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Don’t just do something, stand there

Less can be more for hospitalized elderly

By Jennifer Kearney-Strouse

From the July ACP Hospitalist, copyright © 2008 by the American College of Physicians

When caring for hospitalized elderly patients, sometimes observation is better than quick action, according to Jeffrey Wallace, ACP Member. Dr. Wallace, associate professor of geriatric medicine at the University of Colorado in Denver, offered the following tips for dealing with delirium, nutritional problems and pain management, among other topics, at two Internal Medicine 2008 sessions on “Top 10 Rules for Rounding on Hospitalized Elders.”

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Dr. Wallace: With hospitalized elderly patients, sometimes observation is better than quick action.

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Keep variable illness presentation in mind. Physicians should be aware that some illnesses present differently in the elderly, Dr. Wallace said. For example, in patients age 85 or older, the most common symptom of acute myocardial infarction is dyspnea, not chest pain. In addition, fever in the hospitalized elderly should be redefined as a change in the baseline temperature rather than a specific number, Dr. Wallace recommended. “If you go up two degrees [Fahrenheit] or 1.1 degrees Centigrade over the baseline, you should call that a fever,” he said.

Try nondrug methods for delirium-related behavioral problems. Dr. Wallace recommended using “social” restraints in patients with delirium, such as having a sitter or a family member in the room. If drugs are absolutely necessary, use haloperidol, he advised, except in patients with Parkinson’s disease or extrapyramidal side effects, for whom quetiapine is preferred.

Prescribe prudently. Physicians caring for the elderly should be especially alert for drug-drug interactions. In patients taking at least eight drugs, the chance of an interaction approaches 100%, and nearly 50% of community-dwelling geriatric patients have had at least one drug-drug interaction, Dr. Wallace noted. “Try to have four or less meds as a goal.”

Physicians should also do their best to 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 explicit directions and information on duration of use were provided only 50% of the time. If you tell patients what they’ll be taking and why, compliance will improve, Dr. Wallace predicted.

Avoid drugs for insomnia whenever possible. Moving patients around and letting them see some daylight can help them sleep better at night, Dr. Wallace said. He also cautioned against awakening patients for unnecessary medications or examinations after hours. “I don’t want the vital signs at 2 a.m. unless I have a critically ill patient, but we do it all the time. We don’t even think about it,” he said. When patients are prescribed benzodiazepines as sleep aids in the hospital, he noted, physicians should stop the drugs before discharge to avoid unwarranted long-term use.

Be alert for depression. Although Dr. Wallace generally discourages starting new drugs in the hospitalized elderly, he makes an exception for antidepressants, because even minor depression can have major sequelae in older adults. “If you have a patient that you think might be depressed, at a minimum, flag it. At a maximum, I’m OK if you start proceeding with therapy in the hospital,” he said. Treatment with nondrug approaches, such as psychotherapy and exercise, can also improve outcomes. Hospitalists should also remember to arrange for appropriate postdischarge follow-up when patients are depressed, Dr. Wallace advised.

Avoid nutritional problems by nixing specialized diets. To make sure elderly patients stay nourished, Dr. Wallace recommended letting them eat what they want, other than restricting sodium when warranted, and trying to minimize iatrogenic starvation such as nothing-by-mouth orders for tests. Don’t let worries about glucose levels interfere with nutrition, he advised: “You’re going to get in more trouble trying to adjust the diet” than the insulin dose.

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 hard chair without using their arms for support and walk 10 feet without difficulty. If they can’t do so within 10 to 15 seconds, there’s a good chance they’ll fall once they’re discharged home, Dr. Wallace said.

Don’t discount opioids for pain management. “We are frankly too reluctant to use opioids in older adults,” Dr. Wallace said. In most cases, he noted, the list of potential consequences of undertreating pain is longer and more serious than the list of potential opioid side effects. “We probably do our patients a disservice when we aren’t more aggressive with opioids in particular,” he said.

Take advantage of transitions of care. Transitions are your chance to help the patient maintain the gains he or she has made during the inpatient stay, Dr. Wallace noted. In particular, make good use of the transfer sheet. “Whatever you write on that is gospel” for patients being transferred to other facilities, he said.

Don’t just do something, stand there. That’s Dr. Wallace’s rule for patients over age 75 or age 85. “Let the dust settle and see what you need to do before you jump in,” Dr. Wallace 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 concluded.

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated