Treat the elderly patient, not just the illness
Strategies for managing hospitalized elders and preventing decline
From the November ACP Hospitalist, copyright © 2007 by the American College of Physicians
By Stacey Butterfield
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Sidebar: Drugs to reduce or eliminate in the management of delirium 
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The elderly make up the largest single group of hospital inpatients, yet hospitals still struggle with how to make their stays run smoothly. Geriatrician Robert M. Palmer, FACP, offered some suggestions for improving the care of hospitalized elders during a session at the Society of Hospital Medicine's most recent annual meeting.
"Acute care really should be thought of as geriatrics," said Dr. Palmer, who is head of geriatric medicine at the Cleveland Clinic in Ohio. Although patients over age 65 make up only 13% of the U.S. population, they represent 38% of discharges from nongovernmental acute hospitals and 44% of total days of care, according to 2006 statistics from the Agency for Healthcare Research and Quality.
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"Long lengths of stay are some of the reason why [hospitalists] are employed today. From the hospital's point of view, the faster they can get the patient out, the better." —Robert M. Palmer, FACP |
"These long lengths of stay are some of the reason why you're employed today," Dr. Palmer told his audience of hospitalists. "From the hospital's point of view, the faster they can get the patient out, the better."
But the negative consequences of elderly hospitalizations are more than financial, he noted. "Hospitalization has hazardous effects on functional independence and impacts outcomes and the quality of life of older people."
Often, elderly patients' in-hospital decline is the result of common geriatric syndromes, problems that can be combated by effective hospitalist management, Dr. Palmer said. "You can do something that would enable them to go home instead [of entering a nursing home]."
Fight off delirium
One of the greatest threats to elderly inpatients' well-being is delirium. Between 20% and 30% of patients over age 70 will be delirious at some point during hospitalization, Dr. Palmer said. Intensive care and post-op surgical patients have even higher rates.
Researchers have found that several common components of elderly inpatient care also appear to be precipitants of delirium, including the use of physical restraints, malnutrition, addition of more than three medications and use of a bladder catheter.
"Maybe we can change the processes and in turn prevent delirium and some of its adverse effects," said Dr. Palmer. He noted that an increased risk of death is the most serious complication, but that delirious patients also suffer functional decline, are more likely to be placed in nursing homes, stay longer in the hospital and incur increased costs.
Keep the brain active
Most delirium intervention measures come from nursing research, and can be relatively easily accomplished by hospitalists and their teams. Suggested environmental changes include explaining care clearly to patients, keeping them in a semi-upright position, minimizing abrupt relocations, keeping orienting stimuli (including a clock, TV or personal items) nearby and maintaining interactions with family and friends.
"Try to keep the brain active. Try to get the patient to be engaged," Dr. Palmer said.
Mind all medications
Many medications can contribute to delirium, and Dr. Palmer offered guidelines for determining which drugs present the most danger. "Any pharmacologic class of drugs can put the patient at risk, but those with anticholinergic effects (for example, diphenhydramine) and benzodiazepines are more likely to do so. Think twice before you add on drugs that aren't absolutely essential to the management of these patients."
Don't prescribe bed rest
Treating patients' sensory impairments also can alleviate or avoid delirium, Dr. Palmer said. Hospitalists should make sure patients have the vision and hearing aids that they need for effective communication at the start of hospitalization. "Unfortunately, we don't have convincing evidence that we can cure delirium once it occurs, so our best bet is to prevent it," he said.
Dr. Palmer noted that a controlled trial of such delirium prevention measures, published in The New England Journal of Medicine in 1999, reduced incidence of delirium by 40%. One key aspect of that study was avoidance of patient immobility, which led Dr. Palmer to his next recommendation for management of hospitalized elders.
"No orders for bed rest, please. They are rarely appropriate for a medical elderly patient," he said. Rather than keeping patients in bed, hospitalists should be encouraging them to be active, by walking with patients and making sure they have any assistive devices that they need.
If needed canes or walkers are not immediately available at the hospital, family members should be advised to bring them in from home. If patients have other problems getting around, "get PT [physical therapy] involved right away," said Dr. Palmer.
Obviously, if you want patients moving around, strapping them to the bed is not a good start. "Physical restraints are rarely ever helpful," Dr. Palmer said. He noted that most hospitals are trying to find alternatives to restraints, such as having family members close by and treating the underlying conditions that cause a patient to need restraints.
Avoid malnutrition
Malnutrition is one underlying condition common to hospitalized elderly, as well as another common side effect of hospitalization. Studies show that it is present in 20% to 40% of medically ill elderly patients, Dr. Palmer said. "The interesting thing is that it's really unusual to see malnutrition as a diagnosis in their medical record and it's even more unusual to see that it's being adequately treated."
Even when dietary supplements are prescribed, patients often don't drink them. Dr. Palmer recommends that hospitalists not only prescribe, but monitor, high-risk patients' daily calorie and fluid intake. He also prioritizes giving malnourished elderly patients calories over putting them on restricted diets. "You want protein, you want a balanced diet, but don't let them starve," he said.
A consult with a dietitian or nutritional support team also can provide help in assessing a patient's hydration and nutritional needs.
Teamwork—with nurses, other nonphysician providers, patients, family members and primary care providers—is crucial to successful treatment of hospitalized elders, Dr. Palmer concluded. "You and the rest of the team need to look at patient-centered interventions. What does it take?"
"You can do this just as well as I," he told the hospitalists. "Cognitive decline, and delirium specifically, is preventable."
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