American College of Physicians

Internal Medicine 2007

San Diego, CA
April 19-21, 2007

Ten Rules for Rounding on Hospitalized Older

Adults
Evelyn C. Granieri, MD, MPH, MSEd

Posted Date: April 4, 2007

©2007 American College of Physicians. All rights reserved. Reproduction of Internal Medicine 2007 presentations, or print or electronic
material associated with presentations, is prohibited without written permission from the ACP.
 GOAL
TEN TIPS FOR
ROUNDING ON
HOSPITALIZED TO FAMILIARIZE THE PARTICIPANT
WITH UNIQUE ASSESSMENT
OLDER ADULTS REQUIREMENTS FOR ROUNDING ON
HOSPITALIZED OLDER ADULTS
Evelyn C. Granieri, M.D., MPH, MSEd
Co-
Co-Chief, Division of Geriatric Medicine and Aging
Columbia University College of Physicians and Surgeons

EG2279@COLUMBIA.EDU
February 2007

OBJECTIVES THE 10 TIPS

AT THE END OF THIS SESSION THE
PARTICIPANT WILL BE ABLE TO: 1. REVIEW ALL MEDICATIONS
2. EXAMINE SKIN AND PRESSURE
1. NAME 8 OF 10 DOMAINS TO ASSESS IN A POINTS
HOSPITALIZED OLDER ADULT
2. IDENTIFY 1 TOOL IN EACH DOMAIN THAT 3. PERFORM A COGNITIVE
CAN BE USED TO FACILITATE ASSESSMENT
ASSESSMENT 4. ASSESS FOR DELIRIUM
3. DESCRIBE 2 REASONS WHY THESE ISSUES
ARE IMPORTANT 5. CHECK FUNTIONAL STATUS

THE 10 TIPS IMPORTANCE

6. PERFORM GAIT AND FALL RISK ASSESSMENT

7. DETERMINE IF YOUR PATIENT IS EATING AND „ MORE OLDER ADULTS

DRINKING ADEQUATELY
„ They are getting older
8. MAKE SURE YOUR PATIENT HAS HER/HIS „ MORE HOSPITALIZATIONS
GLASSES OR HEARING AID
„ More expensive
9. DETERMINE SURROGATE AND ADVANCE „ MORE COMPLICATIONS
DIRECTIVES
„ That put the older adult at risk for increased
10. INVOLVE APPROPIATE TEAM MEMBERS FOR morbidity and mortality
CARE DURING AND AFTER HOSPITALIZATION

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 IMPORTANCE
CAUSES OF RISK

COMPLICATIONS CANNOT BE „ INCREASED AGE – PRIMARY AGING

PREVENTED UNLESS WE RECOGNIZE
WHO IS AT RISK AND WHY, HOW TO
ASSESS AND WHAT TO DO TO
PREVENT THE COMPLICATIONS
„ DISEASES – SECONDARY AGING
„ PSYCHOSOCIAL FACTORS –
TERTIARY AGING
„ HOSPITAL FACTORS

CAUSES OF RISK CAUSES OF RISK

INCREASED AGE – PRIMARY AGING

DISESASE – SECONDARY AGING
Decreased reserve
Muscle strength and aerobic capacity Sensory Impairment
Vasomotor Stability Incontinence
Respiratory Function Cognitive Impairment
Demineralization
Functional Impairment
Skin Integrity
Nutritional Status

CAUSES OF RISK CAUSES OF RISK

PSYCHOSOCIAL FACTORS – TERTIARY HOSPITAL FACTORS

AGING Hospital Schedule
Restraints
Isolation Hospital Food
Poverty Bed Rest/Immobility
Medications
Isolation

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 COMPLICATIONS
COMPLICATIONS
PRIMARY AGING
MUSCLE STREGTH AND AEROBIC
CAPACITY VASOMOTOR STABILITY
loss of VO2 max Falls and Syncope
loss of muscle mass
loss of muscle strength – up to 5% RESPIRATORY FUNCTION
per day Fall in PO2
Pneumonia

COMPLICATIONS
COMPLICATIONS DISESASE – SECONDARY
AGING
DEMINERALIZATION
Falls and Fractures Sensory Impairment-
Impairment- Confusion, falls
Incontinence – Falls, Infection
SKIN INTEGRITY
Pressure Ulcers Cognitive Impairment - Delirium
Functional Impairment – Increased slope
NUTRITIONAL STATUS of decline
Dehydration and Increased Burden of Illness

COMPLICATIONS
COMPLICATIONS
PSYCHOSOCIAL FACTORS –
HOSPITAL FACTORS
TERTIARY AGING
Hospital Schedule
Restraints
Hospital Food
Bed Rest/Immobility Isolation – Depression, Delirium,
Medications Confusion
Isolation Poverty – Decline in health status
ALL RESULT IN FUNCTIONAL,
COGNITIVE AND PHYSIOLOGIC
DECLINE

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 TIP #1
TIP #1
REVIEW ALL MEDICATIONS

REVIEW ALL MEDICATIONS „ Older adults take from 4-

4-10 prescription
medications
„ They take an equal number of OTCs
„ Most have multiple providers

TIP # 1 TIP #1
REVIEW ALL MEDICATIONS REVIEW ALL MEDICATIONS
WHAT TO DO
WHY?
D/C UNNECESSARY MEDS
RECONCILE DOSE WITH RENAL INCREASED DRUG/DRUG,
FUNCTION DRUG/NUTRIENT, DRUG/DISEASE
BE REALISTIC WHEN DETERMINIG D/C INTERACTIONS
MEDS DRUG DOSE CHANGES WITH AGE AND
RENAL FUNCTION

TIP #2
TIP #2 EXAMINE SKIN AND ALL
PRESSURE POINTS

EXAMINE SKIN AND ALL „ 10% OF OLDER ADULTS HAVE

PRESSURE SORES AT ADMISSION
PRESSURE POINTS „ SKIN IS SUBJECT TO STRESS AND
SHEAR FORCES IN HOSPITAL
TRANSITIONS

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 TIP#2 TIP #2
EXAMINE SKIN AND ALL EXAMINE SKIN AND ALL
PRESSURE POINTS PRESSURE POINTS

WHAT TO DO WHY?

PERFORM AN EXAMINATION OF TWICE AS MANY OLDER ADULTS LEAVE

EXTREMITIES, OCCIPUT, ACROMIUM, WITH PRESSURE ULCERS AS CAME
OLECRENON, SCAPULA, SACRUM, WITH THEM
BUTTOCK AND HEELS FEET AND NAILS ARE ESSENTIAL FOR
LOOK AT FEET AND NAILS FUNCTIONAL STATUS

TIP #3
TIP #3 PERFORM A COGNITIVE
ASSESSMENT
DEMENTIA
PERFORM A COGNITIVE Age is one the strongest risk factor for
ASSESSMENT dementia
At age 65, prevalence 8-
8-12%
At age 85, prevalence 50%
Persons with dementia in US-
US- 4 million
Projected number by 2040-
2040- 14 million

TIP #3 TIP #3
PERFORM A COGNITIVE PERFORM A COGNITIVE
ASSESSMENT ASSESSMENT
WHY?
„ WHAT TO DO Impaired cognition is evident in up to 50% of OA
hospitalized in a general medical unit
Dementia associated with increased risk of re-
re-
CLOCK DRAWING TEST hospitalization
Hospitalized patients with dementia were more likely to die
MINIMENTAL STATUS EXAM over next year
MINI COG Cognitive impairment is associated with functional decline,
delirium, and iatrogenesis during acute illness

Albert S, Costa R, Merchant C, et al. Hospitalization and Alzheimenrs disease: Results from a community based
study. Journal of Gerontology: Medical Sciences;1999:m267-
Sciences;1999:m267-m271

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 TIP #4
TIP #4
ASSESS FOR DELIRIUM
RISK FACTORS
ADVANCD AGE
ASSESS FOR DELIRIUM DEMENTIA
PREVIOUS DELIRIUM
SLEEP DEPRIVATION
IMMOBILITY
DEHYDRATION
PAIN
SENSORY IMPAIRMENT

TIP #4 TIP #4
ASSESS FOR DELIRIUM ASSESS FOR DELIRIUM
WHAT TO DO
WHY?
REVIEW MEDS
EXCLUDE INFECTION
Delirium is associated with an increased 6
BASIC LABS
month mortality (HR=7.24) NHP
Confusion Assessment Method (CAM)
(HR=2.64), longer hospitalization (HR=2.0)
BOTH acute onset and fluctuating course
AND inattention AND EITHER
disorganized thinking OR altered consciousness

TIP #5
TIP #5 CHECK FUNCTIONAL STATUS

Functional limitations increase with age and

CHECK FUNCTIONAL with cognitive impairment
STATUS Functional decline occurs in substantial
number of hospitalized older adults
Acute illness can lead to further functional
decline

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 TIP #5 TIP #5
CHECK FUNCTIONAL STATUS CHECK FUNCTIONAL STATUS
ACTIVITIES OF DAILY LIVING INSTRUMENTAL ACTIVITIES OF DAILY LIVING
Bathing Using the phone
Dressing Traveling
Transfer Shopping
Continence Preparing meals
Feeding Housework
Taking medicine
Lost in distinct pattern, hierarchical Managing money

TIP #5
CHECK FUNCTIONAL STATUS
TIP #6
WHY?
FUNCTIONAL DECLINE
OUTCOMES
Prolonged hospital stay
ASSESS GAIT DYSFUNCTION
Higher mortality (almost 2 times
relative risk) AND FALL RISK
Higher rates of
institutionalization
Higher health care expenditure

TIP #6 TIP #6
ASSESS GAIT DYSFUNCTION AND ASSESS GAIT DYSFUNCTION AND
FALL RISK FALL RISK

GAIT – GET UP AND GO

WHAT TO DO
Quantitative evaluation of general functional
LOOK FOR RISKS mobility
MEDS Timed command
ORTHOSTATICS and other VS Rise chair
HEAD AND NECK Walk 10 feet
Turn around
MUSCULOSKELETAL
Walk back and sit in chair
NEURO SHOULD TAKE 10 SECONDS
CLOTHING AND FOOTWARE

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 TIP #6
ASSESS GAIT DYSFUNCTION AND TIP #7
FALL RISK

WHY?
DETERMINE WHETHER YOUR
FALLS INCREASE LENGTH OF STAY PATIENT IS EATING AND
FALLS INCREASE MORTALITY AND DRINKING ADEQUATELY
MORBIDITY
FALLS INCREASE RISK OF NURSING
HOME PLACEMENT

TIP #7
DETERMINE WHETHER YOUR PATIENT IS
EATING AND DRINKING ADEQUATELY
UP TO 50% OF HOSPITALIZED OLDER
ADULTS ARE MALNOURISHED
AT LEAST 21% HAVE INADEQUATE
CALORIC INTAKE IN THE HOSPITAL
TIP #7
DETERMINE WHETHER YOUR PATIENT IS
EATING AND DRINKING ADEQUATELY
WHAT TO DO
WATCH THEM EAT AND DRINK
REMEMBER TO D/C NPO
ENCOURAGE HOME FOODS
DON’T USE RESTRICTIVE DIETS
WRITE ORDER FOR ASSISTANCE WITH
MEALS
ORDER HOME NUTRITIONAL
ASSESSMENT

TIP #7
DETERMINE WHETHER YOUR PATIENT IS TIP #8
EATING AND DRINKING ADEQUATELY

WHY ?

MAKE SURE THEIR GLASSES AND

MALNUTRITION INCREASES 1 YEAR
MORTALITY (OR=2.83) HEARING AIDS ARE IN PLACE

MALNUTRITION INCREASES FUNCTIONAL

DEPENDENCE (OR=2.81)

MALNUTRITION INCREASES NHP (OR=3.22)

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 TIP #8 TIP #8
MAKE SURE THEIR GLASSES AND HEARING MAKE SURE THEIR GLASSES AND HEARING
AIDS ARE IN PLACE AIDS ARE IN PLACE
WHAT TO DO

80 PERCENT OF OLDER ADULTS HAVE ASK IF THEY HAVE ASSISTIVE DEVICES

VISUAL IMPAIRMENT MAKE SURE THEY ARE USED
UP TO 60% HAVE AUDITORY PERFORM VISUAL AND AUDITORY EXAM
IMPAIRMENT SIT AND SPEAK AT THEIR LEVEL
MODULATE THE FREQUENCY OF YOUR
SPEECH

TIP #8
MAKE SURE THEIR GLASSES AND HEARING TIP #9
AIDS ARE IN PLACE
WHY?
SENSORY IMPAIRMENT IS ASSOCIATED
WITH COGNITIVE DECLINE DETERMINE SURROGATE
SENSORY IMPAIRMENT IS ASSOCIATED AND ADVANCE DIRECTIVES
WITH DELIRIUM
SENSORY IMPAIRMENT IS ASSOCIATED
WITH FALLS
SENSORY IMPAIRMENT IS ASSOCIATED
WITH IATROGENESIS

TIP #9 TIP #9
DETERMINE SURROGATE AND DETERMINE SURROGATE AND
ADVANCE DIRECTIVES ADVANCE DIRECTIVES

90% OF OLDER ADULTS HAVE NOT
DONE ADVANCE CARE PLANNING FOR
HEALTH
WHAT TO DO
DETERMINE IF CAPABLE
OBTAIN DIRECTIVES IF POSSIBLE

VOW NOT TO HAVE THAT HAPPEN TO

YOUR PATIENTS

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 TIP #9
DETERMINE SURROGATE AND TIP #10
ADVANCE DIRECTIVES

WHY?
INVOLVE APPROPRIATE MEMBERS
OF THE TEAM FOR CARE DURING
OLDER ADULTS WITHOUT DIRECTIVES
DO NOT HAVE THEIR WISHES MET
AND AFTER HOSPITALIZATION
AND DECISIONS MAY NOT BE
CONSISTENT WITH NORMS OF CARE
CPR RESULTS ARE UNSATISFYING FOR
FRAIL OLDER ADULTS

TIP #10
INVOLVE APPROPRIATE MEMBERS OF THE TEAM
TIP #10 FOR CARE DURING AND AFTER HOSPITALIZATION
INVOLVE APPROPRIATE MEMBERS OF THE TEAM
WHO?
FOR CARE DURING AND AFTER HOSPITALIZATION
NURSE
NURSE PRACTITIONER
PA
HOSPITALIZED OLDER ADULTS ARE SOCIAL WORK
PT/OT
BEST CARED FOR BY A TEAM VS. SPEECH
DIETITIAN
SOLO PRACTITIONERS HOME CARE TEAM
CHAPLAIN
CAREGIVER/FAMILY MEMBER
PATIENT
FLOOR STAFF

TIP #10
INVOLVE APPROPRIATE MEMBERS OF THE TEAM
10 TIPS FOR ROUNDING ON
FOR CARE DURING AND AFTER HOSPITALIZATION HOSPITALIZED OLDER ADULTS

WHY? „ IT SHOULD TAKE YOU LESS THAN

FEWER RE-
RE-HOSPITALIZATIONS HALF AN HOUR DURING THE COURSE
BETTER CONTINUITY OF CARE OF THE HOSPITALIZATION TO
PERFORM THESE ROUNDING TASKS
LESS IATROGENESIS
„ YOU CAN MAKE AN APPRECIABLE
DIFFERENCE IN THE CARE AND
STATUS OF YOUR OLDER PATIENTS

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