Home Feature Discharging a frail, elderly patient? Try reviewing function, not just systems

Discharging a frail, elderly patient? Try reviewing function, not just systems

January 2007

Published in the January 2007 issue of Today’s Hospitalist.

Last fall, New York geriatrician Fredrick T. Sherman, MD, MSc, was called to Mount Sinai Medical Center for a bedside consult. He was being asked to weigh in on a frail, elderly patient who was scheduled for discharge.

The reason for the consult? The patient’s medical history showed frequent "bounce-backs" to the facility because the woman’s ability to take care of herself fell apart once she got home. As Dr. Sherman began his assessment by asking the patient to get up from the bed, the other physicians and interns in the room swooped in to help her struggle to a sitting position.

"I had to push them aside, because I wanted to know what her maximum function was without any assistance," says Dr. Sherman, professor of geriatrics and medicine at New York’s Mount Sinai School of Medicine. While not helping an older patient might seem inhumane, he adds, maintaining that distance is crucial for deterring what he calls "learned helplessness." It’s also a key first step in determining how well equipped a patient is physically to leave the hospital.

Seeing how easily a patient can sit or stand is also the first of several targeted physical performance tests that make up Dr. Sherman’s "10-minute geriatric assessment." These tests evaluate patients’ ability to feed themselves, maintain balance while standing, and walk across a room and back, among other things.

Older patients’ performance on simple tasks that require no more than a chair can give you a good idea of how their hospitalization has affected their function. It can also predict how well (or poorly) they will do once they’re discharged.

Engaging hospitalists in geriatric assessment is critical, says Dr. Sherman, because they are so involved in planning for discharge and follow-up-and because assessing function can go a long way to reduce re-admissions."

"There is a big focus on medication reconciliation now, and this is the same kind of concept," says Dr. Sherman, who describes his assessment as "a review of function rather than of systems." Restoring or maintaining function, he suggests, is just as important during a hospital stay as successfully treating the condition that led to admission in the first place.

Function often ignored
Hospitalists are usually so focused on treating an illness that they fail to adequately consider the impact of a hospital stay on elderly patients’ physical performance.

"What happens is that older patients come in frail and leave even ‘frailer,’ " says Dr. Sherman. He points to data that indicate that 40% of elderly patients hospitalized for a week lose one or more activities of daily living, such as the ability to bathe or dress themselves. "From a practical point of view," he adds, "those patients will need someone to help them if they are to safely leave the hospital."

Many elderly patients bounce back to the hospital after discharge because no one has recognized the loss of daily living activities that impairs their ability to care for themselves and ultimately compromises their recovery. Too often, Dr. Sherman says, the physical performance testing that can uncover function deficits quickly just isn’t done.

Why do functional losses or limitations go unassessed, even at discharge? For one, hospitalists and other attendings assume that someone else-a nurse, case manager or physical therapist-is routinely checking function and
making arrangements for whatever post-discharge help a patient may need.

"In reality, these assessments may not occur unless a physical therapy consult has been ordered early in the hospital stay," Dr. Sherman explains.

But even when physical therapists evaluate such factors as bed mobility, static and dynamic balance, strength, endurance, and gait, they often document their findings with unfamiliar abbreviations and phrases that hospitalists need to learn, he adds. And with less than optimum nursing-to-patient staff ratios, nursing notes typically include only brief descriptions of patients’ need for assistance in feeding, transferring and toileting. Nurses usually don’t assess older patients’ ability to dress or bathe themselves.

Another problem: Health care professionals, especially physicians, tend to accept patients’ or proxies’ reports on how well patients function. But frequently, those reports are either overly optimistic or completely off-base. And in the frenzy of activity required to get patients ready to leave the hospital, the status of physical function-beyond the ability to void-is often overlooked.

"The vital signs we physicians look at and the physical examination we do have nothing to do with physical performance," Dr. Sherman points out, even though performance is a critical component of a safe discharge.

The bottom line is that hospitalists "have to think about what is a safe, optimally therapeutic plan for an elderly patient and how they can incorporate performance testing into that decision." While noting that hospitalists are rapidly becoming the nation’s de facto geriatricians, Dr. Sherman points out that "hospitalists do have to think ‘geriatrically’ during the transition from hospital to home, assisted living or nursing home."

Too much time?
Dr. Sherman, who is medical editor of the journal Geriatrics, frequently describes his geriatric assessment at medical presentations, where physicians often express concerns about how much time assessments will take.

In fact, it can be readily done in 10 minutes or less, he explains. And any "findings" shouldn’t delay discharge unduly. "What the hospitalist can do is coordinate a discharge plan that gets physical therapy, the visiting nurse and family in line with the new impairment that the hospitalist has picked up," Dr. Sherman says. "None of these things needs to hold up a safe discharge, if all the recovery and rehabilitative services can be put in place."

And to save time at discharge, Dr. Sherman urges hospitalists to consider doing a quick set of daily rounds, along with a nurse and social worker, to objectively assess elderly patients’ functional status. During these rounds, team members can ask patients to do certain tests, such as sitting up in bed from a reclining position or getting up out of a chair three consecutive times.

"The beauty of daily rounds," he points out, "is that it gets everyone on the team on the same page when it comes time to do a safe and optimally therapeutic discharge plan."

What to assess
Although they’re not highly scientific, the physical performance tests that Dr. Sherman uses can help confirm patients’ or proxies’ statements about physical-function status. They also help you identify high-risk patients who need interventions or assistance.

Here is the series of timed mobility and function tests that Dr. Sherman recommends:

  • Chair rises. Ask patients to get out of a chair unassisted, with their arms folded over their chest. If they can do so successfully, ask them to do three chair rises in rapid succession (in, say, less than 10 seconds).

    "This is an important performance test," Dr. Sherman explains, "that tells me that their quads are strong enough to enable them to get out of bed." It also helps you gauge patients’ ability to independently get on and off the toilet, a key consideration in deciding whether or not patients need help at home.

  • Dressing. Ask older patients to put on their socks or stockings. If they use both hands to do so, says Dr. Sherman, then they can safely dress themselves.
  • Quick cognitive-status "clock completion" test. While this test is no substitute for a full mini-mental status exam, an abnormal clock completion test suggests that patients may not be able to manage basic mental functions such as following a medication schedule and performing simple money-handling tasks.

    First, draw a three-inch diameter circle on an unlined piece of paper and ask an older patient to "put the numbers on the clock." If patients cannot correctly place the clockface numbers, they may have dementia.

    If they show signs of dementia, you need to make sure they’re not suffering from a superimposed delirium as well.

  • Eating test. Ask patients to feed themselves with a spoon (the ubiquitous applesauce containers work well, Dr. Sherman notes) and take a few sips of water.

    Patients who plan to take care of themselves at home should be able to do both without choking, gagging or hoarseness. If older adults don’t pass this simple bedside swallowing test, order a swallowing evaluation to determine their risk of aspiration and to decide what food consistency they need to minimize complications.

  • Balance test. Ask patients to stand with their feet touching each other, side by side, their hands at their sides and their eyes open, for 10 seconds.

    If older patients can’t hold this stance-if they begin to fall to one side or the other or cannot hold the side-by-side stance-"I would call this a pre-transition hospitalist emergency," Dr. Sherman says. When patients fail the side-by-side balance test, you need to get a physical therapy consult for an assistive device, usually a walker, to ensure a safe discharge.

    Also ask patients to assume a semi-tandem stance (with the heel of their right foot placed against the big toe of the left), as well as a full tandem stance, where patients put the heel of one foot directly in front of the toes on the other foot.

    Older patients who can’t hold a semi-tandem stance for at least three seconds are at the same risk of falling as those who can’t keep the side-by-side stance for 10 seconds. And while many older patients won’t be able to hold a full tandem stance for 10 seconds, you can be assured that those who can have excellent balance and don’t need balance exercises.

  • "Get up & go" test. As you stand by their side, have patients stand up from a chair, walk 10 feet across the room, then turn around and walk back-with or without a cane or walker-and sit down in the chair. If they can manage this, ask them to repeat the same test at a safe, yet comfortable pace. If they can complete that circuit in under 14 seconds, their risk of falling is low.

    "If it takes them longer than 14 seconds," Dr. Sherman says, "then you should consider strength, balance and gait training as part of their discharge plan."

    Or you can try another gait speed test known as the "10 feet out and 10 feet back rapid gait" test. Ask a standing older patient to walk 10 feet out, turn and walk 10 feet back, at a rapid yet safe speed. If they can do so in less than 10 seconds, their daily-living activity status is likely to remain stable for the next 12 months.

    Bonnie Darves is a freelance writer specializing in health care. She is based in Lake Oswego, Ore.