1 Hospital Care of Older People: My Wish List PROFESSOR KICHU NAIR AM MBBS, MD, FRACP, FRCPE, FRCPI, FRCPG, FANZGM Hospitalisation “The very first requirement in hospital is that it should do the sick no harm.” Florence Nightingale; 1820-1910 Future • “The future is already here – it's just not evenly distributed” William Gibson, The Economist, 2003” Medical care in old age •Need comprehensive assessment irrespective of the initial disease •Previously unidentified disease •Pre morbid function •Shared care or geriatric care Hospitalisation • Starts at Emergency room • Transfer of care • ACP on discharge – well articulated The Maggie Program General Medicine patients are older with multiple co - morbidities 59% of medical admissions (at JHH) are for people above 60 years of age Average Inpatient Age (years) 55 60 65 70 75 1999/2000 2000/2001 2001/2002 General Medicine Cardiology Immunology Respiratory Gastroenterology 96% of General Medicine patients have multiple diagnoses and have an average of 8.8 co-morbidities 8.8 7.9 6.6 5.7 5.2 General Medicine Immunology CardiologyRespiratoryNeurology Gastro- enterology 6.5 The average Medical patient has 6.7 co -morbidities Mean Inpatient Age (1999 –2002)
Transcript
1
Hospital Care of Older
People: My Wish List
PROFESSOR KICHU NAIR AM
MBBS, MD, FRACP, FRCPE, FRCPI, FRCPG,
FANZGM
Hospitalisation
“The very first requirement in hospital
is that it should do the sick no harm.”
Florence Nightingale; 1820-1910
Future
• “The future is already here – it's just not
evenly distributed”
William Gibson, The Economist, 2003”
Medical care in old age
• Need comprehensive
assessment irrespective of the
initial disease
• Previously unidentified disease
• Pre morbid function
• Shared care or geriatric care
Hospitalisation
• Starts at Emergency room
• Transfer of care
• ACP on discharge – well articulated
The Maggie Program
General Medicine patients are older with multiple co -morbidities
59% of medical admissions (at JHH) are for people above 60 years of age
Avera
ge I
np
atie
nt
Ag
e (
yea
rs)
55
60
65
70
75
1999/2000 2000/2001 2001/2002
General Medicine
Cardiology
Immunology
Respiratory
Gastroenterology
96% of General Medicine patients
have multiple diagnoses and have an average of 8.8 co-morbidities
8.8
7.9
6.6
5.75.2
General
Medicine
Immunology CardiologyRespiratoryNeurology Gastro-
enterology
6.5
The average Medical patient has 6.7 co -morbiditiesMean Inpatient Age (1999 –2002)
2
“The ‘S’s of Elderly”Richard Lindley
•Stumble
•Stuck
•Stupor
•Sepsis
•SOB
•Sore
•Stroke
•Side effect
Creditor.M.C. 1993
Ann of Int Med
Delirium
• Acute confusional state very high
• 30 % in medical patients
• 60% in surgical patients
• Higher mortality and morbidity
• 30% mortality in 30 days (MI
mortality 10%)
• Look for underlying medical cause
(sepsis, medication, CVAs,
metabolic)
Dementia
• Epidemic
• 2.5% above 65 years• Doubles every 5 years• Lead time for diagnosis is 3 years
• Often dementia and delirium co exist• So do cognitive assessment on every
older patient
Falls
• Common presentation in the elderly
• 30 % community dwellers have falls• Recall poor • Best predictor of fall is a fall
• “Pill for an ill and ill for a pill” – suspect new
symptoms as drug side effect
Medications/poly
pharmacy
• Noncompliance with drug therapy• Over- or under-dosage of medication• Therapeutic duplication• Off-label use of medication• Contraindicated use of medications together• Drug-drug interactions• Adverse drug reactions, and• Mounting medication expenses.
Nutrition
• Poor nutrition very common
• 50% of acute admissions
• 25% are malnourished
• Multifactorial – confusion, poor
dentures, loss of appetite, difficult
to reach the tray etc
• Increase LOS, poor wound healing
Frailty
• Many definitions
• But easily spotted
• Older (above 80) more likely
• High risk of cognitive and
functional decline
4
Functional decline
• Common
• Need to mobilise early
• Muscle wasting with bed rest
• No evidence basis for bed rest
• Elderly do not have the pre
admission function on
discharge; takes time !
“The First Law of
Improvement”
“Every system is perfectly designed to
achieve exactly the results it gets.”
“If you don’t like the results, change the
system.”
Don Berwick, CEO,
Institute for Healthcare Improvement, Boston
MJA Supplement “Health Services Under Siege;
Case for Clinical Process Redesign”Acute care
• We need more holistic approach
• Team work
• Not organ based care
• Care or cure
• Chronic disease
• Functional and cognitive decline
with hospitalisation
• Risk of institutionalisation high
Post Hospital Syndrome
The secret
"The secret of the care of the patient is in caring for
