American College of Physicians: Internal Medicine — Doctors for Adults ®

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Don’t just do something, stand there

Less can be more for hospitalized elderly

By Jennifer Kearney-Strouse

When caring for hospitalized elderly patients, sometimes the best thing to do is nothing, according to Jeffrey Wallace, ACP Member. Dr. Wallace offered the following tips at two Friday sessions on “Top Ten Rules for Rounding on Hospitalized Elders.”

Keep variable illness presentation in mind. Some illnesses present differently in the elderly, Dr. Wallace noted. For example, in patients older than age 85, the most common symptom of acute myocardial infarction is dyspnea, not chest pain.

Try nondrug methods for delirium-related behavioral problems. Dr. Wallace recommended using “social” restraints in patients with delirium, such as having a family member in the room. If drugs are absolutely necessary, use haloperidol, he advised.

Beware of drug-drug interactions. In patients taking at least eight drugs, the chance of an interaction is 100%, Dr. Wallace noted. “We have to be careful with medications in the elderly,” he said.

Explain new drugs to patients. A 2006 Archives of Internal Medicine study found that 25% of doctors never told patients the name of the drug they were prescribing, and provided explicit directions and information on duration of use only 50% of the time. If you tell patients what they’ll be taking and why, compliance will improve, Dr. Wallace predicted.

Be alert for depression. Even minor depression can have major sequelae, Dr. Wallace said. Treatment with antidepressants or nondrug approaches, such as psychotherapy and exercise, can improve outcomes. Also, remember to arrange appropriate post-discharge follow-up, he noted.

Avoid specialized diets. To make sure patients stay nourished, let them eat what they want (other than restricting sodium when warranted) and try to minimize iatrogenic starvation such as NPO orders for tests, Dr. Wallace advised.

Assess function before discharge. “I don’t let my older patients out of the door without road-testing them,” Dr. Wallace said. He recommended using the “Get Up and Go” test to see if patients can rise from a chair without support and walk 10 feet without difficulty.

Don’t discount opioids. “I think we are frankly too reluctant to use opioids in older adults,” Dr. Wallace said. In most cases, the list of potential consequences is longer, and more serious, than the list of potential side effects, he noted.

Take advantage of the transfer sheet. “What you write on that is Gospel” for patients being transferred to other facilities, Dr. Wallace said.

Don’t just do something, stand there. That’s Dr. Wallace’s rule for patients over age 75 or 85. “Let the dust settle and see what’s going on before you jump in,” he recommended. But watch out for ageism, he cautioned, and keep the patients’ functional age rather than their chronological age in mind. “The best guides to assessment and management are the clinical circumstances and the patients’ preferences,” he said.

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