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Care of the Hospitalized Geriatric PatientEthan Cumbler MD,
FACPAssociate Professor of MedicineDirector UCH Acute Care For
Elderly ServiceUniversity of Colorado Denver2010
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ObjectivesRecognize patients at highest risk for hazards of
hospitalization such as delirium and falls using simple evidence
based screening tools
Be able to implement elements of an evidence based prevention
protocol for common hazards of hospitalization
Understand treatment options for deliriumDisclosures: The
speaker has no conflicts of interest to disclose
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Changing DemographicsIn 2000 about 1 in 8 Americans was over age
65.
By 2030 it will be 1 in 5
Hospitalization is a time of critical risk for the elderly
We can do better
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Current State of AffairsMajority of inpatient geriatric care is
provided by physicians without specific training in geriatrics.Only
7,000 Geriatricians30,000 Hospitalists
Hospital communications silos inhibit recognition and treatment
of new geriatric syndromes
Physician often the last to know about
barriersPhysicalSocialFinancial
Outpatient caregivers not involved
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What Explains the Status Quo?Barriers to ChangeVulnerable
elderly dispersed across teams and within hospitals
Traditional closed ACE units proven successful but not widely
implemented due to increased resource commitments
Geriatric issues considered less vital than admit diagnosis
Solutions require interdisciplinary approach Team infrastructure
inadequate
Focus can be on more rather than making it easy to do right
Jayadevappa R. Dissemination and Characteristics of Acute Care
for Elders Units in the United States. In J Tech Assess in Health
Care 2003;19:220-227
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Hazards of HospitalizationHigh Risk PatientHigh Risk
SituationHigh Risk
EnvironmentHAZARDFallsDeliriumPressureulcersAdversedrug
eventsFunctional declineTransitionFailure
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There are Some Who Think the Hospital Is a Fancy Hotel
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A Modest ProposalSystem change is required
Geographic concentration
Standardized assessment
Standardized care protocols
Interdisciplinary care
Acute Care for the Elderly Service
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Brief Geriatric AssessmentIdeal Geriatric Assessment
FastTolerated by patientsProvide new informationLeads to new
actionConfusion Assessment Method (CAM)Mini-CogVulnerable Elders
Survey
2 Q Depression ScreenSensory Aid AssessmentFalls
ScreenGet-Up-and-Go Test
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Clinical CaseGertrudes Tragic Tale88 y/o woman admitted for back
pain after a fall stepping off a curb outside her assisted
living
Xray demonstrates thoracic compression fracture.
Admit for pain control, inability to ambulate.
PMHMild Alzheimer's DementiaInsomniaHTNUrge
incontinenceDepression
MedicationsLisinopril 10mg dailyAspirin 81 mg dailyAmitryptiline
50mg qhsOxybutinin 5mg bid
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When Hospitalization is Over.Will Gertrude be going home?How do
you predict discharge location on admission?
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Assessing Need for PlacementVulnerable Elders
Survey-13Originally developed to identify community dwelling elders
at risk for functional decline or death.
10 point score based on:AgeSelf reported health statusAbility to
perform six physical tasks and five activities of daily living.
Saliba D. The Vulnerable Elders Survey: A tool for Identifying
Vulnerable Older People in the Community. J Am Geriatr Soc
2001;49:1691-1699Min LC. Higher Vulnerable Elders Survey Scores
Predict Death and Functional Decline in Vulnerable Older People. J
Am Geriatr Soc 2006;54:507-511
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VES-13Cumbler E. Vulnerability Assessment on Hospital Admission
Predicts Need for Placement upon Discharge for Elderly Patients.
Journal of the American Geriatrics Society 2009; 57:944-946Now
validated to predict need for SNF in elderly admissions
Take Home PointFunction PRIOR to admission predicts need for
placement
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Gertrudes Tragic TaleGertrude is confused about the timeline of
events
Does not remember her home medications
Honey, I dont have to know that at my age when asked for the
year, Can spell WORLD backwards
Tells you a bright and animated story about her dog and how
funny it was when he ate peanut butter
Is Gertrude Delirious?
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Delirium Acute onset of disturbance in consciousness in which
cognition or perception is altered 17%-74% cases unrecognized by
nursesPhysicians may do worse
Over reliance on disorientation/inappropriate behavior
More likely to be missedHypoactiveAge >80 yrsVision
impairmentDementiaAre Nurses Recognizing Delirium? A systematic
review. JOGN 2008;34:40-48Occurrence of Delirium is Severely
Underestimated in the ICU during Daily Care. Intensive Care Med
2009
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DIAGNOSING DELIRIUM: The Confusion Assessment Method
(CAM)Patient must demonstrate the following:
Sensitivity 94-100%, Specificity 90-95%Positive LR 9.6 ,
Negative LR 0.16Inouye SK et al. Ann Intern Med
1990;113:941-948Wong CL. JAMA.2010;304:779-786 OR
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ASSESSING DELIRIUM RISKInouye, S. Ann Intern Med.
1993;119:474-481Medical Inpatient Prediction Rule--Cognitive
impairment--Severe Illness--High BUN/Cr--Vision impairment
Low Risk (0) 10% riskInt. Risk (1-2) 25% riskHigh Risk (3-4) 80%
risk
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Assessing Delirium RiskMini-Cog3 item recall (ball, justice,
tree) (up to 3 pts)Clock Draw (10 minutes after 11)All or nothing--
0 or 2 pts
On Admission:Scores of 0, 1, or 2 carries a 4-5X increased risk
for deliriumTrue regardless of whether the patient has dementia or
notAlagiakrishnan K et al. Simple Cognitive Testing (Mini-Cog)
Predicts In-Hospital Delirium in the Elderly. JAGS 2007;55:314-316
0 points
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DELIRIUM IS COMMONAffects 20% of hospitalized patients over age
65Up to 70-80% of older patients in intensive careUp to 83% of
older patients at the end-of-life
Affects 36.8% of postoperative patientsCataract Surgery
1-3%General Surgery 10-15%Orthopedic Surgery 28-61%
Miller MO. Evaluation and Management of Delirium in Hospitalized
Older Patients. AAFP 2008;78:1265-1270
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Mechanism of DeliriumImbalance of NeurotransmittersAcetylcholine
Dopamine Others ??
Hypothalamic-pituitary-adrenal axis
InflammationCytokines (TNF, Interleukins)
Occult diffuse brain injuryEspecially following sepsis (ischemic
insult)
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WHY DO WE CARE Increased Length of StayBy 8 days
Increased MortalityDouble the mortality in pts with delirium
Functional Decline/NH placement
Prolonged Cognitive Defects
NEW RESEARCH1/3 of pts d/c to SNF delirious will still be
delirious 6 months laterKiely DK, et al. Persistent Delirium
Predicts Greater Mortality. JAGS 2009;57:55-61Miller MO. Evaluation
and Management of Delirium in Hospitalized Older Patients. AAFP
2008;78:1265-1270
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Delirium Prevention Modifiable risk factorCognitive impairment
Immobility Visual Impairment Hearing Impairment Dehydration Sleep
deprivation Prospective InterventionOrienting communicationEarly
mobilization, reduce restraintsVisual aides, adaptive
equipAmplifiers, adaptive equipPrevent and correct
dehydrationUninterrupted sleep, nonpharmacologic aides
Inouye SK et al. A multicomponent Intervention to Prevent
Delirium in Hospitalized Geriatric Patients. NEJM
1999;340:669-676Vidan MT et al. An Intervention Integrated into
Daily Clinical Practice Reduces Incidence of Delirium During
Hospitalization in Elderly Patients. JAGS 2009;57:2029-203640%
Relative Risk Reduction
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One of Hebb's sensory deprivation subjects at McGill. Sensory
Deprivation
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Declassified 1983 CIA Training ManualDeprivation of sensory
stimuli induces stress and anxiety
Some subjects progressively lose touch with reality, focus
inwardly, and produce hallucinations, delusions, and other
pathological effects.
1984 revision states:Deliberately causing these symptoms is a
serious impropriety.Accessed 2/28/09 at
http://www.gwu.edu/~nsarchiv/NSAEBB/NSAEBB27/02-02.htm from
National Security Archive Database
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One of Hebb's sensory deprivation subjects at McGill. Sensory
Deprivation
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Sleep DeprivationConsequences of lack of sleep in healthy
volunteers include impaired attention and irritability
Record for sleep deprivation is approximately 11 days
No longer accepts submissions in this category due to
deleterious health effectsNoiseLightIllnessPainPhlebotomyVital
signsSkin careCould you sleep?Drouot X. Sleep in the ICU. Sleep
Medicine Reviews 2008;12:391-403
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Practical Application
Order set as:
-QI tool
-Psychological manipulation
-Establishment of culture
-Time saving device
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Gertrudes Tragic Tale
Diphenhydramine prn for insomnia
An indwelling catheter is placedHer personal possessions are
safely stored in the closet ClothingGlassesDenturesHearing
aids.
Maintenance IV fluids, telemetry, and SCDs
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Clinical CaseGertrudes Tragic TaleThe following morning Gertrude
is still sleepy when:The intern assesses her at 6:00amThe nurse
assesses her at 8:00amThe attending assesses her at 10:00am
She sleeps through lunchDisoriented and inattentive-- not
following instructions
She becomes confused Trying to get out of bed Pulling at her
IVs
Is she delirious..Who knows?
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Silos of CareHave you ever heard the phrase:
It seemed like the right hand didnt know what the left hand was
doing
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Effective Interdisciplinary Communication15 Minute Daily Team
HuddleAttendings
Residents
Interns
Nursing
Physical Therapy
Occupational Therapy
Pharmacy
Case Management
Social Work
VolunteersGeographic Concentration
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We want you to participate in your care and be as active as
possible while staying safe
Let your team know about any problems or questions.If you use
glasses, hearing aids, or dentures- use them in the hospital just
as you do at home.Your activity care plan will be based on your
abilities and illness.If possible, walk in the hall multiple times
each day to keep your strength up. Eat meals while sitting up,
preferably in a chair.
Your physicians will usually come in to see you and discuss your
plan for the day between 9:00am and 11:00 am
feel free to invite family or other people in your life to be
part of the care discussion
Your team includes an attending physician responsible for your
overall care planEthan Cumbler M.D. Heidi Wald M.D. Jeannette
Guerrasio M.D. Jeanie Youngwerth M.D. Judy Zerzan M.D.
We are interested in your thoughts about your care on the ACE
serviceAfter your discharge we welcome you to write your physician
atACE Servicec/o Hospitalist SectionAnschutz Inpatient
Pavilion12605 E. 16th AveP.O. Box 6510. Aurora, CO. 80045
ENCOURAGING PATIENT INVOLVEMENT
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Response to DeliriumTESTINGChem7, CBC, U/ATroponin, EKGCXR
TSH, Ammonia, B12, ABG?
LP if fever or neck stiffnessCT/MRI brain if focal neurologic
signs or head traumaEEG if clinical evidence of seizuresDrug levels
(Digoxin, anticonvulsants)
Extensive testing of limited value unless driven by a specific
clinical suspicion
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Practical ApproachRemove Problem MedicationsParticularly
Anticholinergics, BNZ, and minimize Narcotics
Treat WithdrawalAlcohol or benzodiazepines
Correct Metabolic DisturbancesElectrolytes, glucose, hydration,
ammonia
Reduce Level of InvasionIndwelling urinary catheters and
lines
Assess and Treat Infection
Adequately Treat Pain Scheduled may be better than prn.
Non-narcotic if possible
Improve Environment and Mobility?
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Medical Therapy for DeliriumNo good evidence that Cholinesterase
Inhibitors (dopepezil) are effective
No good evidence that Benzodiazepines are effective EXCEPT in
alcohol withdrawal
Antipsychotics decrease the degree and duration of delirium
(typical just as good as atypical)Cholinesterase Inhibitors for
Delirium. Cochrane Database of Systematic Reviews
2008Benzodiazepines for Delirium. Cochrane Database of Systematic
Reviews 2009Antipsychotics for Delirium. Cochrane Database of
Systematic Reviews 2007
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When All Else Fails.. ANTIPSYCHOTICSTypical Antipsychotics
(Haloperidol)Does not prevent delirium when given
prophylacticallyExtrapyramidal side effects with high
dosesHaloperidol 0.25 0.5mg PO BID or prn q 4h.
Atypical Antipsychotics (Risperidone, Olanzapine,
Quetiapine)Less QTc prolongation compared to
haloperidolAntipsychotics associated with increased mortality in
dementia--Prolonged QTc--Lowers seizure threshold
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What About Restraints?Restraint chains used to control mentally
ill patients, and documentation regarding Pennsylvania Hospital's
purchase of such restraints in 1751 and 1752.
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RESTRAINT USERestraints ARE appropriate for behavior that is a
risk to life or to necessary medical care
Restraints associated with significant injuries
Restraints associated with 4 fold increased risk of delirium
Distraction VestDunn KS. Et al. The effect of physical
restraints on fall rates in older adults who are institutionalized.
Journal of Gerentol Nurs 2001:27:40-48Evaluation and Management of
the Elderly Postoperative Patient at Risk for Postoperative
Delirium. Clin Geriatr Med 2008;24:667-686
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Gertrudes Tragic TaleShe gets out of bed to use bathroom at 2
a.m. and is found by staff on the floor.Urinary catheter still
attached to the bed
Her scalp laceration requires staples.
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Inpatient Falls2-12% of patients will have a fall in the
hospital30% with minor injury, 4% with major injuryAssociated
increased hospital charges ($4233) Associated increased LOS (12
days)
Injuries from falls in the hospital are Never EventsMedicare
will no longer pay for them
Hospital falls with significant injury are JCAHO reportable
sentinel events
Falls with injury in the hospital pose malpractice risk
Coussement J, et al. Interventions for Preventing Falls in Acute
and Chronic Care Hospitals: A systematic review and meta-analysis.
JAGS 2007;56:29-36
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Fall Risk AssessmentHow do we as physicians assess a patients
risk for this hazard of hospitalization?
A simple falls screen:Have you fallen in the last month or are
you afraid of falling?Get-Up-And-Go testYou learn a lot about
strength, balance, and gait in 30 seconds.
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Identifying the High Risk PatientRisk FactorsPrior fall
historyGait instabilityLower limb
weaknessConfusionDrugsSedative/hypnoticsUrinary incontinenceOliver
D, et al. Risk Factors and Risk Assessment Tools for Falls in
Hospital In-patients: A Systematic Review. Age and Ageing
2004;33:122-130
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The High Risk EnvironmentIV dripsTelemetrySequential compression
devices
Indwelling urinary catheters
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Modifying the High Risk EnvironmentPhysicians unaware of
catheter21% for Medical Students22% for Interns27% for Residents38%
for Attendings
This is not just about fallsIatrogenic infection is a potent
hazard of hospitalizationCMS no longer pays for catheter-associated
UTIsSaint S, et al. Are Physicians Aware of Which of Their Patients
Have Indwelling Urinary Catheters. Am J Med 2000;109:476-480Jain P,
et al. Overuse of the indwelling urinary tract catheter in
hospitalized medical patients. Arch Intern Med
1995;155:1425-1429
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Modifying High Risk TherapyPsychoactive
MedicationsAntidepressants and
neurolepticsBenzodiazepinesLorazepam, Diazepam
NarcoticsMeperidine
Cardiac medications Clonidine, short acting Nifedipine,
Doxazosin, Digoxin
Anticholinergic medications Diphenhydramine, Amitryptiline,
Promethazine, Cyclobenzaprine
Combinations of medications with partial anticholinergic
activityPrednisoloneTheophylineDigoxinFurosemideRanitidine
Woolcott JC et al. Metaanalysis of the Impact of 9 Medication
Classes on Falls in Elderly Persons. Arch Int Med
2009;169:1952-1960Fick, D, et al. Updating the Beers Criteria for
Potentially Inappropriate Medication Use in Older Adults. Arch Int
Med 2003;163:2716-24Tune L, et al. Anticholinergic Effects of Drugs
Commonly Prescribed to the Elderly. Am J Psych
1992;149:1393-1394
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Use of Sleepers in The Elderly15% of elderly inpatients were on
a sleep aid prior to admission
25% received pharmacotherapy for insomnia in the hospital
Non-benzodiazepine hypnotics (zolpidem)Most commonly chosen by
hospitalistsCumbler E. Use of Medications for Insomnia in the
Hospitalized Geriatric Population. JAGS 2008; 56:579-581
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ResultsUCH ExperienceRandomized patients for 1st 6 months ACE vs
usual careResource UtilizationDocumented severity of illness
slightly higher for ACECase mix index for ACE patients was 1.15 vs
1.05 in usual care
Length of stay 3.4 days
Mean Patient Charges $24,617
30 Day readmission rate 12.3%
ACE service model did not significantly change resource
utilization
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3600 EvaluationHouse staff 100% feel better medical care of the
elderly
Patient Satisfaction
Staff-- improved:Care coordinationCommunicationJob
satisfactionOverall I received very good care
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71%29%
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Clinician Behavior Mirrors the System in Which They
Practice!
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Recognition and Treatment of Geriatric Conditions
p < 0.0001
p < 0.01
p < 0.05
*
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ACE ModelWhat Does The Literature Show?Less Functional Decline
at Discharge13% risk reduction
Lower rate of Institutionalization22% risk reduction at 1
year
No influence on LOS
Trend towards reducedReadmission (15% risk reduction but not
statistically significant)Mortality (22% risk reduction at 3 months
but not statistically significant)
Van Craen K. The Effectiveness of Inpatient Geriatric Evaluation
and Management Units:A Systematic Review and Meta-Analysis. J Am
Geriatr Soc 2010;58:83-92Baztan JJ. Effectiveness of Acute
Geriatric Units on Functional Decline, Living at Home, and Case
Fatality Among Older PatientsBMJ 2009;338
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Geriatric Syndromes Have Profound ImpactMiller MO. Evaluation
and Management of Delirium in Hospitalized Older Patients. AAFP
2008;78:1265-1270Kiely DK, et al. Persistent Delirium Predicts
Greater Mortality. JAGS 2009;57:55-61Hazards
Delirium
Deconditioning
Falls
Harmed
The Patient
The Hospital
The Provider
The Insurer
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Keys to Care of the Hospitalized ElderSimple Risk
Assessments
Avoidance of Problematic InterventionsAnti-cholinergic and
Sedative MedicationsTethersRestraints
Interdisciplinary Team Communication
Standardized Care Protocols
***Hospitalist as force multiplier for geriatrics in the
hospital
*ACE Units first described in 1984-85. First RCT of an ACE unit
was done in Case Western in 1994. As of 2000 there were 16 ACE
units in the country and none at all in the West*ACOVE QI measures
include Discharge planning should begin within 48 hours of
admission**The acetylcholine deficit hypothesis is born out by
delirium induced by anticholihnergic drugs such as diphenhydramine.
The Dopamine excess hypothesis is supported by response of delirium
to haldol. Abnormal tryptophan metabolism may also play a
role.Elevated level of CRP in hip fracture patients correlates with
delirium (Beloosesky Y Gerontology 2004;50:216-222)
*NOTE: COG. IMPAIRMENT (MMSE < 24); VISION IMPAIRMENT >
20/70; BUN/CR > 18/1; SEVERE ILLNESS= APACHE II > 16 OR
CHARLSON ORDINAL CLINICAL = RATED AS SEVERE
*ACOVE Quality Measures include evaluation of cognitive status
should occur within 24 hours of admission*ACOVE Quality Measures
include evaluation for potentially precipitating factors must be
undertaken and identified causes treated.*ACOVE quality measures
include justifying use of restraints and methods other than
restraints in the care plan.**2-12% of patients will have a fall in
the hospital. From Coussement J, et al. Interventions for
Preventing Falls in Acute and Chronic Care Hospitals: A systematic
review and meta-analysis. JAGS 2007;56:29-36Inpatient fall cost and
LOS from Bates DW et al. Serious Falls in Hospitalized Patients:
Correlates and Resource Ulilization. AJM 1995;99:137-143*ACOVE
Quality measures include assessment of functional status AND
patients with problems of gait, strength, or endurance should be
offered an exercise program*Risk Factors from Oliver D, et al. Risk
Factors and Risk Assessment Tools for Falls in Hospital
In-patients: A Systematic Review. Age and Ageing
2004;33:122-130Psychotropics are most associated with falls with a
pooled odds ratio of 1.73- From Leipzig RM et al. Drugs and Falls
in Older People: A systematic review and Meta-analysis I.
Psychotrophic Drugs. JAGS 1999;47:30*Saint S, et al. Are Physicians
Aware of Which of Their Patients Have Indwelling Urinary Catheters.
Am J Med 2000;109:476-480- In this study catheters were deemed to
be unnecessary in 31% of cases.Urinary Catheter Use was judged
always inappropriate in 21% of all cases and approximately half of
all patient days.Jain P, et al. Overuse of the indwelling urinary
tract catheter in hospitalized medical patients. Arch Intern Med
1995;155:1425-1429**All of these medications are on the Beers list
although Lorazepam and Digoxin only at certain doses.*25% of
patients over the age of 65 in the care of a hospitalist are
treated with a medication for insomnia during
hospitalization-Cumbler E, Guerrasio J, Kim J, Glasheen J. Use of
Medications for Insomnia in the Hospitalized Geriatric Population.
JAGS 2008; 56:579-581Dementia present in 23% and 15% were
previously on an outpatient sleep aid, of which 30% were
non-benzodiazepine hypnotics. Insomnia medication was prescribed
during hospitalization in 27% of patients. Patients with dementia
were prescribed a medication for insomnia in only 7% of cases
compared to 32% for patients without dementia. Of patients who had
medication ordered for insomnia, Non-benzodiazepine hypnotics were
lone therapy for insomnia in 55%, benzodiazepines in 19%,
antidepressants in 15% and antihistamines in 2%. 9% of patients
were prescribed more than one class. Use of outpatient sleep
medication was positively associated (p < 0.001) with ordering
of medication for sleep in the hospital, and dementia was a
negatively associated (p < 0.001). Age, race, sex, or housestaff
involvement was not significant. Logistic regression models
revealed the presence of dementia significantly decreased
likelihood of a sleep medication order with unadjusted OR of 0.15
and adjusted OR of 0.22 (p = 0.04, 95% CI 0.05-0.96). *Total cost
of treatment full thickness ulcer up to $70,000