By Malaz Boustani, MD, MPH; Stephanie Munger, BS and Michael Weiner, MD, MPH
Indiana University Center for Aging Research
Regenstrief Institute, Inc.
Indiana University School of Medicine
Indianapolis, Indiana
Overview
In 2001, approximately 12.6 million individuals aged 65 or more years were discharged from U.S. hospitals, following an average length of stay of 5.8 days (1). It is estimated that up to 56% of these hospitalized older adults had cognitive impairment (CI) during their hospital stays (2). Hospitalized older adults with CI are more prone to falls, injuries, pressure ulcers, and delirium and are more likely to be restrained (3). These complications contribute to mortality, decreased functional status, limited rehabilitation, prolonged length of stay, increased institutionalization, and higher health care costs (3-7).
Although there is ample room for quality improvement, evidence suggests that interdisciplinary inpatient geriatrics services improve care for hospitalized older adults without CI. However, their effectiveness among older adults with CI is less clear (8-11). One cause of limited effectiveness of inpatient geriatrics consultation may be the ever-quickening pace of care in the hospital setting. This rapid pace limits the window of opportunity for input from the geriatrics team and for communication and timely implementation of geriatrics recommendations. More important, recommendations may come "after the fact": suggestions to avoid potentially inappropriate care often come after that care has been initiated (e.g,. bladder catheterization or anticholinergic or other psychoactive medications). Thus, matching geriatrics evaluation and recommendations to the true pace of hospital care may be one mechanism to improve the care of older adults with CI. Increasing the pace of geriatrics care may improve capacity to provide patient-specific warnings, to avoid potentially inappropriate care at the time of medical decision-making. A recent report from the Institute of Medicine suggested that integrating medical informatics into health care for older adults ("gero-informatics") is the best route to improving the overall safety and quality of the health care system (12).
Vulnerability of Hospitalized Older Adults with CI
CI in hospitalized older adults includes a variety of disorders, such as mild cognitive deficits, delirium, and advanced dementia. Delirium and dementia are the underlying causes of CI among most hospitalized older adults with CI (2). They occur together in approximately 20% to 60% of this population (13). It is estimated that the prevalence of CI (induced by dementia, delirium, or other disorders) in hospitalized older adults ranges from 14% to 66%, depending on the method used to measure cognition, the definition of CI, and the type of hospital unit (e.g., surgical, medical, geriatrics) (2-11, 13). Hospitalized older adults with CI are vulnerable to physical or chemical restraints and hospital-acquired complications, such as urinary incontinence, urinary catheters, falls, injuries, pressure ulcers, and delirium (3-7). In addition, the management of medical or surgical illnesses in hospitalized older adults with CI requires avoiding certain medications with central nervous-system properties that might worsen cognition. Such medications include barbiturates, anti-cholinergic drugs, antispasmodics, muscle relaxants, and stimulants. Furthermore, CI may delay diagnostic and therapeutic procedures, impede informed consent, and result in difficulty adhering to medical care. The special needs and vulnerability of hospitalized older adults with CI lead to more demands on nursing staff, prolonged length of stay, increased risk of post-discharge institutionalization, and higher health care costs (3-7). In one study of 21,251 hospitalized patients aged 60 or more years, patients with dementia were hospitalized four additional days, and their per capita hospital costs were $4,000 higher (7).
Impact of Hospital-Based Geriatric Services on Quality Improvement
Hospital-based geriatric services include two types of care delivery models. One model targets older surgical or medical patients who meet frailty criteria and provides care on a specialized unit. The other model provides a geriatric consultation. Both models of care are usually delivered via interaction between the primary care provider and the interdisciplinary geriatrics team. Published controlled clinical trials that have evaluated the effectiveness of these two models of care report conflicting results (14-21). On one hand, they report that caring for hospitalized older adults in a specialized geriatric unit may lead to improvement in patients' physical function and decrease length of stay without affecting overall mortality (9, 18, 19). Such positive results indicate that changing the system of care may improve outcomes. Unfortunately, inpatient geriatrics units will reach only a small number of the large and growing segment of older hospitalized patients. In contrast to the positive effect of inpatient geriatrics units, studies of geriatrics consultation have generally failed to demonstrate efficacy across a range of health outcomes (14, 15, 20, 21). One exception is a study of patients undergoing surgical repair of hip fracture. In that study, geriatrics consultation decreased the incidence of delirium without affecting other outcomes, such as length of stay, mortality, or functional status (8). Nevertheless, both models of inpatient geriatrics care improve prescribing for hospitalized older adults, by, among other things, decreasing polypharmacy and the use of potentially inappropriate medications.
Despite the high prevalence of hospitalized older adults with CI and the numerous studies indicating that they are a vulnerable population with special needs, few studies have attempted to develop models of care to accommodate their specific needs. Recently, a randomized controlled trial targeting the management of behavioral problems among older medically ill patients with CI compared traditional geriatric consultation delivered via a geriatrician to a geriatrics consultation enhanced with specialized nursing interventions. Mador et al. found that the nursing-based intervention had no effect on agitation, sleep, restraint and psychotropic drug use, length of stay, falls, discharge plans, nursing satisfaction, or next-of-kin satisfaction. However, there was a trend toward more appropriate use of medications (10). In another recent randomized controlled trial of medically ill hospitalized older adults with CI, a nurse-led mental health liaison service did not improve length of stay, mortality, re-hospitalization, cognition, or psychotropic use when compared with usual care. This service included an assessment component, recommendations for management of mental illnesses, and educational supports for nursing staff (11).
There are four potential explanations for the modest impact of inpatient geriatrics services among older adults in general and the lack of efficacy among those with CI in particular. First, currently available management strategies may simply be ineffective. Second, limited efficacy may be explained by the low and incomplete adherence to the recommendations of the geriatrics team. Third, the short and delayed exposure to geriatrics recommendations, even when the primary team accepts such recommendations, may limit their potential impact. Fourth, implementation after an adverse event or exposure may have less impact than an intervention that might have prevented the event. Given these findings from the literature, using new, systems-based, gero-informatics interventions could improve the safety and care of hospitalized older adults with CI. These interventions could reach older adults earlier in the hospital course, be available 24 hours per day, and better integrate inpatient with outpatient services. Computerized decision support systems integrated with available expertise of geriatrics consultants offer an innovative solution to accommodate the pace and complexity of care needed by patients with CI.
Gero-Informatics and Computerized Decision Support Systems (CDSS)
Gero-informatics is the study and application of medical informatics in caring for older adults. Medical informatics refers to the acquisition, storage, retrieval, management, and optimal use of medical information, data, and knowledge (25). We can use gero-informatics to customize CDSS through tools to accommodate patients' and clinicians' needs. A CDSS can retrieve relevant, individualized, and updated information from a health system's data repository across various settings and can then feed these data directly to clinicians at the time of decision making. In many environments, this requires the presence of both electronic medical records and electronic physician order entry. Physicians have a low adherence rate to guidelines, and passive educational initiatives are often ineffective in changing physicians' behaviors (25). Even when physicians accept a given general guideline, they may not recognize that a particular patient is eligible for the actions indicated by that guideline. Numerous personal and systems factors might explain these findings in a hospital setting where, following admission, physicians spend on average 3.5 minutes per day interacting with a patient and 2.5 minutes with the patient's caregiver (25). Equipped with clinical data such as cognitive status, evidence-based guidelines, and the ability to merge patient-specific data with the most relevant guidelines, the CDSS is considered a valuable tool for supporting physicians' medical decisions (22-25).
Over the last three decades, numerous clinical trials (22-24) have demonstrated that CDSS can improve processes of care, lead to better clinical outcomes, reduce medical errors, and decrease health care expenditures (22-25). The first of these studies was published in 1976 and showed that CDSS could improve physicians' adherence to ideal practice standards (25). Since that early trial, evidence supporting the effectiveness of CDSS has continued to accumulate. CDSS improves physicians' performance in ordering mammography and fecal occult blood testing, managing diabetes mellitus, monitoring use of warfarin and digoxin, preventing narcotic-induced constipation, discussing and completing advance directives, prophylactic inpatient prescription of heparin and aspirin, and administering inpatient pneumonia and influenza vaccinations among older adults (22-25). CDSS has reduced inpatient and outpatient charges and length of stay and can restore time for clinical care (22-25).
Rationale for the Use of Gero-Informatics and CDSS to Enhance the Care of Hospitalized Older Adults with CI
A growing body of evidence demonstrates that older patients with CI who are hospitalized for the management of their severe illnesses are especially vulnerable to adverse events. Even our ability to detect CI among hospitalized patients is quite limited. Because detection of CI is low, and CI has adverse effects for older hospitalized patients, screening for CI is considered an inpatient quality indicator. However, few studies have developed and evaluated steps that might follow the results of screening for CI in hospitalized older adults, and the results of these studies have been unimpressive (10, 11, 21). Inpatient geriatrics models of care have not been effective among those with CI (8-11, 13, 21). Missed, delayed, post-hoc, and incomplete implementation of the recommendations are significant factors explaining the poor outcomes among hospitalized older adults with CI, even in the setting of prior clinical trials. Leape outlined four mechanisms for redesigning health care systems to reduce complications and improve safety: reduce reliance on memory, improve access to information, standardize, and train (25). The CDSS provides access to patient-specific guidelines at the point of care, offers standardization through suggested therapeutic and diagnostic recommendations, and presents a valuable matrix for training. At Wishard Memorial Hospital and the Regenstrief Institute, we use gero-informatics and an inpatient geriatrics unit and consultative service (Acute Care for Elders, ACE), to test the impact of CDSS in accommodating the special needs of hospitalized older adults with CI. We believe that this application of the CDSS signals a new type of geriatrics service that is continuously available during the hospital stays of older adults, "ACE version 2".
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