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Geriatrics Cross Cover Challenges What every Intern needs to know before their first call night

Bree Johnston MD MPH Professor of Medicine. Geriatrics Cross Cover Challenges What every Intern needs to know before their first call night. Supported by a grant by the Donald W. Reynolds Foundation. Why is This Important?.

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Geriatrics Cross Cover Challenges What every Intern needs to know before their first call night

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  1. Bree Johnston MD MPH Professor of Medicine Geriatrics Cross Cover ChallengesWhat every Intern needs to know before their first call night Supported by a grant by the Donald W. Reynolds Foundation

  2. Why is This Important? • Increase of population age 65+ from 37 million in 2005 to over 70 million in 2030 • 12% of the US population in 2005 to 20% in 2030 • 2009: Older Americans account for • 35% of all hospital stays • 34% of all prescriptions • 90% of all nursing home use Retooling for an Aging America Institute of Medicine Report 2008

  3. Learning Objectives • By the end of this talk, you should be able to: • Discuss the basic approach to the evaluation and management of falls, delirium, and incontinence in the cross cover setting • Discuss the indications for restraints and foley catheters • Discuss the evidence base for these approaches • Discuss the prevalence and impact of each of these issues

  4. It is Midnight • You have just admitted your third patients, Mrs. Jones. She is an 85 year old woman who has dehydration and urosepsis. She has a history of osteoarthritis and HTN. • The ED physician started her on piperacillin/tazobactam, prn acetaminophen and normal saline at 75cc/hour • She is now on the inpatient unit. Her vital signs are T 37.5, P90, R 16, BP 130/80, 02 sat 99% on RA. • She has an indwelling urinary catheter in. The nurse asks if she still needs it.

  5. Which of the following would be an indication for indwelling catheter placement (or in this case, maintenance) ? • Urinary incontinence • Patient is a fall risk • Delirium with inability to communicate voiding needs • Urinary retention • All of the above DuBeau C, CHAMPFoley Catheter Use http://champ.bsd.uchicago.edu/foleyCath/index.html

  6. Only 4 indications 1. Inability to Void 2. Urinary Incontinence and: • open sacral or perineal wound • palliative care and patient preference 3. Urine Output Monitoring • Always consider daily weights first • Critical Illness—frequent/urgent monitoring needed • Pt unable/unwilling to collect urine 4. After general or spinal Anesthesia • Short term only DuBeau C, CHAMPFoley Catheter Use http://champ.bsd.uchicago.edu/foleyCath/index.html

  7. Only 4 indications 1. Inability to Void 2.Urinary Incontinence and: • open sacral or perineal wound • palliative care and patient preference 3. Urine Output Monitoring • Always consider daily weights first • Critical Illness—frequent/urgent monitoring needed • Pt unable/unwilling to collect urine 4. After general or spinal Anesthesia • Short term only DuBeau C, CHAMPFoley Catheter Use http://champ.bsd.uchicago.edu/foleyCath/index.html

  8. Two Basic Reasons for inability to void: 1. Poor Pump • Meds: anticholinergics, Ca channel blockers, opioids • Sacral Cord Disease, neuropathy 2. Blocked Outlet • Prostate Disease • Constipation / Impaction • Less commonly: • Supra-Sacral Spinal Cord Disease (e.g., MS) • Women: scarring, large cystocele DuBeau C, CHAMPFoley Catheter Use http://champ.bsd.uchicago.edu/foleyCath/index.html

  9. Why should catheter use be minimized? • Infection Risk: • Cause of 40% nosocomial infections • Other morbidity • Associated with delirium • Urethral & meatal Injury • Bladder & renal Stones • Uncomfortable • Restrictive • Increase risk of falls and immobility Saint S LB, Goold SD. Ann Int Med. 2002;137:125-127. Holroyd-Leduc JM MK, Covinsky KE. J Amer Geriatr Soc.52:712-718.

  10. Why should catheter use be minimized? • Medicare will no longer pay for infections associated with foley catheters • Average catheter associated infection costs $600 • Urinary tract associated bacteremia costs $2800 • Increasingly important focus of hospital QI initiatives Saint S et al. Annals of Int Med June 16, 2009

  11. Now it is 3am • You have just gotten to sleep after admitting your 6th patient when you are paged to the medicine floor • The nurse asks you “May I have a restraint order for Mrs. Jones? She is agitated and trying to pull out her IV”. • Her vital signs are T 37.5, P90, R 16, BP 130/80, 02 sat 99% on RA.

  12. Which of the following would be an indication to use a restraint? • Patient is trying to pull out IV • Patient at risk of falling • Patient is trying to pull out foley catheter • Patient is demented or delirious and does not understand the treatment plan • All of the above • None of the above

  13. Restraint Use • Last resort • Only use if all other options exhausted, including changing treatment plan • Do you need an IV or a monitor? • Would the patient do better as an outpatient? • Can you alter the treatment plan/goals? • Use least restrictive restraint (eg, “Geri-Chair” before posey or 4 point) • Use for shortest period possible 2009 Accreditation Process Guide for Hospitals Joint Commission on Accreditation of Healthcare Organizations, http://www.jointcommission.org..

  14. JCAHO has strict standards on restraint use 2009 Accreditation Process Guide for Hospitals Joint Commission on Accreditation of Healthcare Organizations, http://www.jointcommission.org.. • Standard PC.03.02.01:The hospital limits its use of restraint for non–behavioral health purposes. • Standard PC.03.02.03:Written policies and procedures guide the hospital’s safe use of restraint for non–behavioral health purposes. • Standard PC.03.02.05:Use of restraint for non–behavioral health purposes is initiated either by an individual order or by an approved protocol, the use of which is authorized by an individual order. • Standard PC.03.02.07: The hospital monitors patients who are restrained for non–behavioral health purposes.

  15. Indications for Restraints • Patient at danger of hurting self/others AND there are no other alternatives • Restraint must be least restrictive possible AND used for shortest amount of time • Creative approaches can usually eliminate need for restraints • (More difficult in ICU/critical care setting), but often sedation is preferable • Generally NOT to be used in patients who are fall risk • increases risk of injury due to falls

  16. Creative approaches • Minimize use of IVs and think about alternatives to all lines and tubes • Heparin lock IV and cover with dressing • Sit up by nurse’s station during day and provide activity kits • Get family/friends to assist • Treat pain and attend to patient’s comfort • Try to keep patient occupied and active during the day so that they can sleep at night

  17. So how can you reduce falls if you can’t use restraints? • Difficult, probably only 20% preventable • Many of the interventions that work for delirium reduction also work for fall reduction • Keep patient active during day and involve PT early if patient has an abnormal gait • Use low beds rather than restraints or bedrails • Scheduled toileting • Think about reducing risk factors for injury from falls • Osteoporosis • Pros and Cons of anticoagulation • Restraint reduction reduces injuries Inouye et al N Engl J Med 360:2390, June 4, 2009

  18. Ms. Jones is “out there” • When you go to see the patient, she is moaning, pulling at her IV, and seems to be hallucinating. • You perform a physical examination, which is fairly benign. She is crying “help me, help me” and pulling at her IV. She can’t use a numerical pain scale but says her pain is bad. • You review her medications and I’s/O’s. She has taken no prn acetaminophen and no other prns. Her urine output has been good. • Latest labs were normal with the exception of a WBC of 11,000 with a slight left shift, a BUN of 28 (with a creatinine of 1.0)

  19. What should you do next, in addition to repeating her labs? • Order ativan 0.5mg PO or IV • Order haloperidol 0.5mg PO or IV • Order restraints, to be re-evaluated in the morning • Perform and Document mental status testing • Perform CT and LP

  20. Delirium Diagnosis MINI-COG (OR JUST CLOCK DRAW) OR DAYS OF WEEK BACKWARD PLUS CAM • Mini-cog -> normal v. abnormal • 3 item recall plus clock draw test • Normal: • Unlikely to have delirium OR dementia • Abnormal: • Is it delirium OR is it dementia OR is it both (may be hard to know for sure) • It the patient demonstrates inattention during the test, suspect delirium • OR • Consider days of week or months of year backward to look for inattention Inouye Engl J Med 354:1157, March 16, 2006

  21. 1. Acute Onset & Fluctuating Course 2. Inattention AND plus either 3. Disorganized Thinking 4. Altered LOC Delirium: Diagnosis CAM DELIRIUM Inouye SK et al. Ann Intern Med 1990;113:941-948.

  22. Your patient • She remembers 0/3 objects, and just draws squiggles on her clock • Cannot attend to days of week backwards, going back and forth between seeming sleepy and agitated • Based on CAM, you note: • Onset is acute • Patient has inattention • She has both disorganized thinking and altered level of consciousness • You make diagnosis of DELIRIUM

  23. Why is Delirium important? Delirium is Common: • Prevalence • 14-24% geriatric patients on admission • Incidence • 6-56% general hospital populations • ICU • 70-87% geriatric ICU pts • Post Op • 15-53% geriatric patients Inouye, N Engl J Med 354:1157, March 16, 2006

  24. Why is Delirium important? • Delirium is associated with increased mortality • 22-76% in hospital mortality • 35-40 % 1 year mortality • Delirium is associated with increased length of stay and costs of care • Delirium accounts for 49% of geriatric inpatient hospital days • $2,500/pt, + post hospital care • 6.9 billion medicare dollars/year • Life threatening dx in 10-30% of delirium presenting to ED Inouye, N Engl J Med 354:1157, March 16, 2006 Cole MG, Aust J Hosp Pharm 2001;31:35-40.

  25. Diagnosis Problems • Hypoactive most common • Mistaken for depression/withdrawn appearance • May be associated with higher mortality rates in patients with dementia • RNs may not report because patients are well behaved • Temporal variability • Requires multiple time points to assess throughout day • RNs and Family may aid in the diagnosis Yang FM et al. Psychosomatics. 2009

  26. Distinguishing Delirium from Dementia

  27. Follow up Ms. Jones Her examination, with the exception of her delirium, is normal. Her labs are normal, including a renal panel, calcium, CBC. Her ECG is normal. She is moaning and saying “help me, help me”. You note that as an outpatient, she was on MS contin 30 BID for chronic OA and neuropathic pain. What should you do next? A. Order CT scan of head B. Begin around the clock pain medications C. Order restraints

  28. Management (4 steps) 1. Minimize the Risk Factors (Iatrogenic) 2. Search for Medical Etiologies, underlying cause 3. Support the patient/safety concerns 4. Treat Symptoms

  29. Physical restraints, immobilization, foley catheter Malnutrition > or = to 3 medicine classes added or withdrawing chronic medications Sleep deprivation Psychoactive Medications Failure to control pain Urinary Retention (post foley, opiates, anticholinergics) Inouye, N Engl J Med 354:1157, March 16, 2006 Risk Factors for Delirium

  30. Delirium and Pain • Untreated pain is a risk factor for delirium • Pain often overlooked in demented/delirious patients • Low dose around the clock pain medications for patients in pain (e.g. post op) such as acetaminophen, weak opioid, or stronger opioid for worse pain/tolerant patients appears to REDUCE delirium • OVERTREATMENT of pain can contribute to delirium too • Demerol increased delirium risk – avoid it Vaurio, Linnea E Anesth Analg 2006 102: 1267-1273 Fong HK et al. Anesth Analg. 2006

  31. Medications commonly contribute to Delirium • 40% of delirium thought to be related to medications • Common Offending Agents • Anticholinergics • Combinations of meds with anticholinergic properties additive • H2 blockers • Diphenhydramine • Psychoactive medications • Benzos, sleepers • Multiple medications

  32. Directed medical workup • Good history and physical exam • CBC, chemistries, LFT’s, glucose, calcium, CXR, U/A, ECG • Basic infectious workup • Consider oxygenation and CO2 retention • Hydration • Consider ETOH/drug withdrawal • Consider urinary retention/fecal impaction • LP and CT generally low yield • <5% of cases • Consider with head trauma, focal neurologic findings, fever, no other cause, younger patients • EEG generally low yield • Consider in patients at high risk of seizures/status

  33. Pharmacologic Management • No FDA approved pharmacologic treatment • Good data is limited – most recommendations based on expert opinion, observation, and case reports • Probably best to use support with family (ideal) or sitter (second choice) when possible • Would use medications prior to physical restraints in most situations • Only two indications for medications: • severe agitation interfering with care • danger to self or others

  34. ANTIPSYCHOTIC USE IN DELIRIUM • May decrease course and severity • All have black box warnings; all potentially increase mortality • Need to check QTc before and after giving • Discuss risk with family or patients (often not possible) prior to giving • In ICU setting (intubated patients), preferable to use sedatives like propofol or dexdemetomidine Breitbart W. Am J Psychiatry. 1996; 153: 231-7) Lonergan Cochrane Database of Systematic Reviews 2007

  35. ANTIPSYCHOTIC USE IN DELIRIUM • First choice is usually low dose haloperidol 0.5 – 1 mg PO HS or BID and prn • Do not use in Parkinson’s Disease • Do not use in Dementia with Lewy Bodies • If uncertain, get neuro/geri/psych consult • Atypicals can also be used • Lower risk of extrapyramidal SEs, more expensive, higher risk of CVA • Risperidone: 0.5 mg PO BID and prn • Olanzapine: 2.5-5.0 mg PO BID and prn • Quetiapine: 25 mg po BID and prn • Only use benzodiazepines for ETOH, benzo withdrawal Breitbart W. Am J Psychiatry. 1996; 153: 231-7) Lonergan E Cochrane Database of Systematic Reviews 2007

  36. Pharmacologic Management • Treatment algorithm using haloperidol for “out of control” patients: • Load 0.5 – 1.0 mg PO or IM q 30 minutes until manageable • Maximum dose for naïve patients, 5 mg in a 24 hour period • Studies show equal adverse effects to atypicals if <3.5 mg/d • After 24 hrs, use ½ of loading dose in divided doses. • Taper beginning day 2 or 3 over several days. • If IV haloperidol, need telemetry monitoring. • For complex cases, consult psych, geropsych, or geriatrics

  37. Delirium Can be Prevented • Targeting common delirium risk factors can reduce delirium incidence by 1/3 Inouye SK, et al. NEJM. 1999;340:669-676.

  38. Visual Impairment Hearing Impairment Dehydration Glasses, Visual Aids, Early recognition & po repletion Hearing devices, Remove earwax Cognitive Impairment Sleep Deprivation Immobility Early Mobilization Orientation/ Activities Non-drug sleep enhancement

  39. Results • Delirium was reduced by 1/3 by instituting preventive measures • USUAL CARE = 15% ; PREVENTION GROUP = 10% • ARR= 5.1%, NNT = 20 to prevent one episode of delirium Inouye SK, et al. NEJM. 1999;340:669-676.

  40. Summary • Your patients will be helped enormously if you can: • Avoid unnecessary foley catheters and restraints • Try to reduce the incidence of delirium by preventing common risk factors • Recognize delirium • Appropriately manage and treat delirium • Keep your patient active during day and sleeping as much as possible (without sleepers) at night

  41. Resources and References • Vanderbilt U. Medical Center • www.icudelirium.org • SHM: geriatrics tool box • http://www.hospitalmedicine.org/geriresource/toolbox/mini_cog.htm • University of Chicago CHAMP resource • http://champ.bsd.uchicago.edu/ • NICHE Program and Resources • http://wiki.nicheprogram.org/wiki/Main_Page

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