(Editor’s note: In this second part of a two-part series on the elderly, we further discuss delirium and unanticipated hospitalizations.)
To avoid delirium and unanticipated hospital admissions with seniors, you must evaluate the home situation, say sources interviewed by Same-Day Surgery.
“The ambulatory surgical setting is dangerous for individuals with poor health literacy because they are expected to engage in self-care rapidly despite often brief encounters with healthcare providers,” said the Journal of the American Geriatrics Society study authors, quoting a 2013 study. (Access the Society’s study at http://bit.ly/1McrKur.)
Verify if patients are able to take care of themselves at home, and find out if they have support. “If not, patients should be admitted to the hospital after surgery or have some type of formal support by a nurse to help them at home,” said Gildasio De Oliveira Jr., lead author of the Journal of the American Geriatrics Society report.
When patients go home on the day of surgery, “a lot is required of them to take care of themselves, and it’s beyond the capability of a lot of older individuals,” De Oliveira said. “They have to administer opioids and monitor themselves for emergency problems such as bleeding or infection.”
Educate caregivers about delirium, says Sharon K. Inouye, MD, MPH, professor of medicine at Harvard Medical School, director of the aging brain center at Institute for Aging Research, Hebrew SeniorLife, Boston. (Access information at http://www.hospitalelderlifeprogram.org/for-family-members.) Inouye was an author of a study in JAMA Surgery which found that among patients 70 years or older having elective surgery, major complications contributed significantly to a prolonged length of stay. (Access the study at http://bit.ly/1WtRe7J.)
To avoid unanticipated hospital admissions with seniors, consider these additional steps:
• Hospital Elder Life Program (HELP).
HELP was designed to prevent delirium from occurring in high-risk patients.
“It’s been very effective at preventing half of the cases of delirium, preventing hospital falls, reducing length of stay, and it saves costs,” Inouye says.
Inouye developed the program in 1995 as an inpatient program, and it’s being offered in 200 U.S. hospitals. Providers have told Inouye they were adapting the program for outpatients.
The program uses several strategies targeting risk factors for delirium, Inouye says. Areas targeted include early mobility after surgery, prevention of dehydration, provision of vision and hearing adaptions for the impaired, and therapeutic activities in postop. The therapeutic activities are “fun activities to keep them engaged and active so they can be socialized, not isolated,” Inouye says. Examples include discussion of current events, reminiscence, games such as crosswords, music therapy, or dog therapy.
HELP also includes a non-pharmacological sleep protocol to help patients with relaxation and pain, she says. “There’s a reduced need for standing orders for sleep medication, which is a big cause of delirium,” Inouye says.
Discharge planning is an important piece of HELP, Inouye says. “Discharge instructions should be given in large-print written format to the patient and reviewed verbally with both the patient and the caregiver,” she says. “A copy should be sent to the primary care physician, nursing home agency, or rehabilitation facility/nursing home as well.”
Verify that follow-up appoint-ments have been made, Inouye advises.
In the American Geriatrics Society study, a major factor in unanticipated hospital admissions was discharge instructions, says Lauren J. Gleason, MD, associate physician at Brigham and Women’s Hospital and part-time instructor of medicine at Harvard Medical School, both in Boston. Gleason was the lead author of the JAMA Surgery study.
“Like our study, which highlights potentially preventable complications such as delirium following surgery, this study highlights the importance of implementing preventive programs that meet the multidimensional care needs of older adults following surgery,” Gleason says.
• Proactive geriatric consultation.
With this program, a patient receives geriatric consultation at the facility prior to surgery. A geriatric assessment is performed in the areas that need to be targeted, Inouye says.
“It’s similar to Elder Life, but it’s done on an individual basis and done by a physician,” she says. One limitation is that the facility might not have a team that could put the recommendations in place, Inouye says.
• Co-management services.
Many hospitals have this service, in which clinicians with expertise in geriatrics co-manage the patients, Inouye says. “For example, an orthopedic surgeon who is admitting a patient to a hospital might ask a geriatrician to co-manage a patient with him or her,” she says. The geriatrician focuses on areas such as delirium prevention and preventing falls.
Inouye advises outpatient managers to be aware of patients who have factors that put them at a high risk for delirium. Those factors include underlying dementia, mild cognitive impairment, vision and hearing impairment, previous cancer, multiple comorbidities, and kidney failure/disease, because they’re less able to metabolize drugs, she says. “If the patient is frail, if you’re concerned about cognition at baseline, consider getting a geriatric consultation involved,” Inouye advises.
Screening patients to identify those at high risk of postoperative delirium can help you to implement preventive strategies as early in the admission as possible, Inouye says. Information about risk factors can be found in the free American Geriatrics Society Guidelines for Postoperative Delirium at http://bit.ly/1xLUtgQ.
In referring to HELP, geriatric consultations, and co-management services, Inouye says, “All these programs bring geriatric expertise to the patient, through a broad hospital-based program or individual consultation and management.”
