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Acute Care of the Hospitalized Elderly Patient

Acute Care of the Hospitalized Elderly Patient. Rosanne M. Leipzig, MD PhD Patricia Bloom MD Helen Fernandez MD Brookdale Department of Geriatrics Mount Sinai School of Medicine. Why This Talk?. Adults Over 65 years Old. National Hospital Discharge Survey 2007.

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Acute Care of the Hospitalized Elderly Patient

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  1. Acute Care of the Hospitalized Elderly Patient Rosanne M. Leipzig, MD PhD Patricia Bloom MD Helen Fernandez MD Brookdale Department of Geriatrics Mount Sinai School of Medicine

  2. Why This Talk? Adults Over 65 years Old National Hospital Discharge Survey 2007

  3. Fernandez, H. and Callahan, K

  4. ADLs Dressing Eating Ambulation Transfer Hygiene Bathing Toileting Instrumental ADLS Telephone use Getting to places beyond walking distance Grocery shopping Preparing meals Housework/handyman work Taking medications Managing money Functional Status: Activities of Daily Living (ADLs)

  5. Outcomes of Acute Care for Older Adults • Early 1990’s (5 sites): • 31% lose >1 basic ADL at discharge c/w pre-admission • 2/5 of these remained impaired 3 months later • 40% have IADL decline at 3 months • 1998-2008 • 42% lose >1 basic ADL at discharge c/w pre-admission (1 site) • 6 months later • 23.3% non-recovered • 17.4% dead • Similar initial declines in Israel, Italy Sager M et al:Arch Intern Med. 1996 Mar 25;156(6):645-52.; Barry LC et al: JAGS 2011; DOI: 10.1111/j.1532-5415.2011.03453.x

  6. New Admission, RF • 82 year old female admitted for left humeral fracture after fall. Asymptomatic except for pain. • H/O HTN, CHF, osteoarthritis, osteoporosis, depression • Meds: • Lisinopril 10 mg qd, Atenolol 25 mg qd • Furosemide 20 mg qd Vitamin D 1000 IU qd • Paroxetine 20 mg qd Calcium 500 mg tid • Ibuprofen 400 mg tid prn Alendronate 70 mg once a week

  7. New Admission • Lives alone; nonsmoker, nondrinker • Exam • 110/80, 80, 16, 37.5 C, Wt: 100 lb • Alert and oriented x 3 • HR 80, reg; no m/g/r • Chest clear to P+A • Abdomen soft, NT • No CCE • L upper extremity in sling- painful to active or passive motion • Foley and IV catheter in place

  8. Admitting Orders • Admit to …… • Dx: L Humeral fracture • Activity: • Diet:

  9. Admitting Orders • Admit to …….. • Dx: Left humeral fracture • Activity: Bed Rest

  10. Usual Aging Creditor, M. C. Ann Intern Med 1993;118:219-223

  11. Bed Rest and Hospitalization are Dangerous to the Health of Older Adults Bed Rest Creditor, M. C. Ann Intern Med 1993;118:219-223

  12. Bed Rest and Hospitalization are Dangerous to the Health of Older Adults • Loss of strength/day at bed rest • Football players:1-1.5% strength/day (10%/week) • Elderly patients: 5%/day (35%/week) • Reconditioning takes much longer than deconditioning Creditor, M. C. Ann Intern Med 1993;118:219-223

  13. Bed Rest and Hospitalization are Dangerous to the Health of Older Adults • Bone resorption of elderly acutely ill person at bedrest 50 TIMES usual involutional rate Creditor, M. C. Ann Intern Med 1993;118:219-223

  14. Bed Rest and Hospitalization are Dangerous to the Health of Older Adults • Usual Aging: pO2 = 90 – (age over 60) • Costochondral calcification and reduced muscle strength diminish pulmonary compliance and increase RV • Bed rest (supine position) decreases pO2 by 8 mm on average • Closing volume increases, more alveoli hypoventilated • pO2 for an 80 year old: • Normal: 70 • At bedrest: 62 Creditor, M. C. Ann Intern Med 1993;118:219-223

  15. Bed Rest and Hospitalization are Dangerous to the Health of Older Adults • Skin necrosis results from direct pressure > capillary filling pressure (=32 mmHg) for more than 2 hours • Sacral pressure after short immobilization=70 mm • Increased likelihood of shearing forces and exposure to moisture increase risk of skin breakdown • Pressure ulcer prevalence 20-25% Creditor, M. C. Ann Intern Med 1993;118:219-223

  16. Admitting Orders • Admit to • Dx: Left humeral fracture • Activity: Bed Rest

  17. Bed Rest is Only Good for Dead People and a Few Others

  18. Admitting Orders • Admit to … • Dx: Left humeral fracture • Activity: Out of bed to chair; ambulate with assistance day and evening shift • Diet: NPO for surgery • Foley catheter to closed drainage • IV: D5/0.5NS at 75 cc/hr

  19. CTSP for • Temp 38.5, HR 130 irreg, irreg and SOB • Exam: BP 110/70; RR 20; right posterior rales • CXR: possible RLL infiltrate • EKG shows MFAT • Medicine consult called • Surgery held • IV antibiotics started

  20. Orders • Admit to …… • Dx: Left humeral fracture • Activity: Out of bed to chair; ambulate with assistance day and evening shift • Foley catheter to closed drainage • IV levofloxacillin • Diet: NPO for surgery

  21. What Diet Should be prescribed for Ms RF? • A) Regular diet • B) No added salt • C) 2 gm Na+

  22. Bed Rest and Hospitalization are Dangerous to the Health of Older Adults • Sense of taste decreases with age • Hospital food often tasteless • Decreased intake if not salted or seasoned • 25-30% of hospitalized elderly are under/malnourished • Under/malnutrition a strong negative predictor of clinical outcome • Readily available markers: • Serum albumin (after rehydration- ck the Hb) • TLC (WBC x lymph %) (WNL=2000+) Creditor, M. C. Ann Intern Med 1993;118:219-223

  23. Bed Rest and Hospitalization are Dangerous to the Health of Older Adults • Older adults tend toward intravascular dehydration • Thirst is less for degree of hyperosmolarity • Renal concentrating ability often impaired • Salt wasting increases Creditor, M. C. Ann Intern Med 1993;118:219-223

  24. Orders • Admit to…… • Dx: Left humeral fracture • Activity: Out of bed to chair; ambulate with assistance day and evening shift • Foley catheter to closed drainage • IV Levofloxacin • Diet: Regular; monitor food intake • Benedryl 25 mg prn sleeplessness

  25. CTSP for • Agitation, trying to get out of bed and attempting to pull out foley and IV • Exam unchanged from before except more confused • What’s going on?

  26. Bed Rest and Hospitalization are Dangerous to the Health of Older Adults Creditor, M. C. Ann Intern Med 1993;118:219-223

  27. Delirium -- DSM-IV A. Disturbance of Consciousness • Reduced ability to focus, sustain, shift attention B. Cognitive Change • Memory • Perception (Hallucinating, Delusions, Illusions) • Disorientation • Language Disturbances C. Develops over time D. Fluctuates during the course of the day

  28. Abrupt, precise onset Acute illness (days to weeks), rarely over one month Usually reversible Variability hour-to-hour Disturbed sleep-wake cycle, (hour-to-hour ) Gradual onset Chronic Illness, progressing over years Generally irreversible Generally more stable Day-night reversal of sleep-wake cycle Distinguishing Delirium from Dementia Delirium Dementia

  29. Clouded, altered, changing level of consciousness Short attention span Disorientation early Hallucinations early Marked psychomotor changes Consciousness not clouded until terminal Normal Attention span Disorientation late, after months or years Hallucinations late (except with hearing or visual problems or delirium) Psychomotor changes late Distinguishing Delirium from Dementia (cont’d) Delirium Dementia

  30. Delirium in Elderly Hospitalized Patients: Morbidity and Mortality • Increased • Mortality • Institutionalization • Length of Stay • Physical and Chemical Restraints • Pressure Ulcers • Dehydration • Aspiration • Malnutrition • Deconditioning Ref: Inouye SK. NEJM 2006;354:1157-65

  31. Delirium in Hospitalized ElderlyPredisposing Factors • Severe Illness, co-existing medical conditions • Dementia and Structural Brain Disease, h/o delirium, depression • Advanced Age • Impaired functional status • Impaired Hearing or Vision • Decreased oral intake (dehydration, malnutrition) • Drugs (multiple, esp psychotropic; alcohol) Ref: Inouye SK. NEJM 2006;354:1157-65

  32. Delirium in Hospitalized ElderlyPrecipitating Factors • Drugs: • sedative hypnotics, narcotics, anticholinergics, alcohol withdrawal, treatment with multiple drugs • Primary neurologic disease • Intercurrent illnesses • Surgery • Environmental • Physical restraints, bladder catheter, pain, multiple procedures, stress • Prolonged sleep deprivation Ref: Inouye SK. NEJM 2006;354:1157-65

  33. Delirium in Hospitalized PatientsValidation Cohort PredisposingFactors PrecipitatingFactors Inouye and Charpentier JAMA. 1996 Mar 20;275(11):852-7

  34. Confusion Assessment Method (CAM) for Diagnosing Delirium • Both • Acute onset and fluctuating course • Inattention • And either • Disorganized thinking, or • Altered level of consciousness Inouye et al. Ann Intern Med 1990;113:941-948.

  35. CAM: Test Characteristics12 studies pooled • Sensitivity: • 86% (74-93) • Specificity: • 93% (87-96) • + Likelihood Ratio: • 9.6 (5.8-16.0) • - Likelihood Ratio: • 0.16 (0.09-0.19) Wong CL et al JAMA 2010; 304(7):779-786

  36. MMSE Tests of Attentionin Cognitively Intact Subjects • Serial 7s (79) • 43.5% with 5/5 correct • WORLD backwards • 74.1% correct Ganguli M. et al. J Geriatr Psychiatry Neurol. 1990;3(4):203-7.

  37. Attention and ConcentrationAssessment • Serial 7s • Cancellation tasks • Random digits, forwards/backwards • Months of the year, days of the week, forwards/backwards

  38. CONFFUSED C- entral Nervous System O- rgan Dysfunction N- utrition F- ever F- luids and Electrolytes U- rine infection, retention S- ensory over- or under- stimulation E- ndocrine Disorders D- rugs- including withdrawal Leipzig RM 1992

  39. Drugs Commonly Causing Delirium • Alcohol, other sedative/hypnotics • Anticholinergics (diphenhydramine, tricyclics, cimetidine, theophylline) • Opioid analgesics (esp meperidine) • Corticosteroids • Antihypertensives/cardiac drugs • Antiparkinsonian drugs • Psychoactive drugs (anxiolytics, hypnotics)

  40. Delirium Evaluation 1. CONFFUSED 2. Target Labs • CBC, SMA.6, Creatinine, Calcium, Phosphate, LFTs 3. Search for Occult infection: CXR, UA 4. Consider • ABGs, EKG, LP, CT/MRI • Mg, TFTs, B12, Drug Levels, Ammonia, Tox Screen • EEG Ref: Inouye SK. NEJM 2006;354:1157-65

  41. Treatment of Delirium • Treat underlying medical problem • Stop offending medications • Use environmental interventions • Reduce isolation, reassurance, conversation • Identify precipitants • Maximize safety • Restrain or use low dose antipsychotics ONLY when absolutely necessary

  42. Antipsychotics: Weighing the Benefits vs Risks Ref: Image retrieved on 29 June 2011 from: http://office.microsoft.com/en-us/images/MM900283494.aspx

  43. Black Box Warning: June 16, 2008 • Antipsychotics are not indicated for the treatment of dementia-related psychosis. • Elderly patients with dementia-related psychosis treated with conventional or atypical antipsychotic drugs are at an increased risk of death.

  44. Antipsychotics and Mortality • Both atypical and typical antipsychotics • Occur early in course of treatment • For atypicals, NNH= 100 (50- 250) • No differences in risk by: • specific drug • severity of dementia • diagnosis. • For typicals, risk was greatest • During the first 40 days • higher doses Schneider LS, Dagerman KS, Insel P. JAMA. 2005; 294 (15): 1934-1943. Wang PS, Schneeweiss S, Avorn J, et al. N Engl J Med. 2005; 353(22):2335-2341.

  45. Black Box Warning: June 16, 2008 • Antipsychotic drugs are not approved for the treatment of dementia-related psychosis.  • Furthermore, there is no approved drug for the treatment of dementia-related psychosis.  Healthcare professionals should consider other management options. • Physicians who prescribe antipsychotics to elderly patients with dementia-related psychosis should discuss this risk of increased mortality with their patients, patients’ families, and caregivers

  46. When Should Antipsychotics Be Prescribed in Dementia? • When severe symptoms cause suffering for the patient, disrupting needed care, and/or leading to danger, benefits may outweigh risk. • Document: • your evaluation of the benefits and risks for the specific patient • your discussion with family and conclusion that the potential benefits outweigh the potential risks, including those of CVAEs and increased mortality. AGS 2011: Guide to the Management of psychotic disorders and neuropsychiatric symptoms of dementia in older adults

  47. Antipsychotic Drugs of Choice for Delirium • Haloperidol (Haldol) • Starting dose : 1-2 mg po or 0.5-1 mg IM/IV • Average dose/24 hrs : 1.5 – 2 mg IM/IV • Risperidone (Risperdal) • Starting dose : 0.25 – 0.5 mg po • Average dose/24 hrs : 0.5 – 1.5 mg • Olanzapine (Zyprexa) • Starting dose : 2.5 – 5 mg • Average dose/24 hrs : 5 – 7.5 mg

  48. Restraints • Lead to all the hazards of immobilization, plus increased agitation, depression, and injury • Restraints do NOT decrease falls (may increase by increasing deconditioning*) • JAHCO Acute Med/Surg Standard for Restraints: • Applied when a restraint is necessary for the patient’s wellbeing and can be used to improve medical care • All patients have the right to the least restrictive environment of care • Tinetti ME et al. Ann Intern Med. 1992 ;116(5):369-74; • Capezuti E, et al; J Gerontol A Biol Sci Med Sci. 1998 Jan;53(1):M47-52.

  49. Alternatives to Use of Restraints and Antipsychotics • Increase nursing surveillance • Involve family and friends • Modify medications if problematic • Reality orientation, explanation, reassurance • Improve hearing and vision • Modify environment to increase safety • Reconsider NG tubes, IVs and catheters

  50. Orders • Admit to…… • Dx: Left humeral fracture • Activity: Out of bed to chair; ambulate with assistance day and evening shift • Diet: Regular; monitor food intake • Foley catheter to closed drainage

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