Published in the June 2006 issue of Today’s Hospitalist
When it comes to treating older patients in the hospital, physicians need to think of the big picture to keep them healthy both during “and after “their stay in the hospital.
That was the message delivered by Evelyn C. Granieri, MD, MPH, MSEd, who spoke during the annual meeting of the American College of Physicians this spring in Philadelphia. During her presentation, “Eight rules for rounding on hospitalized elders,” she outlined some relatively simple “and often overlooked “strategies that can help physicians spot signs of trouble in elderly patients in the hospital.
Dr. Granieri, co-chief of the new division of geriatric medicine and aging at New York’s Columbia University College of Physicians and Surgeons, urged physicians in the audience, which included a large number of hospitalists, to adopt what she called a “matrix” style of thinking when caring for elderly patients. Put simply, physicians need to do more than focus on and treat individual problems like pressure ulcers or cognitive impairment. To keep these patients healthy, physicians instead need to think about how those problems are intertwined.
Take something as simple as a pressure ulcer. While an obvious cause may be too much time spent in bed, it may be exacerbated by the fact that the patient has a Foley catheter that is keeping her immobile. And if the patient is cognitively impaired, she may not be able to tell you that she is feeling pain on her heel, which further compounds the problem.
“You have to think of older adults not in terms of one rule per patient,” Dr. Granieri said, “but in a very matrix way of thinking. The great complexity of geriatric medicine is such that no patient has one issue or problem.” Here’s a look at her eight rules for rounding and how they can help elderly patients in the hospital.
1. Review all medications. When it comes to reviewing the medications your elderly patients are taking in the hospital, Dr. Granieri said, think about more than just how they are metabolized. Consider how those drugs are affecting the patient as a whole.
“Every day that you round in the hospital, you need to review your patients’ medications and think about what they really need,” she said. “Ask yourself if you can get rid of a certain medication, decrease the dose or increase the interval. Older adults in the hospital are very dynamic in terms of their status, and you need to pay attention to their renal function.”
Dr. Granieri also urged physicians to consider how prescription medications are affecting patients’ mental status. She said that while prescription medications are not the actual cause of delirium “an underlying cognitive impairment is typically the source “prescription drugs may help unmask that condition.
“One of the biggest precipitants of delirium in older adults is medication changes,” Dr. Granieri explained, “so you need to review the medications daily to see how they’re affecting the brain.”
You’ll do right by your patients to think about how the medications you prescribe in the hospital will be used by patients at home after discharge. Dr. Granieri said that about 75 percent of hospitalized patients age 70 and over have some form of cognitive impairment, something that should factor into your prescribing decisions.
“If you send someone who has cognitive impairment home on a new drug regimen and you don’t know how impaired they are,” she explained, “you are dooming that patient to a new hospitalization, a new ED visit or some kind of iatrogenic complication because of those medications.”
Dr. Granieri said that when she has done home visits, she often has problems following the drug instructions that patients receive at discharge. For patients suffering from some form of cognitive impairment, complex instructions will seem unfathomable.
“Don’t send patients home on BID, TID and QID regimens,” Dr. Granieri explained. “Try QD at the most.”
2. Perform a cognitive assessment. While there are a number of tools that can help you assess patients’ cognitive function, Dr. Granieri said that she likes to stick with the basics. She asks patients to draw a picture of a clock and then set the hands to a specific time.
To keep the exercise simple, she said, tell patients only once “don’t repeat the instructions “and give them a minute at most to finish. Once they’ve finished, don’t try to cut them slack. Their picture is either right or wrong, and patients get no credit for effort.
“There’s no reason that everyone can’t draw a perfect clock,” she said, “unless you have some change in your brain due to a condition like vascular disease.”
Dr. Granieri described what happened when she asked a 70- year-old physician who was still practicing to set the clock at 2: 45. The man positioned the hands at two, four and five, and he circled those numbers as if to indicate 2:45. “You will be surprised by how many patients will not be able to do a clock properly,” she explained.
The purpose of the clock exercise is to uncover cognitive impairments, not to locate their exact cause. “It’s not a diagnostic tool,” she said, “it’s an unmasking tool. It doesn’t diagnose dementia, it diagnoses the fact that someone has something wrong, and you have to think in the matrix style. Ask which problems are causing the person to draw the clock wrong. And remember it’s never just one.”
If you uncover a cognitive problem, adjust your discharge strategy accordingly. “People who can’t draw a clock can’t be expected to take medications on their own,” she explained. “If you send somebody home who can’t draw a clock, you can’t expect them to take their own medications. It’s unfair to them.”
What should you do if the patient’s family members or friends refuse to believe that the patient is cognitively impaired? “Show them the clock and explain that it is a measure of cognitive function,” Dr. Granieri said, “that it tells us that your mom is unable to learn or process information.”
“Those of you who have had close relatives or friends with dementia know that this is an unbelievably painful process,” she continued. “Denial is incredibly strong. If you use a clock or something concrete to show them, it’s helpful.”
3. Check pressure points daily for skin problems. For an idea of just how common pressure ulcers are in hospitalized patients, Dr. Granieri said some studies have shown that the prevalence on admission is between 2 percent and 10 percent, but the number jumps to between 10 percent and 20 percent at discharge.
Part of the problem is that pressure ulcers can develop quickly under the right conditions. “If the capillary pressure is greater than 32,” Dr. Granieri explained, “it takes fewer than two hours to develop a stage 1 pressure ulcer.”
Compounding the problem is the fact that nurses often don’t look at the skin of patients in places where pressure ulcers will form, like the occiput and the pinna. Nurses and nurses aids typically examine the sacrum and the buttocks, but not high-risk areas like the scapula, the olecranon, the acromion and the heel.
And if your elderly patient has a cognitive impairment, detecting a pressure ulcer will be that much more difficult. “If your patient is cognitively impaired,” Dr. Granieri explained, “they’re not going to tell you that their heel is killing them. You have to be the person who discovers these things.”
4. Take a multidisciplinary approach to functional status. “One of the first things I do on frail patients over 75 is request a physical therapy and occupational therapy consult,” Dr. Granieri said, “and for a couple of reasons. It guarantees that patients are going to get out of bed, and it guarantees that someone else is going to look at them.”
She noted that physical therapists and occupational therapists are often the first ones to pick up on problems like skin breakdowns, continence issues and problems with patients following directions.
Like pressure ulcers, problems with functional status can develop fairly quickly. After spending only three days in bed, Dr. Granieri explained, older adults can start to experience clinically significant loss of muscle mass. Even more importantly, that loss will occur primarily in the proximal muscles and lower extremities, which hurts patients’ ability to walk, and consequently be continent.
And while muscle is lost quickly, it can take three to six times that long to recoup. “If they lose muscle mass in three days,” she said, “it will take them nine to 12 days to get that muscle mass back, but only with work from physical therapy. That’s why I call physical therapy in early.”
5. Assess gait dysfunction and the risk of falling. While preventing falls is the topic of much conversation among hospitals “and on the radar of accrediting organizations like the Joint Commission “Dr. Granieri said the bad news is that there is no good strategy to completely prevent elderly patients from falling. And some strategies, she added, may be doing more harm than good.
“The truth is that you won’t prevent falls in a frail, older adult who probably has sensory impairment, gait impairment, cognitive impairment and any of a number of other issues,” she explained. “What you can help to do is prevent fractures.”
To do that, Dr. Granieri suggested a number of techniques. If you’re worried that patients will fall as they make their way to the bathroom, a bedside commode can help eliminate the trip. Some hospitals are also putting padded mats on the floors to cushion patients’ falls and using more conventional devices like hip protectors. She said that while there were questions about the effectiveness of tools like hip protectors, recent evidence has shown that they can work in the hospital.
And if you use a Foley catheter “a popular approach to keep elderly patients from falling during trips to the bathroom “you may want to rethink your approach. Not only have Foley and condom catheters been shown to increase the rate of urinary tract infections and drug-resistant bacteria, Dr. Granieri explained, but they can cause iatrogenic complications.
“In addition to infections, you’re inviting pressure ulcers because the patients can’t be moved very often,” she said. “A Foley catheter can lead to agitation, delirium, pain and any of a number of complications including falls. I pull the Foley and give the patient a bedside commode.”
6. Make sure your patients are eating and drinking. The reality is that older adults who need hospitalization will often have nutritional issues, While you’re not going to be able to cure their nutrition during a five-day stay, Dr. Granieri said, you can take some simple steps when rounding to minimize nutritional problems.
Start by making sure the patient’s tray is close enough to the bed. And if there is a feeding program in the hospital and the patient needs it, make sure you’re taking advantage of it.
You should also ascertain that the patient is able to swallow, either through your own observation or by asking for information from the nurses. “Swallowing should be a part of every physical exam,” Dr. Granieri noted.
What about tube feeding? Dr. Granieri cautioned against intubating a patient for the purpose of nutrition unless it’s absolutely necessary. “Tube feedings in patients with dementia do not keep them alive longer,” she explained, “and they increase the rate of iatrogenesis and complications.”
Feeding tubes increase the rate of aspiration and lead to pneumonia, in part because people are aspirating their own secretions. “You’re not going to stop the aspiration by putting a peg in,” Dr. Granieri said.
She added that one strategy that has been shown to decrease aspiration is slow hand feeding, or giving patients tablespoons of food at a time. While hand feeding requires the help of a caregiver or family member, Dr. Granieri said that the technique can dramatically improve the patient’s quality of life, which is important considering that many hospitalized elderly patients don’t have long to live.
“Think about living the rest of your life with a tube that isn’t going to provide you with any extra length of life or quality,” she said. “For patients with dementia who easily get irritated or agitated, you can imagine how frustrating and painful it is to wake up and you see this thing hanging out of your belly.”
7. Ask about glasses, hearing aids and walking devices. Almost everyone over 60 has some visual impairment, Dr. Granieri said, so ask if your patients have a pair of eyeglasses at home.
And while hearing aids can help improve hearing in patients who are cognitively intact, they lose their effectiveness once patients lose their fine motor skills and can no longer adjust the volume. And they are unlikely to help a person with dementia.
When hearing impaired patients can’t use “or don’t have “hearing aids, Dr. Granieri said she uses a tool that lets her speak into a microphone that has a small speaker. Unlike hearing aids, which amplify all sounds, not just the voice of the person speaking, this microphone device amplifies only her voice.
8. Don’t go it alone. Because such a large constellation of conditions can affect your elderly hospitalized patients, Dr. Granieri said it’s important to get help from other providers when the patient is both in and outside of the hospital.
“Make sure you don’t take care of a frail, older adult in the hospital yourself,” she said. “There is a team of clinicians who you should get involved in the hospital and at home. Taking care of these patients in the hospital is the most challenging thing that geriatricians do.”
And when patients are sent home, Dr. Granieri noted, it is just as important to enlist the services of everyone from physical therapists and occupational therapists to dietitians and speech therapists. Don’t forget the caregivers, formal and informal, who are partners in the continuing care of your older patients
“Don’t send any patient home who has any of the things I’ve talked about without a consultation from the visiting nurse or home health agency,” she said. “Too many times, people get sent home without home care follow-up.”
Edward Doyle is Editor of Today’s Hospitalist.