The Hospitalized Elderly: General Principles

Jason Stein, MDEmory Reynolds Faculty ScholarEmory Hospital Medicine ServiceHighest Quality Care for the Hospitalized Elderly

Highest Quality Care in the HospitalGoals for this ModuleIdentify the significance of elderly patients to hospitalists Identify the significance of hospitalizations to elderly patientsAppraise the extent of your hospitals specific approach to its geriatric population Describe how the adverse hospital environment combines with physiologic aging and pathophysiologic changes from disease to impact the hospitalists approach to the care of elderly inpatients

Highest Quality Care in the Hospital:Look at Your Inpatient Census

What do half your patients have in common?(whether youre at EUH, ECLH, Cartersville,Dunwoody, Northlake, or Eastside)

Highest Quality Care in the Hospital:Look at Your Inpatient Census

What is the median age on your census?

Highest Quality Care in the Hospital:Look at Your Inpatient Census

What is the median age of patients on your census?About half your patients are geriatric patients (> 65 years old): patients >65 years old account for ~50% of all inpatient days of care in American hospitals1(while comprising just 13% of the population)

1Kozak LJ et al. National Hospital Survey: 2000. National Center for Health Statistics. Vital Health Stat. 13 (153). 2002.

Highest Quality Care in the Hospital: Is Your Patients Age Clinically Significant?Why geriatric patients are important to hospitalists

Summary:Half your admission H&PsHalf your progress notesHigher complexity demands disproportionate care timeMore than half of your in-hospital deaths (75%)

Why hospitalizations are important to your geriatric patient

If you think geriatric patients are important to you, wait until you hear about how important a hospitalization is to a geriatric patient

Highest Quality Care in the Hospital: Why Hospitalizations Are Important to Your Geriatric Patient

Your patients age is clinically significant.

If you think geriatric patients are important to you, wait until you hear about how important a hospitalization is to a geriatric patient

Highest Quality Care in the Hospital: Is Your Patients Age Clinically Significant?Hospitalization Facts:

Older patients have:More frequent hospitalizationsLonger HospitalizationsHigher Mortality

Highest Quality Care in the Hospital: Is Your Patients Age Clinically Significant?Hospitalization Facts:

Older patients have:

More frequent hospitalizationsPatients > 85 years old: 2x the rate of 65-74 year olds5x the rate of middle aged patients (45-64 year olds)

Highest Quality Care in the Hospital: Is Your Patients Age Clinically Significant?Hospitalization Facts:

Older patients have:

Longer hospitalizations Patients > 85 years old average = 6.2 days Patients 45-64 years old average = 4.8 days

Highest Quality Care in the Hospital: Is Your Patients Age Clinically Significant?Hospitalization Facts: Older patients have:

Higher mortalityPatients > 85 years old:4x the mortality rate of middle aged patients (45-64 year olds)75% of in-hospital deaths occur in patients > 65 years old

Lets delve a little into Higher Mortality is there a link between Hospitalization and Mortality? Turns out there is

Highest Quality Care in the Hospital: Is Your Patients Age Clinically Significant?Why hospitalizations are important to your geriatric patient

If you think geriatric patients are important to you, wait until you hear about how important a hospitalization is to a geriatric patient

Beaufort Scale: 1 - 12(scale of wind velocity)Hurricane = 12 (74 mph)Light breeze = 1 (1 mph)Gill TM. JAMA. 2004; 292: 2115-24Factors Associated With Development of Disability

Beaufort scale, a scale of wind velocity devised (c.1805) by Admiral Sir Francis Beaufort of the British navy. An adaptation of Beaufort's scale is used by the U.S. National Weather Service; it employs a scale from 0 to 12, representing calm, light air, light breeze, gentle breeze, moderate breeze, fresh breeze, strong breeze, moderate gale, fresh gale, strong gale, whole gale, storm, hurricane. Zero (calm) is a wind velocity of less than 1 mi (1.6 km) per hr, and 12 (hurricane) represents a velocity of more than 74 mi (119 km) per hr.

Defining A Key Geriatric TermWhat is Functional Decline?Functional Decline = New DisabilityLoss of ADLs (basic self-care activities)Transfer out of bed to chair independentlyToileting yourselfBathing yourselfDressing yourselfFeeding yourself

Hospitalization:A Threat of Its Own Hospitalization = Functional Decline = Higher MortalityHospitalization = Functional Decline-Prolonged hospital stays are associated with functional decline1

-35% of older hospitalized patients decline in baseline ADLs b/t admission and discharge2 -Compared with any other event along the road to disability in the elderly, hospitalization is a greater hazard by a full order of magnitude3

1 Palmer RM. Acute Hospital Care. In: Geriatric Medicine, 4th ed.2 Kozak LJ et al. Vital Health Statistics. 2002;13(153). 3 Gill TM. JAMA. 2004; 292: 2115-24

The link is Functional Decline. In the elderly Functional Decline is an independent predictor of mortality. And Hospitalization, is the single greatest hazard for Functional Decline. Hospitalization is like a hurricane (74 mph). In contrast, stroke is like a stiff breeze.

Hospitalization:A Threat of Its Own Hospitalization = Functional Decline = Higher MortalityFunctional Decline = Higher Mortality # basic ADLs absent at discharge strong independent predictor of mortality 4,5

4 Inouye SK et al. JAMA. 1998; 279: 1187-93.5 Walter LC et al. JAMA. 2001; 85: 2987-94.

The link is Functional Decline. In the elderly Functional Decline is an independent predictor of mortality. And Hospitalization, is the single greatest hazard for Functional Decline. Hospitalization is like a hurricane (74 mph). In contrast, stroke is like a stiff breeze.

Does your hospital have specific processes to drive the best possible outcomes for its geriatric population?Until it does, your elderly inpatients rely on you alone to deliver all and only the care they need.

Highest Quality Care in the Hospital

(avoid the avoidable being uninformed, indifferent, or superficial is unacceptable)

e.g. a new medicine, a new label/diagnosis

Does your hospital have specific processes to drive the best possible outcomes for its geriatric population?1. Does anyone perform a formal assessment of baseline function (2 weeks prior to hospitalization)?

2. Does anyone perform a formal assessment of current function (at time of admission)?

3. Do daily rounds focus on patient-centered interventions?

4. If your hospital has CPOE, do you have a layer of electronic decision support that focuses on geriatric prescribing (~50% reduction in falls)?

5. Does the discharge process address persistent functional deficits that require special support or sites of ongoing care?

Highest Quality Care in the HospitalGuided Prescription of Psychotropic Medications for Geriatric Inpatients.Josh F. Peterson, et al. Arch Intern Med Volume 165:802-807 April 11, 2005

(avoid the avoidable being uninformed, indifferent, or superficial is unacceptable)

e.g. a new medicine, a new label/diagnosis

Highest Quality Care in the HospitalProcesses

Outcomes

Every system is perfectly designed to achieve exactly the results it gets.

Highest Quality Care in the HospitalProcesses

Outcomes

Whats the difference?

Highest Quality Care in the HospitalProcesses

Outcomes

What do you care more about?

Highest Quality Care in the HospitalProcesses:influence outcomes more amenable to measurement must be tightly associated to outcomes Outcomes:what you really care about ultimatelycan be difficult to measure in real time

Towards An Optimal ProcessWho Will Get Functional Decline?Risk Factors Before AdmissionAge (increasing age)Body (pressure ulcer) Brain (cognitive impairment)Mood (depressive symptoms)Level of functioning (fewer iADLs) Socialization (low social activity level)

iADLs = instrumental ADLs: tasks necessary to run a household (telephone, managing money, shopping, preparing meals, light housework, getting around the community)

There is really a Holistic set of risk factors: age, body, brain, mood, level of functioning, socialization

Towards An Optimal ProcessWho Will Get Functional Decline?

Risk Factors After Admission: Adverse Hospital environment

Iatrogenic illnessSensory DeprivationAltered sleep-wake cyclesDisorientationDeconditioningMalnutrition

Apart From Preventing Iatrogenic Illness,You Can Dampen the Adverse Hospital EnvironmentExample:Deconditioning from Illness-induced immobility your usual good careNeglectful bed rest:Insufficient PT/OT Environmental barrierse.g. lack of handrails in hallways/rooms discourages mobility and self-care insist on handrails and 24/7 PTForced bed rest: tethered to IV poles and catheterstethered to the bed by physical or chemical restraints un-tie your patient

Lets just look at one of the 6 risk factors for Functional Decline after hospitalization and how the Adverse Hospital Environment makes Deconditioning more likely in an older patient.

Why Are Elderly Patients Especially Vulnerable to the Risk Factors for Functional Decline? Adverse hospital environment +Physiologic impairments with age(e.g. less muscle mass, strength, and aerobic capacity) +Pathophysiologic impairments from disease(e.g. painful OA + poor hearing/vision + malaise/dyspnea from pneumonia)

Why Are Elderly Patients Especially Vulnerable to the Risk Factors for Functional Decline?Three Key Geriatric Principles for the Hospital1) At the individual level, variability decreases with age2) Across the geriatric population, variability increases with age 3) To maintain baseline performance, many elderly already have drawn upon physiologic reserves

Recognizing the significance of this will make you a better provider.

How aging is clinically significant

How is Aging Clinically Significant?Most Elderly Are Different from the Young1) At the individual level, variability decreases with age

Individual Variability Narrows Organ function deteriorates (~1% per year, starting ~30yo) and dynamic range of organ/system performance narrows over time e.g. stride length: less nimble (others: HR, FVC, Temp, Na handling, etc)Clinical Implication: detectable extremes tend to be associated with significant underlying illness (or iatrogenesis).

Organ function deteriorates over time, starting around age 30, about 1% per year.

How is Aging Clinically Significant?Most Elderly Are Different From One Another2) Across the geriatric population, variability increases c age:

Population Variability Widens Time Normal aging + Disease Genes/Environment = Wide Variability

How is Aging Clinically Significant?Most Elderly Are Different From One AnotherClinical Implication: Your next elderly patient is likely to manifest the ravages of time and disease in ways that are totally unlike your previous 20 elderly inpatients.

How is Aging Clinically Significant?Many Elderly Are Running on Fumes3) To maintain baseline performance, many elderly already have drawn upon physiologic reserves

Homeostenosis the diminished capacity to maintain homeostasis when stressed (limited physiologic reserve + blunted compensatory mechanisms)Clinical Implication: next 3 slides

susceptibility to disease+ ability to compensate(homeostenosis)

The Frail Elderly

Homeostasis

YouCompensatory MechanismsYou, CompensatedPhysiologic Reservestress

Homeostenosis

Frail ElderlyCompensatory MechanismsLimitedBluntedTapped OutClinically Decompensated Physiologic Reservestress

Age-Related Changes Relevant to Inpatient CareClinical Implication: The acutely ill elderly patient frequently presents with non-specific signs or symptoms. The absence of classic findings places greater value on the hospitalists diagnostic evaluation.

Age-Related Changes Relevant to Inpatient CareBody Composition

lean body mass total and visceral body fat

higher concentration of water soluble drugs longer T1/2 fat-soluble medicationsrisk of excessive medication doserisk of excessive medication schedule

propensity to DM, HTN, hyperlipidemiarisk of under-diagnosis or treatmentrisk of over-treatment c polypharmacy/ADEs

Renal

GFR RAAS and ADH response to hypovolemia natriuresis (Na excretion in hypervolemia)

delayed clearance of water-soluble medicationsrisk of excessive medication doserisk of excessive medication schedule

blunted ability to return to euvolemia in face of volume depletion or overloadrisk of excessive IV fluid administration (type/amount/rate)risk of over-diuresis (or insuff. monitoring)risk of under-diuresis

Water soluble medications: alcohol, digoxinFat-soluble: amiodarone

Age-Related Changes Especially Relevant to Hospital MedicineCardiovascular

Medial sclerosis (stiffening of LV/arteries) -receptor responsiveness maximum HR and CODiastolic dysfunction risk of under-recognized HF risk of underestimated impact from a.fib on CO (loss of atrial kick) on tolerance of HR (rate control)

blunted HR response to stressrisk of overlooking enormous significance of sinus tachycardia (work-up sinus tachycardia)

Pulmonary

chest wall compliance elastic recoil of lungs strength diaphragm mucocilliary clearance P02 and A-a gradient*

Higher risk pulmonary infectionsrisk of not vaccinating (PVX and flu shot)risk of overlooking smoking cessation adviceLower threshold for hypoxemiarisk of occult hypoxemiarisk of iatrogenic respiratory depression

* Normal A-a gradient: [(age/4)+4] Normal PO2: [110-(0.4 x age)]

If sinus tachycardia, must assume represents serious underlying process.

Age-Related Changes Relevant to Inpatient CareGastrointestinal

swallow coordination/esophageal motility lactase levels colonic motilityDysphagiaaspiration riskmalnutrition risk Lactose Intoleranceoccult diarrhea risk Tendency to constipationrisk of remaining occultrisk of being exacerbated

Immunological

barrier integrity (skin, mucous membranes)Altered cytokine response to infection humoral Ab response to infection

Susceptibility to skin, urinary, pulmonary infxnsdecubitus ulcer riskurosepsis riskaspiration risk Blunted febrile response to infection occult infection risk: (work-up T > 99F (37.2C)) (work-up new WBC/bandemia)(Up to 25% of septic elders can be afebrile. Using T > 99F [37.2C] increases sensitivity for detecting fever to 80% and maintains specificity=90%)

Aspiration risk: HOB, suctioning (nursing orders)Malnutrition risk: food consistency, lactose-free diet, speech therapy consult (diet/consult orders)

(Up to 25% of septic elders can be afebrile. Using T > 99F [37.2C] increases sensitivity for detecting fever to 80% and maintains specificity=90%)

Patient Cases

Case #1: Inappropriate75 yo woman being admitted after falling at home. She hit her head. She lives alone and this is her 2nd ER visit in 2 weeks (last treated for a facial laceration): Fell in middle of the night on way to bathroom (she felt dizzy)Has fallen two other times in last month:1) Tripped over the edge of a rug2) Lost balance when her cat stepped in her path

Case #1: InappropriatePMH: 1. HTN. HCTZ 25mg qd. 2. Depression. Zoloft 100mg qhs and Ativan 1mg bid prn. 3. OA. Ibuprofen prn.Social Hx: lives alone; no tob/ETOH

Case #1: InappropriatePE: supine HR 64, BP 132/70 standing HR 70, BP 122/68HEENT: vision 20/40 (mildly impaired)Neuro: LE strength 5/5 B, gait stableGet-Up-and-Go test = 10 seconds

Case #1: InappropriateWhich of the following is the most appropriate next step in managing this patients recurring falls?

Refer to ophthalmologyDiscontinue ativanDiscontinue HCTZRefer to physical therapySubstitute buspirone for zoloft

Case #1: InappropriateWhich of the following is the most appropriate next step in managing this patients recurring falls?

Refer to ophthalmologyDiscontinue ativanDiscontinue HCTZRefer to physical therapySubstitute buspirone for zoloft

Case #1: InappropriateObservational studies show medications are the most readily modifiable risk factors for fallsEspecially psychotropics (bdz, neuroleptics, TCAs)

Case #1: InappropriateRCTs show specific single interventions to reduce falls: removal of psychotropic medicationshome hazard assessment and modificationexercise programs

Case #1: InappropriateFalls in elderly:usually multifactorial (so address all potential contributing factors)

Case #2: Adverse Hospital Environment?78 yo woman with DM 2 admitted with cellulitis, top of R foot, which seemed to start spontaneously. No improvement after one week outpatient Keflex.3 days of increased pain and redness. Unchanged localized swelling. No fever, chills. No open wound.She is not able to give you an estimate of the highest/lowest BG in the last 2 weeks.

Case #2: Adverse Hospital Environment?PMH/Meds:DM 2. Recent HgA1C 8.5%. No h/o microvascular disease. Metformin 500mg bidGlyburide 10mg qdHypothyroidism. Synthroid increased by PCP 2 months ago when TSH = 8.Synthroid 150 mcg qd3. HTN. Lisinopril 40mg qd

Case #2: Adverse Hospital Environment?PE: T 37.4C HR 90 BP 154/85 RR 12Gen: non-toxic appearingLungs/CV/abd: normalExt: well-demarcated area of tender erythema dorsum of R foot. No ulcer. No fluctuance in surrounding soft tissue; palpation of adjacent bone shows no point tenderness; peripheral pulses 1+ BNeuro: A&O to time, place, situation. Light touch intact. Lab: BG 188, WBC 9K (70% neutrophils, no bands)EKG: NSR, 90Rad: non-diagnostic for OM

Case #2: Adverse Hospital Environment?Hospital Day #1:1) Cellulitis. Start Vancomycin. Serial exams. 2) Pain. Hydrocodone and acetaminophen. Laxative.3) DM2. Continue home medications. Target good glycemic control. 4) DVT prophylaxis. Age and anticipated immobility. Lovenox 40mg SQ QD.

On night of first hospital stay, she cant sleep. X-cover writes for ambien 5mg qhs.

Case #2: Adverse Hospital Environment?Hospital Day #2:Not oriented to month or year. Correctly identifies place.

NL vitals and O2 sat. NL PEBedside BG = 54. Other labs NL.

You start D50W and halve glyburide to 5mg qd.Check back in on her 45 minutes later: fully oriented to time and place, NL BG.

On night of 2nd hospital stay, she complains of itching and so cross cover writes for hydroxyzine 10mg q6hrs prn.

Any thoughts, commentary?

Case #2: Adverse Hospital Environment?Hospital Day #3:On rounds again not oriented to month or year. VS review normal except for a single HR recorded at 100 at 5am. O2 sat NL. On PE you note an irregular rhythm, rate ~90s. BG = 55. EKG afib, rate 98.CBC NL, Trop negative, CMP NL except BG 64.

Whats going on?

Case #2: Adverse Hospital Environment?The most likely cause of this patients hospital complications is:

Polypharmacy with adverse effects from hydrocodone and ambienAdverse drug event from hydroxyzineSurreptitious ETOH use and withdrawal following hospitalizationForced adherence with adverse effects from outpatient medications glyburide and synthroid

Case #2: Adverse Hospital Environment?The most likely cause of this patients hospital complications is:

Polypharmacy with adverse effects from hydrocodone and ambienAdverse drug event from hydroxyzineSurreptitious ETOH use and withdrawal following hospitalizationEnforced adherence with adverse effects from outpatient medications glyburide and synthroid

Case #2: Adverse Hospital Environment?Enforced Adherence in the Hospitalized ElderlyAnticipate likelihood of poor compliance before hospitalization e.g. from HPIpatient not responding to appropriate or increasing doses of medicationsSuspect when you see different problems evolving at oncee.g. in hospitalnew confusion, hypoglycemia, low BP, atrial fibrillation

Case #2: Adverse Hospital Environment?Enforced Adherence in the Hospitalized ElderlyWhy Enforced Adherence is Particularly Relevant to Your Elderly Patient:

High Incidence: Polypharmacy - non-compliance due to: multiple medications cost complexity unwanted side effects, orjust lack of support

Identifiable and Correctable: Homeostenosis - effects of medications dosed too high tend to reveal themselves (if youre looking)

Case #3: Non-specific81 yo male admitted with altered mental status, poor po intake, and involuntary weight loss over the last 5 weeks.

Baseline: Historically very active. Until two months ago he was collaborating with his wife on writing and distributing a bi-monthly newsletter to the WWII vets from his military battalion. Until 1 month ago was driving and doing own yard work.

Case #3: Non-specificFour weeks ago went to PCP with fatigue, rising agitation, and with R shoulder pain. Told he probably had early Alzheimers. Given Rx for Bextra for OA of shoulder.

Two weeks ago went back to PCP reporting same symptoms and now poor appetite. PCP note describes focal point tenderness over trapezius. Given Rx for Flexeril and Darvocet for muscle spasms, referral to outpatient geriatric-psychiatrist.

Today he agreed to let his wife to drive him to the ER b/c he felt like he couldnt get out of bed. He ate almost nothing yesterday. The geriatric-psychiatry appointment is four days away.

Case #3: Non-specificCollateral history: Wife tells you hes seeing little women and little tigers. Patient corroborates and goes on to say hes very much aware that they cant be real and that he knows nobody else sees them.

Wife also points out that:1) this 5-week illness interrupted a course of chemotherapy hed been getting as an outpatient for bladder CA2) theyve been to another hospital ER twice in the last month to try to get this explained

Case #3: Non-specificOther collateral history: You talk to the nurse taking care of him in the ER. She tells you he seemed to choke a bit on the sandwich shed given him an hour ago. Patient and wife acknowledge that hes had difficulty swallowing his food.

Case #3: Non-specificPMH:Bladder CA. Currently receiving outpatient chemotherapy.H/O Prostate CA. S/p prostatectomy. H/O Tobacco Abuse. Quit 20 yrs ago after 25 pack-years. PSH: S/p cholecystectomyS/p prostatectomy

Case #3: Non-specificAllergies: NKDAMeds:Risperdal 0.5mg bidMVI c iron dailyBextra qdDarvocet prnFlexeril prnROS: no fever, chills, malaise. No abd pain, N/V/D. No SOB/cough. No focal weakness but poor balance. No CP/LH/syncope.

Case #3: Non-specificPE: T 100.8F HR 102 BP 120/72 RR 16Gen: non-toxic appearing, well-nourishedHEENT: OP very dry; neck supple; NL visionCV: No JVD, RRR, II/VI systolic murmur at RUS borderLungs/abd: normalExt: No synovitis. No lesions. 2+ peripheral pulses.Skin: Warm and dry. No rash.Neuro: A&O to time, place, and situation, and o/w NLLab: Na 130, Cl 96, Cr 1.4, WBC 12K (85% neutrophils), UA ketones, 10-25 RBCs and WBCs. No leuk est or nitrite.EKG: NSR, 96.Micro: urine culture growing gram+ cocci

Case #3: Non-specificHospital Day #1:1) Hyponatremia. Appears hypovolemic. NS at 150cc/hr for 2L and re-evaluate. 2) Fever/leukocytosis. 3 sets of blood cultures over next 24 hrs. No antibiotic until infection confirmed. TEE if blood cultures c/w SBE.3) Dysphagia. Observe at bedside. Formal swallow evaluation. Nutritional assessment and support. Aspiration precautions. 4) DVT prophylaxis. Age and anticipated immobility. Lovenox 40mg SQ QD.

Case #3: Non-specificHospital Day #2:In AM, urine cultures growing Enterococcus. In PM, blood cultures also growing Enterococcus.

Start Ampicillin and GentamicinFollow Cr closelyOrder TEE

Case #3: Non-specificHospital Day #3:TEE: aortic leaflet vegetation, 1cm; moderate-severe AI, NL LV

Subsequent Hospital Course:Hallucinations, anorexia, fatigue, and dysphagia resolved. Started ace-inhibitor.

Follow Up: Completed 2 weeks Amp/Gent, another 4 weeks Ampicillin. Returned completely to previous baseline. Echo 3 months later with no changes in LV.

Especially if Your Hospital Lacks Specific Geriatric ProcessesYour elderly inpatients need you to minimize the impact of hospitalization, with special emphasis on appropriate prescribing

2) Your elderly inpatients need you to decipher the root cause of their non-specific signs & symptoms

3) Your elderly inpatients need you to be able to explain and address their sinus tachycardia, T > 99, and leukocytosis

If you think geriatric patients are important to you, wait until you hear about how important a hospitalization is to a geriatric patientIf you think geriatric patients are important to you, wait until you hear about how important a hospitalization is to a geriatric patientLets delve a little into Higher Mortality is there a link between Hospitalization and Mortality? Turns out there isIf you think geriatric patients are important to you, wait until you hear about how important a hospitalization is to a geriatric patientBeaufort scale, a scale of wind velocity devised (c.1805) by Admiral Sir Francis Beaufort of the British navy. An adaptation of Beaufort's scale is used by the U.S. National Weather Service; it employs a scale from 0 to 12, representing calm, light air, light breeze, gentle breeze, moderate breeze, fresh breeze, strong breeze, moderate gale, fresh gale, strong gale, whole gale, storm, hurricane. Zero (calm) is a wind velocity of less than 1 mi (1.6 km) per hr, and 12 (hurricane) represents a velocity of more than 74 mi (119 km) per hr.

The link is Functional Decline. In the elderly Functional Decline is an independent predictor of mortality. And Hospitalization, is the single greatest hazard for Functional Decline. Hospitalization is like a hurricane (74 mph). In contrast, stroke is like a stiff breeze. The link is Functional Decline. In the elderly Functional Decline is an independent predictor of mortality. And Hospitalization, is the single greatest hazard for Functional Decline. Hospitalization is like a hurricane (74 mph). In contrast, stroke is like a stiff breeze. (avoid the avoidable being uninformed, indifferent, or superficial is unacceptable)

e.g. a new medicine, a new label/diagnosis(avoid the avoidable being uninformed, indifferent, or superficial is unacceptable)

e.g. a new medicine, a new label/diagnosisThere is really a Holistic set of risk factors: age, body, brain, mood, level of functioning, socialization

Lets just look at one of the 6 risk factors for Functional Decline after hospitalization and how the Adverse Hospital Environment makes Deconditioning more likely in an older patient.

Organ function deteriorates over time, starting around age 30, about 1% per year.

Water soluble medications: alcohol, digoxinFat-soluble: amiodaroneIf sinus tachycardia, must assume represents serious underlying process.Aspiration risk: HOB, suctioning (nursing orders)Malnutrition risk: food consistency, lactose-free diet, speech therapy consult (diet/consult orders)

(Up to 25% of septic elders can be afebrile. Using T > 99F [37.2C] increases sensitivity for detecting fever to 80% and maintains specificity=90%)