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CHAPTER 1
Introduction and Overview
Brent C. Williams
Preeti N. Malani
David H. Wesorick
Approximately one in three hospitalized adults in the United States is over 65 years of age [1]. With multiple comorbidities and limited physiological and functional reserve, hospitalization inherently represents a period of heightened vulnerability for this population [2]. The risks are clear: falls, delirium, healthcare-associated infections, and adverse effects of drugâdrug interactions are common. Even a relatively short period of bed rest can result in profound deconditioning and loss of muscle mass. Between admission and discharge, more than a third of older hospitalized patients experience a decline in activities of daily living (ADLs). Overall, about a quarter of older adults require post-acute care due to loss of independence in basic ADLs and impaired mobility, and a remarkable one-third are rehospitalized within 90 days of discharge [3].
While the risks associated with hospitalization among older patients have been recognized for some time, in recent years significant progress has been made in identifying older patients at highest risk for adverse outcomes, and in structuring interventions to avoid or ameliorate morbidity. Although there is a paucity of research surrounding interventions that improve outcomes in older patients hospitalized on general wards, there is much information from trials among special hospital units (acute care of the elderly, or ACE units), geriatric assessment programs, as well as through intervention programs directed at specific outcomes, such as falls and delirium. A primary purpose of this text is to summarize recent research among hospitalized older patients in a single source, to facilitate incorporation of these findings into hospital practice.
The field of Hospital Medicine has experienced unprecedented growth over the last decade, and hospitalists now provide care for a substantial portion of all hospitalized patients [4]. Although hospitalists treat older patients routinely, most have received little or no specific training in the care of older adults. This book attempts to present relevant scientific information about the care of older adults in a way that will be useful to a practicing hospitalist.
Intended Audience and Use
This book is written for hospitalistsâbusy clinicians caring for acutely ill patients who need practical, evidence-based information and recommendations to improve the care of the vulnerable elderly. However, we believe other healthcare providers, including nurses, pharmacists, nutrition counselors, and physical and occupational therapists, will find several chapters germane to their work as well.
We also envision this book as a teaching tool, for use especially by hospitalists, medical students, and house officers seeking deeper and more comprehensive assessment and care plans for individual patients, and then embedding new practices into their daily routine.
Each chapter is intended to summarize âbest practicesââthat is, to provide concise, practical recommendations to hospitalists in the assessment and care of older hospitalized patients based on the most recent scientific evidence. In areas where evidence is scant, authors were encouraged to give practical advice based on their own experience. Topics were selected that addressed areas of high morbidity (e.g., falls, delirium, and medications), controversy (e.g., psychopharmacy and nutrition), or that are particularly difficult to âget rightâ in a busy hospital practice (e.g., informed decision-making and caring for patients with limited prognosis). Topics for which information and practice recommendations are readily available through other sources, such as management of medical conditions common among older hospitalized patients (e.g., atrial fibrillation, congestive heart failure, and pneumonia) were not included.
We hope hospitalists will use the text in several ways:
- To build a systematic approach to older patients. Chapters 2 (Communication and Physical Examination), 3 (Geriatric Assessment for the Hospitalist), 5 (Informed Decision Making), and 13 (Transitional Care Planning) address issues relevant to virtually all older patients, and are applicable in any clinical context.
- To improve practice in specific contexts. Many of the chapters address specific clinical contexts (Chapter 9 Hip Fracture, Chapter 10 Falls, and Chapter 11 Pressure Ulcers), and help inform the care of specific types of patients.
- As a teaching resource. The chapters in this book are up-to-date, and written by experts in their fields. They are a good starting point for clinical teaching on these topics, and they provide key references that can be used to foster additional reading and discussions.
- To improve work flow among healthcare team members. Although our primary audience is hospitalists, in order to be effective, many (if not most) of the recommended practices described in the book require collaborative interactions among physicians, nurses, pharmacists, therapists, social workers, and others. The practice recommendations offered readily lend themselves as a basis to review and redesign local practice with other health team members. Hospitalists who are already involved in quality improvement activities are encouraged to look for specific ideas and practice recommendations to discuss with administrators and other healthcare providers that are most relevant to their own practice environment.
As editors, we learned much from the many talented authors who willingly provided their time and insights to bring this book to fruition. We hope hospitalists and other hospital-based health care providers and administrators will find it equally valuable.
Acknowledgments
The editors are grateful to our contributing authors, who worked tirelessly to refine text to maximize its usefulness, timeliness, and evidence base, as well as provide expert advice in critical areas where good evidence to improve care is lacking. We are also grateful to Thomas H. Moore, Senior Editor at Wiley-Blackwell Health Sciences, for his thoughtful support and guidance in organizing and compiling the text.
References
1. National Hospital Discharge Survey. 2009 table, Number and rate of hospital discharges. 2009. Available at: http://www.cdc.gov/nchs/fastats/older_americans.htm (accessed April 11, 2013).
2. Cigolle CT, Langa KM, Kabeto MU, Tian Z, Blaum CS. Geriatric conditions and disability: the Health and Retirement Study. Ann Intern Med 2007;147:156â164.
3. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare Fee-for-Service Program. N Engl J Med 2009;360:1418â1428.
4. Kuo Y, Sharma G, Freeman JL, Goodwin JS. Growth in the care of older patients by hospitalists in the United States. N Engl J Med 2009;360:1102â1112.
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CHAPTER 2
The Hospitalized Older Adult: Communication and Physical Examination
Mark E. Williams
Introduction
Effective interpersonal communication among hospitalists and patients and their families throughout the hospital stay is critical to high-quality care. Good communication can enhance the patient's overall experience, prevent avoidable mishaps and complications, improve diagnostic accuracy and therapeutic efficacy, and foster professional satisfaction. However, the hospital setting is not inherently conducive to effective communication; frequent interruptions, competing demands for physicians' attention, simultaneous tasking, and background distractions of noise and activity are among the myriad barriers. Patients and their caregivers are often anxious and worried about poor outcomes. They feel uncertain about the future and are often groping for some combination of information and assurance that everything will be okay. Despite these challenges, hospitalists can substantially improve communication with patients and their caregivers by applying a few simple principles along with some habits of mind and behavior.
The basic premises of effective clinical care are that clinicians treat individuals not diseases and that the relationship between the doctor and patient is the conduit through which all therapeutic benefits flow. The experienced physician can perceptively gather and integrate clinical information, understand how people behave when they are ill, and develop a plan of care in the patient's best interest. Truly superlative clinical care also requires communicating the necessary therapeutic interventions in a way that maintains and even strengthens the patientâphysician relationship. The expert clinician appreciates that he or she is an essential component of the healing intervention. Plato stated: âYou ought not attempt to cure the eyes without the head, or the head without the body, so neither should you attempt to cure the body without the soul. And this ⌠is the reason why the cure of many diseases is unknown to the physicians of Hellas, because they disregard the whole, which ought to be studied also, for the part can never be well unless the whole is well.â
Pearls for Communicating with Older Patients
Make It a Habit to Demonstrate Reverence for Older Patients
In his classic 1927 Journal of the American Medical Association monograph, Francis Ward Peabody said the art of caring for the patient is to care for the patient. He also wrote âThe treatment of a disease may be entirely impersonal; the care of a patient must be completely personal.â This succinct advice epitomizes the need for craftsmanship in caring.
Caring for patients goes far beyond the important but superficial actions of shaking hands and introducing yourself. For example, we can observe the reverence in how people handle objects they perceive to be extremely valuable. There is a precious delicacy of the touch, with attention to each nuance in movement. The pottery bowl or rare book commands total concentration with an obvious appreciation for the material or artistic value. In the same way, it is easy to identify the clinician who is âcaring for the patientâ by how he or she takes the patient's hand for the initial handshake or to begin the physical examination. Again, there is a sense of conscious appreciation, respect, and reverence.
Control the Environment to Facilitate Communication
Conscientious information gathering requires awareness of the dynamics of the clinical encounter and structuring both the internal and external environment to facilitate communication. This can be particularly challenging in the emergency department or a typical inpatient room. The attitudes and habits of physicians and other healthcare personnel strongly influence the quality of information available from the patient history. In particular, two factors can make all the difference. First, it is important to keep in mind that the overall goals of care are to reduce morbidity and improve function and quality of life by whatever means possible, not necessarily eliminating the cause of the distress (which may be impossible in many circumstances). Second, during the few minutes of each clinical encounter, the hospitalist should develop the habit of clearing clear his/her mind, quieting internal distractors, and paying full attention to the patient through empathic listening. Inattentiveness leads to erosion of the therapeutic relationship and compromises the quality of observations.
Attention to a few specific external environmental considerations can also help by facilitating sensory input to the older person and putting them at ease. Because some older people have visual impairments, techniques to improve nonverbal cues become useful. For example, physicians should avoid having a strong light behind the...
