Hospital Care Geriatrics

Assessment of the Hospitalized Patient “When we’re struggling with thinking about how to support the clinical enterprise in geriatrics, there are tremendous opportunities in looking at how we can improve care for older adults in the hospital,” said Seth Landefeld, MD, Professor of Medicine, Department of Epidemiology and Biostatistics; Professor and Chief, Division of Geriatrics, Department of Medicine, University of California, San Francisco (UCSF); and Director, UCSF Mount Zion Center on Aging; and Associate Chief of Staff for Geriatrics and Extended Care, San Francisco VA Medical Center. According to the speaker, 36% of acute care admissions are persons age 65 or older, and patients in this age group are hospitalized approximately three times as frequently as younger adults and account for nearly 50% of hospital expenditures. Throughout his presentation, Dr. Landefeld discussed the positive and negative aspects of hospital care, the effects of hospitalization on acutely ill older patients during and after admission, and the implications for assessment of older adults in the hospital. When elderly patients leave the home and are admitted to the hospital, they may be less afraid, their families may cope better with their illnesses, and there are health care professionals available to care for them. Unfortuantely, many patients are unhappy about being there, there is a lot of waiting involved, hospitals are generally not designed to work well from patients’ point of view and do not run on patient time, they can be dangerous for a variety of reasons, and they are often insensitive to what patients feel their needs are. “We know that medical mistakes kill,” the speaker said. Mistakes—some of which are fatal—that occur in hospitals seem to disproportionately affect many patients. The Institute of Medicine reported that each year medical mistakes account for approximately 100,000 deaths in the United States. Dr. Landefeld noted that preventable adverse events are more common in older hospitalized patients; persons age 65-75 are at lower risk than the very frail, many of whom are admitted from long-term care settings or the home. The speaker suggested that the problems with hospital care of older adults may be attributed to issues other than errors. In their study on whether more health care improves survival, Fisher and coauthors^1,2 noted that Medicare spending per capita varies twofold throughout the United States, which is attributed to variations in services associated with the local supplies of doctors and hospitals. Researchers found that the amount of resources provided in hospital care is not associated with improved health outcomes in patients with hip fracture, colo- rectal cancer, and acute myocardial infarction (MI), and may even be dangerous for patients with certain diseases. How hospitalized patients function (ie, how well they are able to care for themselves, the level of their activities of daily living [ADLs] and instrumental ADLs [IADLs]) is quite dynamic. The speaker observed a study by Covinsky and coauthors³ in which approximately two-thirds of hospitalized older patients were discharged with the same ADL function that they had at the time of admission, while the ADL function in one-third of participants declined. At the time of admission, 57% of patients were stable, 45% remained stable during hospitalization, and 12% declined. Among the 43% of the patients who were admitted with a decline, nearly half improved during hospitalization, while the remainder either did not recover or worsened. According to the speaker, ADL disability is “the ticket to nursing home placement, the place that most people don’t want to be,” and is the most common high risk factor for death at discharge. Older age is an independent risk factor for functional decline and increases the risk for worse ADL outcomes only after admission to a hospital; those over age 85 are less likely to recover function after they have declined, even before hospitalization. In order to promote ADL recovery and/or prevent further decline during hospitalization, Dr. Landefeld suggested identifying high-risk conditions and high-risk patients for whom physicians might try to intervene. Risk factors for failure to recover include delirium, dementia and cognitive impairment, depression, protein-energy malnutrition, starvation, certain hospital interventions, and financial disability. Researchers have referred to delirium as a symptom of how hospital care is failing older patients, and have demonstrated that the condition is associated with worse hospital outcomes, higher death rates, higher rates of nursing home placement, and longer lengths of stay. According to the speaker, episodes of delirium may either precipitate or worsen underlying cognitive impairment and dementia. Dementia and cognitive impairment, depression, and protein-energy malnutrition are all very common and are frequently overlooked in hospitalized elderly patients. Rates of dementia and cognitive impairment vary depending on the different patient populations and the instruments used. Cognitive impairment slows recovery of ADL and IADL function. Major or minor depression, which may increase both functional decline and death rates, occur in about one-third of hospitalized elderly patients, and worsens ADL and IADL function at discharge and afterwards. Patients with depressive symptoms and other serious diseases are likely to die faster after the measures of that illness are taken into account. Protein-energy malnutrition can lead to higher death rates, ADL dependence, and nursing home placement. Starvation is associated with anorexia, cognitive impairment, decreased intake, and difficulty chewing. “Not only are many of our patients malnourished on admission and associated with bad outcomes, but we often forget to do things to help folks eat during hospitalization,” Dr. Landefeld said. Certain hospital interventions may exacerbate outcomes as well. Foley catheters, for example, are associated with lower survival and longer length of stay. Financial disability (ie, not having enough money to pay for groceries, bills, medications) causes both functional decline after discharge and a higher mortality after discharge. To improve the outcomes of acutely ill older patients, the speaker recommended that physicians think twice about hospitalization. “There’s a lot of evidence to suggest that the hospital is a dangerous place, and if you can do what you need to do elsewhere, you’re better off doing it,” he said. In addition, by managing the six risk factors of delirium (ie, cognitive impairment [orienting people frequently], sleep deprivation [no vital signs late at night or early in the morning], immobility [walking patients whenever possible], visual and hearing impairment [ensuring patients have the things they need to see and hear], avoiding dehydration), the incidence of delirium will reduce substantially. Because there is no evidence suggesting that treating delirium will be successful, prevention is the best strategy. Nonetheless, it is also important to eliminate medications such as sedatives, hypnotics, narcotics, and anticholinergics; to treat the metabolic causes (check sugar levels), monitor sodium and oxygen levels as well as renal or liver failure and hypercalcemia; to consider occult infection; and to normalize patients by walking with them, talking to them, and orienting them. In addition, ensuring that malnourished patients eat and administering oral supplementation may lead to weight gain, increased arm circumference, mortality, no significant affect on complications, and a shorter length of stay. Two methods to improve hospital care include Geriatric Evaluation and Management (GEM) and Acute Care for Elders (ACE). In GEM, a multidisciplinary and comprehensive approach to the care of frail elderly patients after stabilization in acute care hospitals, patients become stabilized after 3-5 days and are transferred from the VA setting to a GEM unit. GEM was first initiated in the 1980s, and demonstrated improvements in various SF-36 subscales, physical functioning, number of basic ADLs, energy, general health, physical performance, and a decrease in bodily pain at discharge. In ACE, which is not as selective as GEM, patients are admitted to the hospital from the ER. Patients are able to maintain and improve ADL function, more have reported excellent or good health at discharge, more have shown improvements in mobility, there are fewer mean number of depressive symptoms, and a higher proportion of patients return home rather than to a nursing home. It also reviews frequently used drugs and procedures to eliminate those that are harmful. Effects of ACE include improved satisfaction of the patient’s family members, doctors, and nurses, reduced use of restraints and high-risk drugs, improved process-of-care measures, and an approximate 10% reduction in hospital costs and length of stay. “I think one of our big challenges as geriatricians is to really work with our health systems to try and develop these sorts of interventions,” the speaker said. “These are not things you can do alone. It really depends on that core geriatric technology of having a multidisciplinary team that involves us with nursing and social work to make these things happen.” Perioperative Management of the Older Patient According to a study cited by G. Alec Rooke, MD, PhD, Professor of Anesthesiology, University of Washington, Seattle, the more diseases that patients have, the more likely they are to have perioperative complications.⁴ Consequently, the speaker noted “the better control we have of a patient’s medical diseases prior to surgery, the better off we hope the patient will be.” In his presentation, Dr. Rooke discussed preoperative preparation, the effects that aging has on perioperative recovery and adverse events, and how the reduction of postoperative stress may improve outcome. During preoperative evaluation, it is important to have a clear and extensive evaluation of the patient’s current medical status in order to reduce the patient’s risk to the absolute minimum. In addition, risk stratification, an important part of the preoperative evaluation, must be tempered by the benefits of the surgery and the patient’s desire to have the surgery; thereby making it imperative that the discussion of the proposed surgery should involve the patient, the anesthesiologist, the surgeon, and the primary caregiver. The cardiac guidelines⁵ have helped determine who may benefit from preoperative testing and incorporate the cardiac risk factors, the patient’s exercise tolerance, and the severity of surgery. Dr. Rooke noted that problems with these guidelines include that they may recommend more patients than necessary for preoperative testing. “I think there’s a growing opinion that someone doesn’t really need to go to angioplasty or cardiac surgery unless they have an indication for that intervention in the absence of surgery,” he said. The guidelines are also complicated. A means to get around this problem is illustrated with the example of perioperative beta blockade’s proven efficacy and how it may justify not sending the patient for an intervention, which would delay the surgery. Other cardiac issues include blood pressure, although the speaker believes that, while it is important to achieve reasonable control (ie, stop a patient’s diuretics prior to surgery, monitor for the presence of malignant hypertension), it does not have a major impact on perioperative outcome. He noted that use of statins, endocarditis prophylaxis, and taking special care in patients with pacemakers and ICDs are important. In Dr. Rooke’s opinion, a patient’s pulmonary history, including exercise tolerance, will disclose more information about the patients’ status than their pulmonary function tests (PFTs). He stated that having baseline PFTs may be useful, but not as a decision-making tool for anything other than lung surgery. If a patient’s breathing at baseline is adequate, then it is generally acceptable to perform the surgery. If there is concern about breathing status, the speaker recommended increasing bronchodilator therapy, or adding it if the patient was not on it or not taking it regularly; a steroid burst is also often useful. Sleep apnea is another concern, as the vast majority of people with the condition are undiagnosed. Patients with sleep apnea should be treated differently perioperatively, especially if they are going to be administered IV narcotics, and should be placed in a monitored bed. According to Dr. Rooke, all medications should be reviewed prior to surgery to avoid polypharmacy. Unless there are reasons otherwise, aspirin, clopidogrel, dipyridamole, and ticlopidine should be stopped 7-10 days prior to surgery; Nonsteroidal anti-inhibitors 2-3 days prior to surgery; maintenance warfarin 4 days prior to surgery; metformin at least 24 hours before surgery and not restarted until another 24 hours after surgery if the patient is stable; and diuretics the day of surgery. It is important to note that clonidine and beta-blockers are probably the two most important groups of drugs to continue. “Beta-blocker use should extend at least 7 days after surgery and may require a taper to avoid a rebound phenomenon, depending on duration,” said the speaker. In those who are malnourished, low albumin may be a major risk factor for adverse outcome in surgery. “If you had the opportunity well in advance of an elective surgery to address this issue, it certainly is worth trying,” recommended Dr. Rooke. The patient should be monitored for dehydration, and there should be assessment of the ability of patients to take care of themselves or their caregivers to take care of them once they return home. Many institutions are working with social workers early on to ensure that patients will receive adequate care in the home. In addition, cognitive assessment is also important in measuring baseline status and in determining competency. Perioperative management is affected by the aging process, particularly in the areas of cardiovascular, pulmonary, renal, hepatic, central nervous system, and general health. The elderly heart experiences a decrease in response to beta-receptor stimulation, which produces a lower heart rate at any degree of stimulation, and will therefore have an effect on the baroreflex, blood pressure control, maximum oxygen capacity, etc. Decreased beta-receptor response also leads to a dependence on the Frank-Starling mechanism (ie, cardiac filling is particularly important to maintain cardiac output in an elderly patient’s heart). Elderly patients may experience decreased alpha-receptor response, although sympathetic nervous system activity increases with age and thus there may be increased vasoconstriction both at rest and in response to normal stimuli. According to Dr. Rooke, the sympathetic blockade that typically accompanies anesthesia can place the patient at greater risk for hypotension. In addition, the chronic systolic hypertension that develops from arterial stiffening can lead to myocardial hypertrophy. Hypertrophy produces a dependence on late diastolic filling. This predisposition to diastolic dysfunction causes the heart to require an elevated atrial pressure, which can become dangerous if atrial pressure rises further with volume overload. On the other hand, hypovolemia can quickly lead to hypotension in a stiff heart that requires a high filling pressure to achieve adequate filling volumes. Veins get stiffer with age, which makes it difficult to buffer changes in blood volume and produces blood pressure lability. Patients, therefore, will not tolerate hypovolemia and will be at higher risk for postoperative heart failure. Pulmonary congestion or edema can develop when third-space fluid returns to the circulation and raises atrial pressure. The speaker recommended frequent assessment of the volume status of the patient (ie, listening to lungs) along with prescribing furosemide at the first sign of volume overload. Hypotension and hypertension are very common in elderly surgical patients. Those with chronic hypertension, whether treated or not, tend to have even more blood pressure lability in response to the changes in sympathetic tone that normally occur during surgery and postoperatively as pain fluctuates. Changes in sympathetic tone can affect all components of blood pressure. Dr. Rooke finds alpha-agonists such as phenylephrine useful for treating hypotension in the absence of hypovolemia. “Anesthesiologists use drugs whose effects are largely eliminated by the redistribution of that drug into the peripheral tissues, away from the brain or other target organs,” he said. Because metabolism is not being depended on, the initial volume of distribution is important. Due to alterations in body physiology, elderly patients tend to have higher drug blood levels and may experience increased brain sensitivity to certain drugs; thus any initial bolus will have a greater effect on an older patient. Nevertheless, if enough drug is administered, residual blood levels will eventually build up and produce clinically significant effects, forcing the clinician to rely on the actual metabolism of the drug to eliminate that effect. A noticeably reduced elimination rate of most drugs occurs in older patients as elimination is dependent on clearance, which decreases with age due to changes in liver blood flow and liver mass or kidney function, and on the volume of distribution, which increases with the higher fat content of elderly persons. The loss of elastin with aging causes the lungs to become less stiff and more easily inflated, which leads to ventilation-perfusion mismatch and increased closing volume. To prevent small airway collapse and atelectasis, the lungs must be kept more inflated. Perioperative consequences include an increased risk of hypoxia and pneumonia. In addition, the chest wall becomes stiffer with age, which causes increased work of breathing. A patient with borderline muscle strength is more likely to go into respiratory failure. Hypoxic and carbon dioxide drives as well as with anesthesia decrease with age; there is a greater risk of hypoxia after a general anesthetic than after a pure spinal anesthetic. The effects that aging has on renal function include loss of nephrons, lower glomerular filtration rate (GFR), decreased sodium, and water excretion. The perioperative consequences are reduced drug clearance, risk of drug toxicity, volume overload, and heart failure. Body metabolism decreases as people age, which causes the body to make less heat; and elderly patients do not vasoconstrict as effectively, which makes it harder to preserve what heat is produced. Lower body temperature contributes to an increased risk of wound infection and adverse cardiac events. “As a consequence, we are taking much better precautions about maintaining body temperature in the operating room than we ever have before,” the speaker said. In addition, the decreased muscle mass, poor physical fitness, and impaired gait that occur with aging can lead to requiring a higher level of care after surgery. Postoperative delirium is an important issue. About 50% of medical patients who are delirious in the hospital entered the hospital with this condition, whereas the vast majority of surgical patients who develop delirium do so during their hospital stay. Surgery itself may have something to do with it. The incidence of delirium varies widely with different surgical procedures (eg, there is nearly a 50% incidence after major joint replacement). This high incidence may be related to methyl methacrylate or fat embolus that occur with the implantations. The speaker noted that programs designed to reduce the incidence of delirium have been proven effective in both medical and surgical patients. Dr. Rooke believes that anticholinergic medications and meperidine should be avoided. Since it cannot be proven that there is a difference in delirium between general anesthesia and a neuraxial block such as a spinal anesthetic, it is difficult to prove a difference between various general anesthetic techniques. Cognitive dysfunction can also occur in elderly patients after surgery. A study by Moller et al⁶ demonstrated that 3 months after surgery, 10% of surgical patients suffered significant cognitive decline compared to only 3% of control subjects. According to Dr. Rooke, the cause of cognitive dysfunction in surgical patients is unclear. “We have even less understanding of what is going on here than we do with delirium,” he said. He did note, however, that there is no evidence that shows any clear relationship between delirium and cognitive decline. Dr. Rooke stated that the purpose of the anesthesiologist is to protect the patient from the surgeon. In order to do this, he or she must understand and be capable of managing medical disease. The speaker is a proponent for regional anesthesia and balanced anesthesia (ie, using drugs such as beta-blockers or opioids to reduce the amount of gas administered to the patient). He noted the importance of decreased drug doses in older patients as well as preemptive analgesic techniques and postoperative neuraxial analgesia to provide better pain control. After surgery, patients suffer from tissue damage, deviations from homeostasis in virtually all organ systems, hormonal and chemical changes, an increase in catecholamines and cortisol, psychosocial issues, and pain. Many elderly persons have atherosclerotic plaque, and surgery is associated with hypercoagulability, which places perioperative patients at a higher risk for myocardial infarction or stroke than those in the general population. However, Dr. Rooke noted that indirect evidence suggests that stroke is not caused by brief episodes of hypotension. “If hypotension were an issue, you would expect stroke to occur more often in border zones, and that is not the case,” he said. In addition, when global ischemia is triggered by severe hypotension such as during cardiac arrest, it does not appear to result in focal events. To control postoperative pain, the speaker recommended that opiates not be the sole analgesic modality, in order to produce less postoperative ileus and delirium. When an opiate is prescribed to a patient, the speaker recommended patient-controlled analgesia (PCA) rather than intermittent IV or IM injection. Non-steroidal agents such as rofecoxib prior to surgery are a good option, although it is important to assess renal function in patients before administration. The concept of preemptive analgesia, such as can be achieved with local anesthetic infiltration or peripheral nerve blocks, suggests that if you block the sensitization that occurs at the nerve endings in the surgical site as well as in the spinal cord, the amount of pain that someone has later on can be reduced. Older studies have demonstrated improved outcomes with epidural analgesia (eg, fewer cardiac complications, deep vein thrombosis [DVT], pulmonary embolism, renal failure, or pulmonary events). More recent, large, randomized trials confirm better pain relief, but have failed to confirm a reduction in organ complications. Epidural analgesia is labor-intensive and will also cause sympathectomy. In order to avoid an epidural hematoma—which, though rare, Dr. Rooke deemed the biggest risk of an epidural—the placement and removal of the epidural catheter has to be timed carefully if a patient is on subcutaneous heparin. If the patient is taking regular heparin twice a day or low-molecular- weight heparin once a day, the catheter should be removed approximately 2 hours before the next dose. If the patient is receiving low-molecular-weight heparin twice a day, then a dose should be held and the catheter removed approximately 22 hours after the previous dose. In conclusion, physiologic aging increases perioperative vital sign instability and interacts with comorbid disease to increase the risk of complications in elderly patients. “I think that optimization of medical status may improve physiologic reserve and may decrease risk,” Dr. Rooke said. He also pointed out that close postoperative care is vital in order to reduce complications (eg, pneumonia, heart failure, delirium). Recovery from surgery is slower in elderly patients, and surgeons may not recognize this or may not inform their patients of this issue. Home care must be evaluated for adequacy and may need supplementing. Lastly, in order to provide the best care for older patients, the surgical, medical, and anesthesia specialties must cooperate with each other.