CHAPTER 8 ACUTE CARE
Practice of Geriatrics
SECTION II SYSTEMS OF CARE IN GERIATRIC PRACTICE
CHAPTER 8 ACUTE CARE
Robert Marshall Palmer, M.D., M.P.H.
Aging and Hospitalization
Geriatric Syndromes: Detection and Management
Patient Values and Comfort
Whereas hospitalization offers older patients the potential benefits of specialty consultation and advances in medical technology, it also exposes them to the risks of iatrogenic illness and functional decline (a loss of independence in self-care activities). Knowledge of the risks of hospitalization and the management of common geriatric syndromes, however, helps primary physicians optimize their patients’ independent self-care and quality of life.
AGING AND HOSPITALIZATION
Patients aged 65 years and older account for 31% of hospital discharges and 42% of inpatient days of care.1 Rates of hospitalization are higher for the age group 85 years and older compared to the age group of 65 to 74 years. These trends continue despite changes in health care delivery such as that of the prospective payment system and the growth of managed care programs. Compared to younger patients, elderly patients have longer and more frequent hospitalizations, and the severity of illness is greater. Even when older patients recover from acute illnesses they may remain too functionally impaired to return home safely, necessitating discharge to a subacute care or long-term care facility. Early unplanned readmissions from these settings or from home are common for elderly patients, especially those with acute exacerbations of chronic diseases such as congestive heart failure.
Longitudinal studies demonstrate that a small proportion of older adults are consistently extensive users of hospital services. In the Longitudinal Study on Aging, a population-based study of 7527 individuals aged 70 years or older who were followed by interview from 1984 through 1991, 42.6% had no hospital episodes; among those with one or more hospital admissions, hospitalization occurred less than once a year among survivors as a rule, whereas about 20% of survivors and decedents were consistently high users of hospitalizations.2 These data imply a need for physicians to target their efforts to prevent functional decline in the high-risk patient, many of whom have chronic medical conditions, functional impairments at admission, and inadequate social supports at home.
GERIATRIC SYNDROMES: DETECTION AND MANAGEMENT
Hospitalized elderly patients are likely to show evidence of one or more of the common geriatric syndromes. Among the most important of these are iatrogenic illness, functional dependency (functional decline), cognitive dysfunction, immobility, depression, and undernutrition. Despite their high frequency among hospitalized elderly patients, these syndromes are often unrecognized or are not addressed. A systematic assessment for each of these syndromes, however, is achievable and can be facilitated through interdisciplinary collaboration and the use of common screening instruments. Interventions directed at detection and management of these syndromes will help to optimize patient care and improve the functional outcomes of hospitalization (Table 8-1).
TABLE 8-1 GERIATRIC SYNDROMES: PREVENTION AND MANAGEMENT
Iatrogenic illness is any illness that results from a diagnostic procedure or therapeutic intervention or any harmful occurrence that is not a natural consequence of the patient’s underlying illness. Iatrogenic illness may be categorized as cardiopulmonary complications, hospital-acquired infections (for example, urosepsis following insertion of an indwelling catheter), adverse drug events, complications of diagnostic or therapeutic procedures, unintentional injuries, or nonspecific events (e.g. pressure sores).3 Rates of iatrogenic illness and negligence are higher in elderly patients, in part because of the higher rates of comorbid illness in these patients and their longer lengths of hospitalization.
Iatrogenic illnesses are potentially preventable (see Table 8-1). In particular, careful attention to the prescription of drugs and the rational use of medications will help to lessen the risk of iatrogenic effect. Drugs with psychoactive effects, especially benzodiazepines and narcotic agents, are potential causes of cognitive impairment in elderly hospitalized patients. The risk of cognitive impairment from benzodiazepines is greater in patients who have abnormal cognitive function when they are admitted. These and other psychoactive drugs should be used judiciously in high-risk patients (e.g., patients with dementia or malnutrition). Drug-drug interactions, leading to adverse drug events, may occur when patients receive two or more drugs that undergo biotransformation in the liver by the cytochrome P450 oxidase system (e.g., diazepam and theophylline); act as inducers (e.g., phenobarbital) or inhibitors (e.g., cimetidine) of the microsomal oxidases; or compete for protein binding, especially albumin (e.g., warfarin and sulfa antibiotics), thereby increasing the availability of the unbound portion of the agent at the receptor site. Thus, the risk of adverse drug events can be reduced by prescribing drugs without known drug-drug interactions (e.g., hydrophilic drugs that undergo hepatic conjugation); by cautiously monitoring patients who receive drugs known to have narrow therapeutic windows (e.g., warfarin, gentamicin); and by adjusting the doses of drugs that compete for albumin binding.
Iatrogenic illness may be manifested as a nosocomial infection—e.g., from the use of broad-spectrum antibiotics that eliminate normal flora and lead to infections due to resistant microorganisms. Nosocomial infections can also be transmitted by professional caregivers or hardware (e.g., unclean stethoscopes). Nosocomial urinary tract infections are likely to occur in patients who undergo prolonged urethral catheterization. However, if careful attention is paid to hygienic handwashing techniques, cleaning of medical equipment, and the use of alternatives to continuous catheterization, the risk of iatrogenic illness can be reduced.
At the time of hospital admission, over half of patients aged 70 years and older who are admitted for medical illness are dependent in one or more activities of daily living.4 From admission to discharge, 25% to 35% of elderly patients lose independence in one or more of the basic activities of daily living. The loss of independent functioning during hospitalization is associated with important sequelae including prolonged length of hospital stay, greater risk of institutionalization, and, in some studies, higher mortality rates.4
The pathogenesis of functional decline is complex and involves an interaction among aging, hospitalization, acute illness, and comorbid illnesses. Elderly patients are predisposed to functional decline related to the impact of multiple comorbid conditions, impaired homeostatic reserves, and elements of hospitalization (e.g., physical restraint) that limit mobility and self-care.
Patients at risk of functional decline in the hospital can be identified at the time of hospital admission. Functional decline occurs more often in patients aged 75 years and older, those with cognitive impairment as indicated by correct responses to fewer than 15 of the first 21 items on the mini-mental state examination, and those who are dependent in two or more instrumental activities of daily living prior to admission.5 Functional decline in hospital may also occur more often in patients who are admitted with a pressure sore, baseline functional dependency, or a history of low social activity level.6 Symptoms of depression and delirium are consistently associated with functional decline and with poor recovery in both functional and psychosocial status following hospitalization.
Detection of functional impairment is achievable through self-reports of basic activities of daily living (ADL) and bedside observations. During their work rounds, physicians and nurses can observe a patient’s ability to bathe, dress, transfer from bed to chair, toilet, and eat independently, and they can monitor the patient’s ability to maintain continence. Balance and gait can be assessed simply by observing the patient getting out of bed or up from the chair and walking to the door of the room and back.
Patients with impaired independence in performance of basic ADL, gait, or ambulation often benefit from physical and occupational therapy consultation. Graded bedside exercises, increased physical activity, avoidance of restraints, and the use of assistive devices or aids may help to enhance the patient’s independent self-care.
Elderly patients are often admitted with evidence of cognitive dysfunction, commonly attributable to either dementia or delirium. Dementia is the single most important risk factor for the development of delirium or acute confusional state. Delirium is found at admission or during hospitalization in about 25% of elderly patients admitted for acute medical illnesses. Patients with baseline dementia and severe systemic illness are predisposed to delirium. Factors known to precipitate delirium include the use of physical restraints, the addition of more than three medications to the regimen, the use of a bladder catheter, malnutrition, and any iatrogenic event.3 These precipitating factors are potentially amenable to medical intervention (e.g., alternatives to physical restraint), underscoring the importance of a careful assessment of risk factors in every elderly hospitalized patient.
The diagnosis of delirium is suspected in patients with changes in mental status—impaired alertness, orientation, behavior, and perception. The diagnosis is further confirmed through bedside observations including brief tests of attention (e.g., digit span) and cognition (e.g., mental status examination); through interviews with family members and caregivers to ascertain the baseline level of cognition and the presence of recent changes; and through a review of progress notes and nurses’ observations to determine whether patients have had a fluctuating course in hospital, inappropriate behaviors, and delusions or hallucinations. The confusion assessment method (CAM) provides good sensitivity and specificity for the diagnosis of delirium: delirium is likely in patients with a change in mental status characterized by an acute onset and fluctuating course, inattention, and either disorganized thinking or an altered level of consciousness.7
The diagnosis of delirium should lead to intensive investigation of its cause and management (see Chapter 27). Both medical treatments and behavioral approaches are effective in alleviating the symptoms of delirium. In selected cases, low doses of anxiolytics or neuroleptics are indicated for treating patients with severe anxiety, delusions, or hallucinations. The symptoms of delirium may persist following hospital discharge. Many of these patients fail to return to their baseline level of cognition, and in their self-care abilities may remain impaired, suggesting the need for careful follow-up of their cognition level following hospital discharge.
Symptoms of depression are present in 10% to 25% of older patients at hospital admission and may coincide with symptoms of anxiety. In the absence of typical symptoms or a past history of major depression, a diagnosis of depression should be suspected in patients who appear withdrawn, uncooperative, or intermittently agitated. These patients are often functionally impaired and may have cognitive deficits. Detection of depressive symptoms is achievable with case-finding instruments such as the Geriatric Depression Scale or observations of the patient’s mood by professional caregivers or family members.
Therapy of patients with depressive symptoms includes environmental, psychosocial, and pharmacologic interventions. Environmental changes, physical and occupational therapy, increased frequency of family visits, and psychological counseling may be of immediate benefit to the depressed patient. Psychiatric consultation is most useful in characterizing the depressive disorder and in initiating antidepressant drug therapy. Therapies begun in the hospital should be continued following discharge to maximize their effectiveness.
Aging, decreasing muscle mass and strength, diminished physiologic reserves, and acute illness combine to predispose older patients to immobility and functional decline.8 During an acute illness, many older patients prefer to remain in bed. However, sustained bedrest has adverse physiologic effects. For example, it leads to cardiac deconditioning, muscle atrophy, and accelerated loss of muscle strength. After several days of prolonged bedrest, many older patients are unable to transfer from bed to chair or to stand without assistance. The deleterious effects of acute illness and immobility are further exacerbated by bedrest, the use of physical or chemical restraints, restrictions on patient mobility imposed by intravenous lines and catheters, and limitations on independent mobility due to environmental conditions, such as absent handrails in hallways or slippery floors.4,8
Patient mobility can be readily evaluated through observations of patient transfers and walking and can be addressed each day during hospital rounds. Activities that maintain joint function and strength of the lower extremities should be prescribed on the first hospital day, particularly for bedbound patients. As patients convalesce from acute illnesses, the intensity of prescribed exercises should increase. Prescribed exercises range in intensity from both passive and active range of motion of joints to resistive exercises of the lower extremities and assisted ambulation and to even more rigorous exercises performed in the physical therapy department. Low-impact resistance exercises are especially recommended for bedbound patients to maintain the strength of the lower extremities until they regain weight-bearing capacity. Gentle resistance or pressure is applied by hand as the patient completes foot circles (pressure is applied to the ankle as each foot moves around in a circle), knee bends (pressure is applied as the patient straightens each leg), leg lifts (pressure is applied as the patient lifts each leg off the bed), and side leg stretches (pressure is applied to each leg during abduction). In many hospitals these exercises are conducted by nursing care assistants or physical therapy technicians with a physician’s order. Patients at high risk of falls and those who develop postural instability or gait impairment are evaluated by physical therapy. The value of these exercises is worth underscoring; even the marginal benefits of aerobic and resistive exercises may enable the patient to regain the physical independence needed to return home rather than entering a nursing care facility following hospital discharge.
Patients whose activity is limited to bed or chair are at risk for development of stage II (or greater) pressure ulcers. Ulcers occur more often in patients who have nonblanchable erythema, lymphopenia, immobility, dry skin, and decreased body weight.9 Patients with these risk factors need aggressive mobilization to avoid developing pressure sores.
Malnutrition is present in 30% to 40% of elderly hospitalized patients with medical illnesses.4 Elderly patients are at risk for undernutrition before and during hospitalization. The risks are due to the common concurrence of chronic medical illnesses (e.g., heart failure, chronic obstructive pulmonary disease), cognitive impairment, social isolation, poor dentition, reduced thirst perception, and limited access to food and fluids. Protein-calorie malnutrition is associated with functional dependency and contributes to a higher risk of death from chronic diseases such as congestive heart failure.10
Malnutrition is diagnosable on the basis of objective anthropometric measurements such as scapular skin-fold thickness and body mass index and on biochemical measures of nutrition. Malnutrition can be suspected on clinical grounds in patients who report a significant history of weight loss in the previous 6 months and who have physical findings suggestive of malnutrition (loss of subcutaneous fat, muscle wasting, ankle edema, sacral edema, and ascites). Many of these patients also have abnormal biochemical parameters consistent with a diagnosis of protein-calorie malnutrition—e.g., a serum albumin level of below 3.5 g/dL, normocytic anemia, and a serum cholesterol level of less than 160 mg/dL). They may also have anergy to common antigens, a low total lymphocyte count, and depressed levels of transferrin or prealbumin.
Patients who are identified as malnourished at admission or who are at high risk of undernutrition in hospital (e.g., patients who have impaired self-feeding ability or are cognitively impaired) may benefit from consultation with a dietitian and from prescribed and monitored quantities of food and fluids consumed daily. For some of these patients, calorie-dense and nutritious but palatable food supplements or snacks can be offered. Patients with generalized weakness or a history suggestive of aspiration pneumonia should be carefully assessed for oropharyngeal dysphagia. Formal evaluation of swallowing conducted by a speech therapist and complemented by a modified barium swallow examination is useful when patients are at risk for aspiration pneumonia. Patients with dysphagia when swallowing liquids may benefit from a pureed diet or thickened liquids, which enable them to swallow safely and provide sufficient calories and hydration.
Patients with a significant risk of aspiration due to severe oropharyngeal dysphagia or to severe weakness or confusion may require short-term enteral or parenteral alimentation. Enteral dietary supplementation was shown to reduce the rate of complications and mortality in patients with hip fractures who were given a balanced nutritional supplement.11 The benefits and risks of nasoenteral supplementation should be discussed with the patient and with family members prior to placement of the feeding tube. A percutaneous endoscopic gastrostomy tube should be considered for patients who are severely malnourished or have dysphagia that is unlikely to resolve in the foreseeable future. When enteral alimentation is contraindicated for an indefinite period of time (e.g., due to bowel obstruction or inflammatory bowel disease), total parenteral nutrition should be considered following consultation with the nutrition support team.
PATIENT VALUES AND COMFORT
The patient’s personal values and perceptions of the hospital experience should be sought early in the course of hospitalization. Because many acutely ill patients may lose their ability to make medical care decisions, preferences for care and advance directives should be reviewed early in the hospitalization with the patient and family members. The patient’s expectations of treatment and attitudes toward cardiopulmonary resuscitation may serve to guide medical treatment. This information can assist the physician in making critical decisions about the aggressiveness of diagnostic evaluation or the management of difficult medical problems (e.g., whether to transfer a patient to an intensive care unit or to undertake invasive diagnostic or therapeutic interventions).
Periodic discussions with the patient and family members also help to allay their fears and anxieties about hospitalization, the patient’s illness, the prognosis, and home care requirements. The patient’s personal and emotional needs can be further supported through other measures including continuity of nursing care, correction of sensory deficits, reality orientation, and a quiet environment that promotes relaxation and sleep at night.4
The complex physical, psychosocial, and medical needs of older patients are often best addressed through interdisciplinary collaboration. Physicians work with a variety of health care professionals, each of whom has an important role to play in the complex assessment and management of elderly patients (Table 8-2). Collaboration between the physician and nurses is of paramount importance. This collaboration facilitates early detection of treatable functional impairments that may benefit from interdisciplinary interventions (e.g., physical therapy evaluation for patients with generalized weakness, or dietitian consultation for patients with malnutrition). The physician and nurse may agree on specific care plans for the patient including clinical pathways and the need to include other health professionals in the patient’s hospital management.
TABLE 8-2 THE INTERDISCIPLINARY TEAM
Interdisciplinary collaboration between physicians and other health professionals has beneficial effects on patient outcomes. The effectiveness of a nurse-directed, multidisciplinary intervention on rates of hospital readmission of elderly patients with congestive heart failure was recently demonstrated.12 Elderly patients receiving the intervention—comprehensive education of the patient and family, prescribed diet, social service consultation and early plans for discharge, review of medications, and close follow-up after discharge were less likely to be readmitted for the same diagnosis and reported a higher quality of life 90 days later.
The benefits of interdisciplinary collaboration have also been demonstrated in acute care geriatric units.13 These acute care units typically include a physical environment that fosters independent patient functioning, emphasize expanded roles for nurses and multidisciplinary collaboration, initiate comprehensive discharge planning early in the patient’s hospital course, and make provisions for transition of care from hospital to home. In a clinical trial of an acute care of elders (ACE) unit, interdisciplinary collaboration was one of the interventions associated with a decrease in the prevalence of functional decline (loss of independent self-care) in hospitalized, medically ill, elderly patients.14 ADL function was significantly better at discharge than on admission for patients receiving the ACE intervention than for patients receiving the usual medical care. Fewer patients receiving ACE intervention were discharged for the first time to institutional long-term care (9% compared to 16% of patients receiving usual care), and mean hospital charges and length of stay were similar for both groups of patients.
Ongoing interdisciplinary collaboration throughout the patient’s hospitalization may be the key to improving clinical and functional outcomes. When geriatric assessment at the time of admission is performed by a team not involved in the patient’s care, no benefit of consultation on hospital outcomes or mortality is demonstrated.15
Comprehensive Discharge Planning
The process of discharge planning is most effective when it is initiated shortly after the patient is admitted. Most hospitals employ either a clinical nurse specialist, clinical nurse manager, or other discharge planner to assist physicians with the process of discharge planning. When clinical nurse specialists coordinate the discharge planning of hospitalized elderly patients with common diagnoses such as congestive heart failure and myocardial infarction, patients are less likely to be readmitted to the hospital, have fewer total days of rehospitalization, and to incur lower charges for health care services after discharge.12,16 However, the interdisciplinary process of discharge planning is easiest to conduct in ACE units, where all health professionals have an opportunity for daily interaction through team rounds and contact with the nurse specialist.13
The pressure on physicians to discharge patients rapidly from the hospital makes the need for early discharge planning more critical. Discharge planning helps physicians estimate a patient’s hospital length of stay, create a trajectory of the patient’s functional status at hospital discharge, and anticipate the patient’s needs for social support and services following discharge. Collaboration with the interdisciplinary team helps the physician decide the best disposition site for patients following discharge.
Most elderly patients return home after hospitalization, but some require rehabilitation or short-term subacute care, whereas others require home care with skilled nursing services or long-term care placement. Patients admitted with a self-limited illness who can perform self-care activities independently may return home, usually without the need for formal (paid) home-care services. Patients with categorical illnesses, such as hip fracture or stroke, who have good rehabilitative potential and adequate informal supports may be accepted for transfer to a rehabilitation hospital. For patients who are unable to tolerate the rigors of extensive physical therapy (e.g., 3 or more hours daily) in a rehabilitation hospital, a subacute care unit (skilled nursing facility) can provide short-term restorative services prior to the patient’s return home. Home health care is a reasonable alternative when patients and their families prefer to receive restorative services at home. Patients who are functionally impaired and lack adequate social supports will probably require placement in a long-term care facility. Terminally ill patients can be admitted to palliative care (hospice) programs either in a hospital or at home.
Patients should not be discharged from the acute care hospital if there is evidence of clinical instability on the day preceding the planned discharge (Table 8-3). Patients who are discharged to home in an unstable condition have a higher mortality risk after hospitalization compared to patients whose condition is stable.17,18
TABLE 8-3 CLINICAL INSTABILITY: DAY OF PLANNED DISCHARGE
The loss of functional independence is not an inevitable consequence of acute illness and hospitalization among elderly patients. Interventions—daily assessment linked to treatment, medical care review, and interdisciplinary care with comprehensive discharge planning—may improve the functional outcomes of hospitalization.14
United States Department of Health and Human Services: Vital and Health Statistics: Health Data on Older Americans, 1992. Series III: Analytic and epidemiological studies, No. 27. DHHS Publication No. 93-1411. Hyattsville, MD, U.S. Dept. of Health and Human Services, 1993.
Wolinsky FD, Stump TE, Johnson RJ: Hospital utilization profiles among older adults over time: Consistency and volume among survivors and decedents. J Geront Soc Sci 1995;50B:S88–S100.
Inouye SK, Charpentier PA: Precipitating factors for delirium in hospitalized elderly persons. Predictive model and inter-relationship with baseline vulnerability. JAMA 1996;275:852–857.
Palmer RM: Acute hospital care of the elderly: Minimizing the risk of functional decline. Cleve Clin J Med 1995;62:117–128.
Sager MA, Rudberg MA, Jalaluddin M, et al: Hospital admission risk profile (HARP): Identifying older patients at risk for functional decline following acute medical illness and hospitalization. J Am Geriatr Soc 1996;44:251–257.
Inouye SK, Wagner DR, Acampora D, et al: A predictive index for functional decline in hospitalized elderly medical patients. J Gen Intern Med 1993;8:645–652.
Inouye SK, Viscoli CM, Horwitz RI, Hurst LD, Tinetti ME: A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med 1993;119:474–481.
Creditor MC: Hazards of hospitalization of the elderly. Ann Intern Med 1993;118:219–223.
Allman RM, Goode PS, Patrick MM, Burst N, Bartolucci AA: Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA 1995;273:865–870.
Cederholm T, Jagren C, Hellstrom K: Outcome of protein-energy malnutrition in elderly medical patients. Am J Med 1995;98:67–74.
Delmi M, Rapin C-H, Vengoa J-M, Delmas PD, Vasey H, Bonjour J-P: Dietary supplementation in elderly patients with fractured neck of the femur. Lancet 1990;335:1013–1016.
Rich MW, Beckham V, Wittenberg C, Leven CL, Freedland KE, Carney RM: A multidisciplinary intervention to prevent the re-admission of elderly patients with congestive heart failure. N Engl J Med 1995;333:1190–1195.
Palmer RM, Landefeld CS, Kresevic D, Kowal J: A medical unit for the acute care of the elderly. J Am Geriatr Soc 1994;42:545–552.
Landefeld CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J: A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med 1995;332:1338–1344.
Reuben DB, Borok GM, Wolde-Tsadik G, et al: A randomized trial of comprehensive geriatric assessment in the care of hospitalized patients. N Engl J Med 1995;332:1345–1350.
Naylor M, Brooten D, Jones R, Lavizzo-Mourrey R, Mezey M, Pauly M: Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Ann Intern Med 1994;120:999–1006.
Kosecoff J, Kahn KL, Rogers WH, Reinisch EJ, Sherwood MJ, Rubenstein LV, Draper D, Roth CP, Chew C, Brook RH: Prospective payment system and impairment at discharge. The “quicker and sicker” story revisited. JAMA 1990;264:1980–1983.
Brook RH, Kahn KL, Kosecoff J: Assessing clinical instability at discharge. The clinician’s responsibility. JAMA 1992;268:1321–1322.