Principles of Care for Older Persons

Mudanai Sabapathy

Bruce J. Naughton

CLINICAL PEARLS

Chronic disease management and prevention of functional impairment are major goals of elder care across delivery sites.
Interdisciplinary comprehensive assessment and long-term interdisciplinary management improve outcomes.
Implement systems to improve safety across sites of care.
Recognize delirium as a major adverse event in an acute illness.
Reduce adverse drug events and polypharmacy.
Avoid treatment of asymptomatic bacteriuria.
Treat pneumonia at home and in the nursing home when possible.
Anticipate functional decline during acute illness.
Establish indications for palliative care early and review the indications following a significant change in clinical condition.
Learn to recognize symptoms of dying.

CASE: PART ONE

An 85-year-old woman is transferred from a nursing home to the emergency department (ED) with drowsiness and increased confusion. The patient has a history of stroke, hypertension, angina, type 2 diabetes mellitus, and osteoarthritis. She is on multiple medications. She normally ambulates with a two-wheeled walker and is dependent in several activities of daily living (ADLs). She was at her baseline the day prior to the ED visit but was found to be lethargic and incontinent of urine on the morning of admission. She was not able to ambulate and refused her breakfast.

Chronic diseases and functional impairment are major challenges in the care of the older patient. Patients aged 75 years and older are different from the young, both in terms of physiology and the frequent presence of multiple comorbidities. Among older patients, acute illness is often an acute exacerbation of one or more underlying chronic conditions. Stabilization, relief of symptoms, preservation and/or restoration of function, and prevention of recurrences are the primary aims of treatment in the older adult, regardless of whether care is provided at home, in the hospital, or at the nursing home.

In general, for patients older than 75 years with cognitive and/or functional impairment and for patients with
multiple chronic illnesses, the principles of management of acute illness and chronic conditions are similar. Care is directed toward preventing exacerbations, maintaining function, and providing good pain control while avoiding adverse drug effects, infections, and injury.

Evaluation of symptoms in older adults involves the recognition that different illnesses may present with similar symptoms. For example, the episode of delirium described in the above clinical vignette has many potential etiologies, including infection, cardiovascular events, adverse drug effects, constipation, and dehydration. Evaluation should begin with an understanding of the patient’s baseline functional status, a detailed history, and a thorough physical examination. Particular attention should be paid to the patient’s medication list and medications that may be bought over the counter. Older individuals often take several vitamin and herbal supplements, and side effects from such medications should be considered when evaluating the patient’s symptoms.

Programs or efforts that begin with a detailed assessment of the older patient’s medical, functional, cognitive, and social status and address acute and chronic issues concurrently have been shown to improve outcomes.¹, ², ³, ⁴ Outcome measures must include the patient’s values and goals. For example, older patients by themselves or through a health care proxy may choose to forego artificial nutrition and hydration or other forms of treatment when faced with a heavy burden of chronic illness and advancing age.

ORGANIZATION OF CARE

Ambulatory Care

A primary care approach combining an initial interdisciplinary, comprehensive assessment with long-term interdisciplinary outpatient management has been shown to improve outcomes for targeted older adults.⁵ The assessment involves physical, psychosocial, and environmental factors that impact on the well-being and function of older individuals. The use of an organized approach employing objective measurements helps target key areas of functional status. Evaluation areas include ADLs, cognition, mood, social supports, gait and falls, nutrition, sensory impairments, incontinence, polypharmacy, elder abuse, pressure sores, pain, and advance directives.⁶

A primary care clinician who organizes and coordinates outpatient care that meets the complex needs of functionally impaired older adults may achieve outcomes similar to those of an interdisciplinary team. In these cases, the care plan inevitably includes services delivered by an ad hoc multidisciplinary team. Geriatric assessment centers have been developed to implement preorganized interdisciplinary teams and enhance traditional primary care management.

Care in the Hospital

Hospital programs have embraced the patient-centered care model. These models include intensive review of medical care with a view to minimizing the adverse effects of procedures and medications. They have established protocols for prevention of disability and for early rehabilitation. Hospital programs implement discharge planning early in the admission to develop a continuum of care plan. Taken together, these interventions reduce the incidence of delirium, lower the frequency of discharge to institutions for long-term care, and reduce health care costs.¹,²,⁴ Some programs use geographically defined units with specialized personnel. Others have enhanced the training of existing hospital personnel who serve patients meeting the criteria throughout the hospital.

In some facilities, a practitioner can order geriatric hospital services for at-risk older adults during hospitalization as a holistic service. Alternatively, the practitioner may act more independently, applying the principles of careful medication management and medical procedure review to minimize adverse outcomes, and ordering specialty services such as physical therapy as needed. Either pattern may reduce functional loss and the length of hospital stay if implemented with input from social workers and rehabilitation services.

Care in the Long-term Care Facility

Long-term care residents are usually dependent in three or more ADLs and have one or more sources of disability, such as Alzheimer disease, multi-infarct dementia, stroke, chronic heart disease, chronic obstructive pulmonary disease (COPD), and osteoarthritis. Care is multidisciplinary, involving the collaboration of physicians, nurses, nursing aides, physical therapists, speech therapists, occupational therapists, and social workers.

The federal Medicare program requires a physician to see the nursing home resident at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. Physician visits may be alternated with visits by a nurse practitioner. Because the physician may see the patient infrequently, a Minimum Data Set (MDS) has been developed to help the nursing staff recognize and evaluate common clinical syndromes that occur in nursing home residents. Certain answers on the MDS trigger the use of resident assessment protocols (RAPs) to facilitate nursing staff-to-physician communication about clinical issues.⁷

Many nursing homes do not have daily attendance by a physician and depend upon telephone contact with a physician. As a result, physician orders are frequently given over the telephone. Many facilities use nurse-driven guidelines or protocols for common acute illnesses such as pneumonia. This standardization reduces medication error and the need to hospitalize patients for management of many acute illness episodes. Regular presence of a nurse
practitioner or a physician assistant provides support to the nursing staff and families while promoting management of acute illnesses in the nursing home.

TRANSITIONS IN CARE

Exchange of information between care settings is vital for patient safety and to prevent complications arising from poor coordination of clinical services. This interface is called transitional care. Transitional care is a set of actions designed to ensure the coordination and continuity of health care as patients are transferred between different care settings. In the absence of coordination, care must be provided without full knowledge of the problems addressed, services provided, medications prescribed, or preferences expressed by the patient in the previous setting.⁸ Poorly executed care transitions result in medication errors⁹ and failure to address the primary purpose of a transfer. In the above case, the nursing home was aware of the allergy to ceftriaxone, but failure to convey the information led to an avoidable hospital admission.

Concise information on diagnosis, allergies, and medication management is vital for safe and efficient transition of care. Transitional care may be improved by keeping the patient and caregiver informed and using advanced practice nurses.¹⁰ Care pathways and protocols, integration of acute and long-term care,¹¹ identification of patients at risk for complications and poor outcomes,⁸ and electronic medical records can improve transitional care.

COMMON COMPLICATIONS

Delirium

Delirium is the most common complication of acute hospitalization among older adults. Delirium is a marker for increased morbidity, mortality, and functional decline as well as prolonged hospital stays and increased costs. Approximately 50% of older adults who experience delirium during hospitalization are already delirious upon presentation to the ED. Therefore efforts to prevent delirium depend on whether the patient is at home, in a nursing home, or in the hospital.

Age and preexisting cognitive impairment are two important and easily identified risk factors for delirium. Other risk factors include poor premorbid functional status, visual and hearing impairment, and Parkinson disease. Features of delirium include acute onset, fluctuating course, inattention, plus disorganized thinking and/or altered level of consciousness.¹² Inattention, a hallmark of delirium, can be assessed by asking the patient to say the days of the week backwards.

Acute illnesses associated with fever, such as pneumonia or urinary tract infections (UTIs), and conditions that cause hypoxia, such as COPD or congestive heart failure, are major precipitants of delirium.¹³ Other preventable precipitants include medications, particularly polypharmacy, pain, urinary retention, fecal impaction, and dehydration. Benzodiazepines, narcotics and anticholinergic medications including tricyclic antidepressants, medications for urinary incontinence, and antihistamines are commonly associated with delirium.

Delirium in the Hospital

A comprehensive and systematic approach to preventing delirium has been shown to reduce the rate of the incidence and prevalence of delirium.¹⁴ (see Table 2.1) Delirium prevention programs are associated with an overall improvement in ADLs, immobility, dehydration, and cognitive status.¹⁴ For patients aged 65 years and older admitted to an orthopaedic surgery service with hip fracture, a routine geriatric consultation focused on discontinuation of medications known to precipitate delirium, early mobilization, and removal of Foley catheters significantly reduced postoperative delirium. Another trial focused on avoiding the use of benzodiazepines and anticholinergic medications also found a significant reduction in the hospital rate of delirium.¹⁵

Delirium Outside the Hospital

These principles may also be applied in the home and at a skilled nursing facility. Particular emphasis on avoiding medications known to precipitate delirium reduces the incidence of delirium. The need for hospitalization and length of stay may also be reduced if medications associated with delirium are promptly stopped or significantly reduced should delirium occur (see Table 2.2).

Medication Management

Adverse Drug Events at Home

Older adults are at increased risk for, and experience a disproportionate amount of, adverse drug events. Sound medication management is a fundamental tenet of good geriatric medicine practice. In all settings, medication lists should be reviewed at each contact with an eye toward
limiting medications to those that have specific indications and are essential to address immediate acute and underlying chronic conditions. Medication dosage should be adjusted to the individual’s conditions, remembering that failure to adjust for age-associated changes in renal function is a common source of error. See Table 2.3 for commonly used medications to be avoided in older adults with specific diagnoses. Pharmacists can provide valuable support in making dosage adjustments.

TABLE 2.1 DELIRIUM/BEHAVIOR ASSESSMENT AND INTERVENTION

Part I: RN’s initial screen
Mental status evaluation
	▪	Cognitive impairment
	▪	Delirium
Review assessment with physician Precipitating factors:
	▪	Pain
	▪	Fecal impaction
	▪	Acute medical illness:
		•	Dehydration (BUN/creatinine ratio >18)
		•	Urinary tract infection
		•	Pneumonia
		•	Stroke
		•	Fracture
		•	Postoperative state
		•	Foley catheter
		•	Restraints
Environmental stimuli (noise, sleep disruption, disruptive roommate):
	▪	Avoid benzodiazepines
	▪	Avoid anticholinergics
	▪	Simplify pain regimen (minimize p.r.n)
	▪	Consider synergistic agents (such as neuroleptics or antidepressants that supplement behavior treatment)
Review with physician evidences of psychosis:
	▪	Hallucinations (“I see those children”)
	▪	Delusions (“This is a nice hotel”)
	▪	Paranoia (“That medicine is poison”)
Part II: Intervention (Interdisciplinary)
Implement Behavior Measurement Scale
For delirious patients or individuals with reports of behavior disturbances: Record all categories of behavior that occur during each shift for first 24 h postadmission
Treat underlying medical factors Treat precipitating factors: Remove precipitating medications Immobility Provide family support Use nonpharmacological intervention for: Physically nonaggressive behavior Episodes triggered with ADL care
RN, registered nurse; BUN, blood urea nitrogen; ADL, activities of daily living.
From Naughton BJ, Saltzman S, Ramadan F, et al. A multifactorial intervention to reduce prevalence of delirium and shorten hospital length of stay. J Am Geriatr Soc. 2005;53(1):18-23.