A quick checklist for rounding on hospitalized seniors
From the June ACP Observer, copyright © 2006 by the American College of Physicians.
By Deborah Gesensway
PHILADELPHIA—You may have only 10 minutes with your newly hospitalized elderly patient--but in that time, you can cover eight areas that will reduce hospital complications and speed up discharge. That's according to Evelyn C. Granieri, MD, MPH, a nationally known geriatric medicine educator who heads Columbia University Medical Center’s new division of geriatric medicine and aging.
Evelyn C. Granieri, MD
During her presentation on "Rounding on Hospitalized Elders" at Annual Session, Dr. Granieri outlined the eight steps internists should take with older inpatients:
Screen for and document underlying cognitive impairment. Dementia is extremely common in hospitalized older patients, and as many as 70% of hospitalized patients over age 70 have cognitive impairment. But some studies show that only between 2% and 10% have that condition documented in the medical record.
Cognitive impairment affects everything from patients’ ability to manage complex drug regimens after discharge to the likelihood that they will develop delirium during their hospital stay. Dr. Granieri recommended that internists perform a simple cognitive assessment on all elderly patients when they are first admitted. Asking the patient to draw a clock face showing, say, 2:45, is one easy screening test.
Another important and easy screening test is to ask "memory" questions at every visit, such as questions about current events. Because hospitals tend to be so disorienting, you should avoid questions about orientation, such as what day of the week it is. "That's difficult when patients are acutely ill and off their schedule," she said.
Keep in mind that delirium could be a sign of underlying cognitive impairment or dementia. The first inkling of former President Ronald Reagan’s dementia, Dr. Granieri pointed out, was the delirium he developed in the hospital after being shot. A person with underlying dementia will take much longer to recover from delirium, she noted.
Because the natural course of delirium is to wax and wane, nurses must pay close attention and report its progress so doctors can identify and modify the factors contributing to it.
Review all medications. Studies have shown that older adults tend to leave the hospital taking between eight and nine medications—the same number they were taking when they came in. However, half of those specific drugs will be different.
Because many elderly patients have trouble adjusting to new and complicated drug regimens, Dr. Granieri advised physicians to order a home visit for patients after discharge. Some elderly patients, she explained, “don't know what to do with the meds at home, and they sometimes have no one to ask.”
Look for pressure ulcers. Examine all pressure points every day to make sure pressure ulcers don’t develop. Studies have found that between two and 10 elderly patients coming into hospitals already have a pressure sore, and about twice that number leave with one.
Check functional status. Although performing a thorough functional assessment can be time-consuming, here are four quick, basic points an internist should cover on each visit:
- Observe the state of the bed sheets—are they rumpled and full of crumbs? This will tell you if patients have been able to get out of bed to go to the bathroom or if they have been able to feed themselves.
- Ask patients to slide over to the edge of the bed.
- Order patients to get out of bed if at all possible every day.
- Call in occupational and physical therapists early in a hospital stay.
During the average three-day hospitalization, Dr. Granieri said, elderly patients can lose muscle and bone mass that will take them a month or more to recover.
Monitor nutrition and dehydration. While there is little evidence to support strategies to significantly improve nutrition in chronically ill older inpatients, Dr. Granieri urged physicians to encourage family members to help patients eat—even suggesting that they bring in favorite and familiar foods—and to refrain from ordering restrictive diets. “Anything that stimulates eating is good,” she said.
If the patient has no family around to help, Dr. Granieri said she asks the hospital’s dietitian to help determine what the patient likes to—and can—eat. She also asks the hospital to help find volunteers to feed the patient.
And just like poor nutrition, dehydration can be a real problem. Because water tends to be extremely difficult to swallow; patients should be given something thicker to drink that has more nutritive value, like a milkshake.
'Looking in the mouth can be just as important as looking at heart and lungs.'
—Evelyn C. Granieri, MD
Checking mouth care on daily rounds helps prevent aspiration pneumonia and can detect and prevent pain. Moreover, because many elderly people never see a dentist, internists are “left to be their oral health practitioners,” she said. “Looking in the mouth can be just as important as looking at heart and lungs."
Assess gait dysfunction and fall risk. Watch older adults walk at least once during their hospital stay to evaluate them for gait dysfunction. And watch them get out of bed to assess their risk of falling.
Avoid sensory deprivation. Remember that the sensory deprivation common in hospitals contributes to delirium. Internists should make sure patients have their glasses and hearing aids and are using them—and should not order a hearing test while seniors are in the hospital.
Embrace a team approach. Dr. Granieri’s final tip was to remind internists that caring for elderly patients requires a team. “You can’t," she said, "take care of this patient by yourself."
Deborah Gesensway is a freelance health care writer in Toronto.
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
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