Angela G. Catic

Identification and management of in-hospital drug-induced delirium in older patients.

Delirium, an acute confusional state with changes in attention and cognition, is a common cause of morbidity and mortality among hospitalized elders. Medications are responsible for up to 39% of delirium cases in the elderly. The incidence of drug-induced delirium is particularly high in this population due to the altered pharmacokinetics and pharmacodynamics of aging, high prevalence of polypharmacy and occurrence of co-morbid disease. Although certain medications are more often associated with the development of delirium, including opioids, benzodiazepines, anticholinergics and antidepressants, any medication can cause delirium in the elderly. Evaluation of delirium should include a thorough medication history, which should determine if any new medications have been initiated, if medications have been discontinued, and the details of any recent dosage adjustments.It is important to understand the utility of medications in preventing and treating delirium in the elderly. Acetylcholinesterase inhibitors have not been found to reduce the incidence of delirium or length of hospitalization. Study results regarding the utility of antipsychotic medications in preventing delirium have been mixed. Haloperidol prophylaxis did not reduce the occurrence of delirium, but it did reduce the severity and duration. Olanzapine and risperidone were associated with a reduced incidence of delirium compared with placebo.Pharmacological therapy to treat delirium should be implemented only if patients pose a safety risk to themselves or others. Typical and atypical antipsychotics are effective in treating the symptoms of delirium, but it is important to note that they are not approved by the US FDA for this indication. Short-acting benzodiazepines are second-line therapy and are typically reserved for patients with sedative/alcohol withdrawal, Parkinson’s disease or neuroleptic malignant syndrome. Study results regarding the utility of acetylcholinesterase inhibitors have been mixed.

ECHO-AGE: An Innovative Model of Geriatric Care for Long-Term Care Residents With Dementia and Behavioral Issues

OBJECTIVES To design, implement, and assess the pilot phase of an innovative, remote case-based video-consultation program called ECHO-AGE that links experts in the management of behavior disorders in patients with dementia to nursing home care providers. DESIGN Pilot study involving surveying of participating long-term care sites regarding utility of recommendations and resident outcomes. SETTING Eleven long-term care sites in Massachusetts and Maine. PARTICIPANTS An interprofessional specialty team at a tertiary care center and staff from 11 long-term care sites. INTERVENTION Long-term care sites presented challenging cases regarding residents with dementia and/or delirium related behavioral issues to specialists via video-conferencing. METHODS Baseline resident characteristics and follow-up data regarding compliance with ECHO-AGE recommendations, resident improvement, hospitalization, and mortality were collected from the long-term care sites. RESULTS Forty-seven residents, with a mean age of 82 years, were presented during the ECHO-AGE pilot period. Eighty-three percent of residents had a history of dementia and 44% were taking antipsychotic medications. The most common reasons for presentation were agitation, intrusiveness, and paranoia. Behavioral plans were recommended in 72.3% of patients. Suggestions for medication adjustments were also frequent. ECHO-AGE recommendations were completely or partially followed in 88.6% of residents. When recommendations were followed, sites were much more likely to report clinical improvement (74% vs 20%, P < .03). Hospitalization was also less common among residents for whom recommendations were followed. CONCLUSIONS The results suggest that a case-based video-consultation program can be successful in improving the care of elders with dementia and/or delirium related behavioral issues by linking specialists with long-term care providers.

Aging and ESRD demographics: consequences for the practice of dialysis.

The disproportionate increase in the prevalence of chronic kidney disease (CKD) and end‐stage renal disease (ESRD) in the elderly is now recognized as a national and global reality. Among the major contributing factors are the aging of the population, a growing prevalence of CKD, greater access to care, and increased comorbidities. The utilization of renal replacement therapy in the geriatric population has concomitantly increased. It is imposing enormous challenges to the practice of ESRD care, the largest of which may be to determine the best application of clinical performance targets to a population with limitations in life expectancy. Concurrently, increased focus on quality of life will be required. The effective dialysis practitioner will need to adapt to the aging ESRD demographics with an increased focus on physical and mental well‐being of the geriatric patient.

A standardized, bundled approach to providing geriatric-focused acute care.

To determine whether a bundled intervention can increase detection of delirium and facilitate safer use of high‐risk medications.

Preliminary Data from an Advanced Dementia Consult Service: Integrating Research, Education, and Clinical Expertise

Hospitalized individuals with advanced dementia often receive care that is of limited clinical benefit and inconsistent with preferences. An advanced dementia consultation service was designed, and a pre and post pilot study was conducted in a Boston hospital to evaluate it. Geriatricians and a palliative care nurse practitioner conducted consultations, which consisted of structured consultation, counseling and provision of an information booklet to the family, and postdischarge follow‐up with the family and primary care providers. Individuals aged 65 and older with advanced dementia who were admitted were identified, and consultations were solicited using pop‐ups programmed into the computerized provider order entry (POE) system. In the initial 3‐month period, 24 subjects received usual care. In the subsequent 3‐month period, consultations were provided to five subjects for whom they were requested. Data were obtained from the electronic medical record and proxy interviews (admission, 1 month after discharge). Mean age of the combined sample (N = 29) was 85.4, 58.6% were from nursing homes, and 86.2% of their proxies stated that comfort was the goal of care. Nonetheless, their hospitalizations were characterized by high rates of intravenous antibiotics (86.2%), more than five venipunctures (44.8%), and radiological examinations (96.6%). Acknowledging the small sample size, there were trends toward better outcomes in the intervention group, including greater proxy knowledge of the disease, better communication between proxies and providers, more advance care planning, lower rehospitalization rates, and fewer feeding tube insertions after discharge. Targeted consultation for advanced dementia is feasible and may promote greater engagement of proxies and goal‐directed care after discharge.

Acute Pain Control in the Elderly

As the number of elderly patients undergoing surgery rises, acute pain control in the postsurgical setting is an increasingly important concern. The consequences of poorly controlled pain in the elderly patient can be significant and lead to negative outcomes.

Feeding Issues in Advanced Dementia

Ninety percent of individuals with advanced dementia will experience trouble with feeding issues. Enteral feeding is frequently offered as a long-term solution to this problem. This intervention is driven by misperceptions regarding the benefits of tube feeding as well as hospital, nursing home, and long-term care facility factors. In this chapter, we will review the evidence regarding enteral feeding in patients with advanced dementia. Briefly, it does not show any benefit in preventing aspiration pneumonia, improving nutrition, improving survival, preventing or improving pressure ulcers, or providing additional comfort to those unable to eat or drink compared to hand-feeding. Enteral feeding may also precipitate unintended consequences resulting in increased acute care visits. In contrast to enteral feeding, hand-feeding provides the benefits of increased personal care and social interaction as well as the enjoyment tasting food and drink.

Special Considerations in Older Surgical Patients

As the population is aging, more individuals are living into advanced old age. A greater number of older adults, including those in the oldest old (>85 years) segment of the population, are undergoing surgical procedures. Prior to surgery, especially in the geriatric population, it is important to obtain a clear understanding of the indication and goals of the procedure. As part of the presurgery preparation, special attention should be given to ensuring the patient is cognitively able to engage in the informed consent process. It is often helpful to include health-care agents and involved family members in this conversation. In addition, instead of automatically rescinding do-not-resuscitate (DNR) orders in the perioperative setting, conversations should occur to establish alignment between the overall and operative goals of the patient and the practices of the surgical team.

Perioperative education in geriatrics.

Secondary to declining fertility and increasing life expectancy, the median age of the world’s population is increasing. In the United States, the population of people aged 65 years or older is expected to double in the next 20 years. With the aging of America, the number of individuals aged 65 years and older will increase from 35 million in 2000 to 71 million in 2030. The number of oldest old, aged 80 years and older, will catapult from 9.3 to 19.5 million during the same timeframe. The percentage of the population living into late life is also projected to increase from 13% in 2000 to over 20% by 2030. This aging trend is also occurring on a worldwide basis. The number of individuals aged 60 years and older is growing by 2%/y, and those aged 80 years and older are growing by 3.8%/y. By 2050, the percentage of people aged 60 years and older worldwide is expected to be 21% and will exceed the number of younger individuals for the first time in history. The number of older patients undergoing surgical procedures is also increasing. Currently, 30% to 40% of all surgeries are performed on elderly patients. Although advancements in preoperative screening, perioperative care, and new surgical techniques have contributed to making surgery safer for elders, there is risk involved. Population-based evidence from Washington state found that 90-day mortality increased sharply with age from 2.5% in individuals aged 65 to 69 years to 16.7% among those aged 90 years and older. In addition to advancing age, increasing numbers of medical comorbidities are also associated with worse surgical outcomes. Nursing home residents, often considered the frailest elders, experience significantly higher rates of postoperative complications and mortality compared with noninstitutionalized Medicare enrollees.

The Perioperative Geriatric Consultation

With the recent aging of America and prediction that the number of individuals aged 65 years or older will skyrocket to 87 million by 2050, the number of geriatric patients undergoing surgical procedures will continue to increase over the next several decades. Currently, more than half of all surgeries occur in elders. The most common procedures in this population include percutaneous coronary intervention with stenting, coronary artery bypass graft surgery, and open reduction internal fixation for hip fractures. Preparation for surgery and the postoperative course are impacted by many conditions common in elders including dementia, frailty, poor nutrition, and inability to care for oneself. In addition, postoperative cognitive dysfunction (POCD) and delirium are more common among geriatric patients. Geriatric consultation can improve outcomes in elders undergoing surgical procedures through assessment of risk prior to surgery and management of complications during the postoperative period.