pain
ADULT FAILURE TO THRIVE
Bowel Status
DEMENTIA IN CCE S BEHAV
Diagnosis DRG
ALZHEIMER'S DISEASE
Recommendation
Meds_BS
Med Change_Med Mgmt
DRUG-INDUCED DELIRIUM
PT Rec
HX FALL
Rx Rec_Pain
OTH PERSIST MENT DIS CCE
SNF
DEPRESSIVE DISORDER NEC
Protocol in Chart
DELIRIUM D/T CCE
0
10
20
30
40
50
60
0
70
20
40
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Could
This
Be
Delirium?
60
80
100
120
140
160
180
# of Times Recommendation was Given
# of ACE Patients
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Could This Be Delirium?
• Diagnosis: Confusion Assessment Method
(CAM)
•
•
•
•
•
•
Recent onset
Fluctuating awareness
Memory impairment
Attention impairment
Disorganized thinking
Unable to concentrate, sustain, or shift attention
• Two aspects to the diagnostic process
Acute Care for Elders (ACE): Physical Therapy in an
Interdisciplinary ACE Consult Team—Dementia, Delirium,
and Beyond. Pokorney, LaLonde, 2013.
Could This Be Delirium?
• Hyperactive (25%)--easier to diagnose, better
outcomes
• Psychomotor activity is increased
•
Recognize the presence of delirium
•
Uncover underlying medical illness that has caused
delirium—again we need to be asking WHY?
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Could This Be Delirium?
• Under-recognized and misdiagnosed
– Some report up to 70%
• Agitation is prominent
• Expensive to treat
• Delusion and hallucinations more common
• Complications
• Hypoactive (25%)
• Psychomotor activity is decreased
• Can be misdiagnosed as depression
• Mixed Delirium (35%)
• No change in activity levels (15%)--difficult to
treat
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
– Increased LOS
– Increased SNF admission
– Increased LTC needs
– Increased cost of care
– Increased long-term cognitive effect
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
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Delirium: Costs
Delirium: NICE Recommendations
for Prevention in At-Risk Adults
• NIH estimation
• Additional $2500 per patient
• $6.9 billion annual Medicare dollars (2004)
• 30% of older adults experience delirium at
some point in hospitalization
• Post-operative risk 10-50%
Synopsis of the national institute for health and clinical excellence
guideline for prevention of delirium. Ann Intern Med.
2001;154:746-751.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Ensure team that is familiar with person at
risk- avoid moving between rooms or wards
Assess and give multi-component
intervention, tailored to patient needs within
24 hours of admission
Intervention should be delivered by team
trained in delirium prevention
Address cognition— provide clocks, signs,
calendar, re-orient, facilitate family visits
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Delirium: NICE Recommendations
Delirium: NICE Recommendations
Address dehydration & consumption
Carry out a medication review for number and
Assess for hypoxia
Address infection: Treat cause, avoid
unnecessary catheterization
Address immobility: Mobilize soon after
surgery, provide readily accessible walking
aids. If unable to walk, provide active ROM
exercises
Address pain: Look for nonverbal signs of
pain, especially in dementia population
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
type of medications
Address nutrition: Follow clinical guidelines,
ensure dentures fit properly
Address sensory impairments: Ear wax, use
hearing aids, use glasses, check that aids are
working
Promote good sleep patterns: Avoid nighttime
nursing or medical procedures; if able, schedule
meds to avoid sleep disruption, reduce noise to
a minimum during sleep periods
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Delirium: Risk factors
Delirium: Role of ID Teams
• Risk factors: CVA, Parkinson’s, advanced
• Due to fluctuating nature: Provider teams are
•
•
•
•
age, sensory impairment
Dementia risk factor: Delirium develops in 2289% per meta-analysis of studies
Precipitating factors: Poly-pharmacy,
infection, immobility, restraint use, catheters,
malnutrition
Occurs in 30% of elderly CABG patients
Occurs in 50% of hip fracture patients
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
essential
– Each has a different role, different patient
experience
– Putting together the clinical presentation gathered
from each provider enhances identification,
diagnosis and treatment
• PT role
– Per NICE guidelines and evidence, need to
mobilize this population early and often
– Train staff on safety and complex patient
mobilization
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
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Delirium: Prevention & Treatment
• Treatment is NOT as effective as prevention
• Little evidence about treatment of delirium
once it has developed
• Early Geriatrics Consult may be helpful in
prevention of delirium
• RCT, n=126, of those >65 years admitted for surgical hip
fracture
• Proactive Geriatrics/Interdisciplinary consults reduced
delirium risk 32 vs 50%
Role of PT in ACE: Delirium
• Every time you see the patient
– Open shades, lights ON
– EDUCATE STAFF
– Mobilize
– Orient
– Signs, pictures, handouts
– Give “busy” work/activities
– Move to nursing station, take outside, etc.
Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc.
2001;49(5):516.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
PT Autonomous Practice
• Back to the CGA model
– Must consider the WHY in all areas
– Not just the quick home safety eval, WFL, needs
SNF story
• Assess meds, history, and current admission
in relation to PT
• Don’t just go along with a plan that doesn’t
seem right
– Question the MDs, question the plan, use your
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
PT Autonomous Practice
• Use of the ACE experience and ID model to
increase confidence
• Look at meds on ALL older adult patients
• Question indication, repetition
• Resistance at first, respect as a result
• Suggest referrals
• Geriatric clinics, falls clinics, memory clinic
clinical skills for support
– Not challenging the system is detrimental to care
and growth
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
PT Autonomous Practice
• Use PT consult/educational role
– Patients, family, staff
– Deleterious medications, available older adult
services, less restraint use
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
PT Autonomous Practice:
Cognitive Testing
• Complete quick cognitive screens
– Clock, SLUMS, Animal naming
• Activity orders: few reasons for bed rest
– WHY in bed?
– Show evidence of early mobilization (PLENTY out
there)
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
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PT
Autonomous
Practice:
Cognitive
Testing
Acute Care for Elders (ACE): Physical Therapy in an
Interdisciplinary ACE Consult Team—Dementia, Delirium,
and Beyond. Pokorney, LaLonde, 2013.
Literature Review: Hip Fractures
and Delirium Prevention
• Journal of Gerontology. 2003 Nov; 58(11):1042-1045.
Time to ambulation after hip fracture surgery: relation to
hospitalization outcomes. CONCLUSION: 131 patients,
time to ambulation was significantly less on orthopedic
floors compared to general surgery service. Time to
ambulation was an independent predictor of new
pneumonia, new onset delirium, and to prolonged
length of hospital stay.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Literature Review: Hip Fractures
and Delirium Prevention
• Disability and Rehabilitation. 2005; 27(18-19):1123-1127.
Five-year experience with the ‘Sheba’ model of
comprehensive orthogeriatric care for elderly hip fracture
patients. CONCLUSION: 538 patients, mean age 83.2
years, treatment within this facility was associated with
low rates of major morbidity and mortality, short stay and
acceptable functional outcomes. Data provided clinical
evidence to support the concept that hip fracture
represents a geriatric rather than orthopedic disease—
surgical, medical, rehab management all occurred at the
same facility.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Literature
Review: Hip
Fractures and
Delirium
Prevention
Acute Care for Elders (ACE): Physical Therapy in an
Interdisciplinary ACE Consult Team—Dementia, Delirium, and
Beyond. Pokorney, LaLonde, 2013.
Literature Review: Hip Fractures
and Delirium Prevention
• Clinical Orthopaedics and Related Research. 2004 Aug;
(425):44-49. The Older Orthopaedic Patient.
CONCLUSION: Older patients undergoing orthopaedic
surgery are more likely to have peri-operative
complications. Early mobilization after surgery, avoiding
certain drugs, avoiding restraints (including foley
catheter), encouraging hydration, promoting normal sleep,
compensating for sensory disorders, and stimulating
daytime activities are important to minimize complications.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Literature Review: Hip Fractures
and Delirium Prevention
• Aging Clinical and Experimental Research. 2008 Apr;
20(2):113-122. Orthogeriatric care for the elderly with hip
fractures: where are we? CONCLUSION: Orthogeriatric
care should be viewed as a radical alternative to the
traditional model of care for improved outcomes in the
fractured elderly. Key points of care are early surgery,
immediate mobilization, prevention and management of
delirium, pain and malnutrition, as well as comprehensive
geriatric assessment (CGA).
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
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Literature Review: Hip Fractures
and Delirium Prevention
• Age and Aging. 2007 Mar; 36(2):190-196. Proactive care
of older people undergoing surgery (‘POPS’): designing,
embedding, evaluating, and funding a comprehensive
geriatric assessment service for older selective surgical
patients. CONCLUSION: 108 patients, 54 non-POPS vs
54 POPS. POPS group had fewer post-op complications
including pneumonia and delirium, fewer pressure sores,
better pain control, faster mobilization, less inappropriate
catheter use, and length of say was reduced by 4.5 days.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Never Events - Observation - and
Transitions of Care
• Patient Protection and Affordable Care Act of 2010
• Requires the Secretary to issue Medicaid regulations effective
July 1, 2011 prohibiting federal payments to states for any
amounts expended for providing medical assistance for health
care-acquired conditions (HCACs)
• Define the term "health care-acquired condition" in accordance
Medicare's inpatient hospital statutory language at
1886(d)(4)(D)(iv)
• Apply Medicare’s provisions re: Identifiable hospital-acquired
conditions (HAC) and never events to Medicaid regulations,
excluding any condition identified for non-payment under
Medicare that may not be applicable to Medicaid
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Never Events - Observation - and
Transitions of Care
•
Ten Category 1 HCACs—of which half can be
caused by immobility or prolonged hospitalization
associated with delirium
• Stage III and IV Pressure Ulcers
• Falls and Trauma
Never Events - Observation - and
Transitions of Care
•
• Will penalize hospitals for 30-day readmissions of
patients with geriatric diagnoses including Pneumonia,
CHF, or acute MI
•
• Catheter-Associated Urinary Tract Infection (UTI)
• Deep Vein Thrombosis (DVT)/Pulmonary
Embolism (PE) Following TKA or THA
• Surgical site infection
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Never Events - Observation - and
Transitions of Care
Dementia patients are often admitted with increased
confusion or a fall
Likely not a diagnosis that qualifies for Inpatient Classification
May also experience pre-hospital delirium
Delirium is NOT considered a diagnosis for Inpatient
Classification (even though it can be life-threatening)
Often not safe to return to prior living situation without
therapy/SNF rehab intervention
ALSO high risk of readmission within 30 days (risk of
Medicare non-payment)
Referral to Transitions of Care Program
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Affordable Care Act (ACA)
•
These patients are all at high-risk of delirium
with associated prolonged hospital stay or
readmission because of side-effects from a
delirious episode during hospital admission
These patients are all being referred to our
Transitions of Care Program at UW Hospital
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Never Events - Observation - and
Transitions of Care
• At UWHC, currently focused primarily on CMS-
identified diagnoses of CHF, acute MI, and pneumonia
• Expanding to include complicated geriatric diagnoses at high
risk of failure at home
• MD, APN, and RN Case manager
• Enhanced discharge POC, med reconciliation, red flags,
expedited follow-up for OP visits
• Can overlap with HH services
• Bridges care between hospital and primary care teams,
prevention of re-hospitalization
• Outcomes to be tracked by Health Innovation Program
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
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Never Events - Observation - and
Transitions of Care: Benefit of ACE
Case Studies
• ID approach for Never Events
• Mobilize the pt, remove catheters, minimize restraints/tethers,
facilitate fastest discharge
• ID approach for Observation status
• Maximize mobility; solve medical/medication issues causing
falls, weakness, confusion; complete/find out about HCPOA,
PLOF, supervision, safety, make recs for safe discharge
• ID approach for TOC
• Make ID recommendations, especially for the geriatric patient at
high risk to fail (non-CMS dx)
• Make additional recommendations for follow-up: Memory Clinic,
Balance & Falls Clinic, Adult Day Care
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Thank you!
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
References
• Adunsky A, et al. Five-year experience with the Sheba model of comprehensive
orthogeriatric care for elderly hip fracture patients. Disabil Rehabil 2005;27(18-19),11231127.
• Amador L, Reed D, Lehman C. The acute care for elders unit: taking the rehabilitation model
into the hospital setting. Rehabilitation Nursing. 2007;32(3),126-132.
• American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication
Use in Older Adults. J Am Geriatr Soc 2012.
• Americal Medical Directors Association. Delirium and Acute Problematic Behavior Clinical
Practice Guideline. Columbia, MD:AMDA 2008.
• Baztan J, Suarez-Garcia F, Lopez-Arrieta J, Rodr uez-Manas L, Rodr uez-Artalejo F.
Effectiveness of acute geriatric units on functional decline, living at home, and case fatality
among older patients admitted to hospital for acute medical disorders: meta-analysis. BMJ
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• Chapman D, Williams S, Strine T, Anda R, Moore M. Demential and its implications for
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• Davidson J, Dunton N, Christopher A. Following the trail: connecting unit characteristics
with never events. Nursing Management 2009;40(2),15-19.
• De Morton NA, Keating JL, Jeffs K. Exercise for acutely hospitalized older medical patients.
Cochrane Database Systematic Review, 24(1). Accessed 01 Sept 2012.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
Acute Care for Elders (ACE): Physical Therapy in an Interdisciplinary ACE Consult Team—Dementia, Delirium, and Beyond. Pokorney, LaLonde, 2013.
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