Senior Syndromes

Attendees at the session “Managing Hospitalized Elders,” presented by Robert Palmer, MD, MPH, head of the section of Geriatric Medicine at Cleveland Clinic in Ohio, gained insights into the unique dangers hospitalization presents to their oldest patients.

“As every hospital-based physician knows, increasingly, hospital care is geriatric care,” said Dr. Palmer. “We’re seeing not only more people over 65, we’re seeing more people over age 85—the most complex and challenging cases. The question is, how do we work our way through the chronic diseases, the acute on top of chronic disease, deal with the psychosocial issues and family issues of the frail elderly person during hospitalization.”

The problem is that simply being hospitalized may trigger or exacerbate a functional decline in an elderly patient. Hospitalization itself can lead to delirium, undernutrition, immobility, pressure ulcers, incontinence, and ultimately placement in a nursing home.

“The process of care, a hostile environment, bed rest, starvation, medications—especially those that are inappropriate for use with older people—and depression all conspire to create a dysfunctional older person,” stressed Dr. Palmer. Common co-morbid conditions in the elderly include dehydration, chronic obstructive pulmonary disease (COPD), hypertension, chronic heart failure, diabetes, and anemia.

“We rarely treat these patients for just one condition,” Dr. Palmer pointed out.

Common Geriatric Syndromes

Common clinical presentations in elderly hospitalized patients include dysfunction, delirium, depression, and dementia.

“Some well-designed cohort studies show that 20% to 32% of these patients lose independent performance of one or more basic activities of daily living [ADL] at discharge,” said Dr. Palmer. Basic ADLs include bathing, dressing, moving from bed to chair, using the toilet, and eating. Why is this important? Patients admitted who were dependent in all six basic ADLs were at greater risk for in-hospital mortality or one-year mortality, 90-day nursing home use, and up to 50% higher DRG hospital costs.

“Not all older patients are at risk,” Dr. Palmer assured his audience. Risk factors for functional decline to watch for include patients over 75, those who are cognitively impaired, those dependent in two or more instrumental ADLs (shopping, housekeeping, taking medications), depression, and pressure ulcers.

Focus on Delirium

Dr. Palmer paid special attention to delirium.

“This is the most risky syndrome during hospitalization,” he warned. Delirium, or the acute decline of attention and cognition, can be called several things: acute confusional state, acute change in mental state, metabolic encephalopathy, toxic encephalopathy, acute brain syndrome, or acute toxic psychosis.

However it is categorized, delirium is found in 10% to 15% of hospitalized elders upon admission, and 10% to 15% of elderly patients develop it after admission. In ICUs, 70% to 84% of elderly patients suffer from delirium.

What causes delirium during hospitalization? Risk factors include severe illness, dementia, dehydration, sensory impairments (trouble hearing or seeing), and psychoactive medications. Identifiable precipitants of delirium are the use of physical restraints, malnutrition, the addition of three or more new medications, use of a bladder catheter, and any iatrogenic event.

“The major concern with delirium is the increased risk of mortality,” said Dr. Palmer. “But it also leads to prolonged length of stay, increased costs, and potential nursing home placement upon discharge.”

Diagnosing delirium versus dementia is based on four factors:

• The onset of confusion is abrupt with delirium and gradual for the early stages of dementia;
• Consciousness is fluctuating and clouded with delirium; with dementia it’s not affected;
• Attention span will be reduced with delirium but not with dementia; and
• A delirious patient will show hyperactive or hypoactive psychomotor changes, whereas this change will not show in early stages of dementia.