CHAMP Care of the Hospitalized Aging Medical Patient

CHAMP: Care of the Hospitalized Aging Medical Patient For Medical Students Shellie Williams, M. D. University of Chicago

Objectives • Understand current trends in hospitalization of the elderly. • Identify issues to address at admission to limit functional decline. • Increase recognition of delirium in elderly. • Devise overall plan for addressing hospital care of elderly.

Hospitalization of the Elderly: Hospital Focus • 45 -50% discharges US hospitals >65 yo • Hospital focus: managing illness, not improved function. • Diminishing LOS 8. 7 days 5. 7 days (19902000) • Increased procedures iatrogenic events

Geriatric Focus of Hospitalization • Improving/Maintaining functional status • Facilitating safe transition to community • Identifying and addressing geriatric syndromes 4 “D” Physical Delirium Psycho Dementia social Depression FUNCTION Diet

Geriatric Review of Systems: Daily • Sensory function • Bowels/bladder • Appetite/Nutrition • Sleep • Cognition • Mobility • Pain

Key Risks of Hospitalizing Elderly: • Functional Decline (Adl, IAdl) • Institutionalization (Dispo Card) • Cognitive Decline (CAM) • Mortality (Walter Index)

Function and the Hospitalized Elder: • Activities of Daily Living (ADLs): Assess self care capability Bathing Dressing Toileting Continence Transfers Gait Feeding • Instrumental ADLs (i. ADLs): Assess living independence Telephone use Travel Shopping Meal Preparation Housekeeping Medication management Financial management

Functional Decline and the Hospitalized Elder • 1279 pts >70 yo • ADL measure at DC and 3 mo post-DC • 31% decline baseline-adl at DC • 59% unchanged; 10% better at DC • 3 months: • 11% died • 40% further adl deficits Sager, M. Arch In Med 1996; 156: 645 -2

Etiology of Functional Decline Constipation Medications *BZD Malnutrition *Antihypertensives Insomnia Fatigue Incontinence Pain Sensory deficits Iatrogenic Atelactasis DVT Ulcers Functional Decline/ Deconditioning Immobility Depression/frustration General Weakness Restraint Confusion (Physical, Behavioral, Conceptual-foley, iv) Acute medical illness

Hospitalization and Bed-rest: n Table 1. Effects of Bed Rest System Effect Cardiovascular ↓ Stroke volume, ↓ cardiac output, ^ pvr, orthostatic hypotension, < plasma volume Respiratory ↓ Respiratory excursion, ↓ oxygen uptake, ↑ potential for atelectasis Muscles ↓ Muscle strength, ↓ muscle blood flow Bone ↑ Bone loss, ↓ bone density GI Malnutrition, anorexia, constipation GU Incontinence Skin Sheering force, potential for skin breakdown n Psychological n n n n Social isolation, anxiety, depression, disorientation

Functional Decline Other Geriatric Syndromes: n n n n n Pressure Ulcers Delirium Dehydration Malnutrition Falls 13 x increased Incontinence Insomnia Pain Creditor, M. Ann In Med 1993; 118: 219 -23. Restraint devices: IV, Foley, PEG, wrist

Walter Prognostic Index 1 year prognostic index patient >/= 70 Factor Points Male ADL dependence dispo 1 -4 All CHF Cancer solitary/mets Createnine >3. 0 Albumin 3 -3. 4/<3. 0 1 2 5 2 3/8 2 1/2

Walter Prognostic Index 1 year prognostic index patient >/= 70 • 1 year mortality: • 1 -4 points 4% • 2 -3 points 19% • 4 -6 points 34% • >6 points 64% • >6 consider hospice or EOL focused care. Appropriate for prognostic consideration in pts with cancer, chf, dementia, copd, acute irreversible process.

Diagnosis: Confusion Assessment Method (CAM) Inouye SK et al. Ann Intern Med. 1990; 113: 941 -948 • (1) Acute change in mental status with a fluctuating course • (2) Inattention AND • (3) Disorganized thinking OR • (4) Altered level of consciousness Sensitivity: 94 -100%, Specificity: 90 -95%

How to Distinguish Delirium from Dementia • Features seen in both: – – – Disorientation Memory impairment Paranoia Hallucinations Emotional lability Sleep-wake cycle reversal • Key features of delirium: – – – Acute onset Impaired attention Altered level of consciousness

Assume it is Delirium until Proven Otherwise Delirium may be the only manifestation of life-threatening illness in the elderly patient

Predisposing Factors i. e. baseline underlying vulnerability • Baseline Dementia – 2. 5 fold increased risk of delirium in dementia patients – 25 -31% of delirious patients have underlying dementia • Medical comorbidities: – Acute medical illness • Visual impairment • Hearing impairment • Functional impairment • Advanced age • History of ETOH abuse • Male gender

Precipitating Factors i. e. noxious insults • Medications • Bedrest • Indwelling bladder catheters • Physical restraints • Iatrogenic events • Uncontrolled pain • Fluid/electrolyte abnormalities • Infections • Medical illnesses • Urinary retention and fecal impaction • ETOH/drug withdrawal • Environmental influences

Some drug classes that are associated with delirium • Medications with psychoactive effects: – 3. 9 -fold increased risk – 2 or more meds: 4. 5 -fold • Sedative-hypnotics: 3. 0 to 11. 7 -fold • Narcotics: 2. 5 to 2. 7 -fold • Anticholinergic drugs: 4. 5 to 11. 7 -fold

Prevention of Delirium: It can be done! • Find patients with 1 -4 of the following predisposing characteristics: – Visual impairment (worse than 20/70 corrected) – Severe illness – Cognitive impairment (MMSE<24/30) – High BUN/Cr ratio (>18) • (Inouye SK et al. Ann Intern Med. 1993; 119: 474 -481)

Take Home Points: Delirium in the Elderly • A multi-factorial syndrome: predisposing vulnerability and precipitating insults • Delirium can be diagnosed with high sensitivity and specificity using the CAM • Prevention should be our goal • If delirium occurs, treat the underlying causes • Always try non-pharmacologic approaches • Use low dose anti-psychotics in severe cases

Targeted Interventions for Prevention of Decline: n n n Fall precautions/PT: hx dementia, confusion, fall in prior 12 months Dysphagia diet/speech eval: stroke, difficulty swallowing, aspiration Bowels: prunes, mobility, home foods Social work/case manager: limited community support, self neglect, cog deficits Nutrition/supplements, 1: 1 Feeding: Hx weight loss, low albumin, advanced dementia, liberal diet

Geriatric Complications and Screens for Assessing: GERIATRIC HOSPITAL COMPLICATION: SCREENING METHOD: Delirium: CAM review with nurse or Confusion Assessment Method; Mini Cog family? Deconditioning: What was your function 2 weeks prior to hospital and now? ADL/IADL; mobility status Poly-pharmacy: What are potential Geriatric priniciples: start low go slow, ½ 1/3 dose abx, bp meds; Beers list hazards with the medications? Pressure ulcers: Assess patient’s perineum, See Stage, assess with Braeden system heels, elbows Environmental Assessment : What aides Gait device, glasses, hearing aide, dentures does the patient use, what is present? Pain: PQRST step pain review Type pain, location, duration, intensity, exac/relieving Restraint Review : How many restraints ? foley, PICC< drains, SCDs, catheter/drains need and discontinuation plan are present on this patient? Nutrition: How is your appetite? Observe patient eating, desired foods, dentures, last BM Medical decision making: What have the doctors told you about why you’re in the hospital? Applebaum review of decision making

Geriatric Screens Web Access: • CAM: http: //www. healthcare. uiowa. edu/igec/tools/cognitive/CAM. pdf • Mini-Cog http: //www. hospitalmedicine. org/geriresource/toolbox/pdfs/clock_drawing_test. pdf • ADL: http: //www. healthcare. uiowa. edu/igec/tools/function/katz. ADLs. pdf • Options for assisting with ADLs: http: //www. family-friendlyfun. com/disabilities/adaptive-equipment. htm • IADL: http: //www. annalsoflongtermcare. com/article/7453 • Braden scale: http: //www. ruralfamilymedicine. org/educationalstrategies/braden_scale_for_predi cting_pres. htm • Pressure Ulcer Staging: http: //woundconsultant. com/sitebuilder/staging. pdf • Decisional Capacity: See next slide + http: //www. nejm. org/doi/full/10. 1056/NEJMcp 074045

Appelbaum, P. NEJM 2007; 357: 1834 -1840