Hospitalists Take the Lead in Geriatric Patient Care

Larry Beresford

Disclosures

November 19, 2015

Hospitalists and the Older Patient

One half or more of all adult inpatient days of care are for patients aged 65 and older, but few of them will have the direct involvement of a geriatric specialist. In most cases, hospitalists, not geriatricians, will manage the care of these patients. But are hospitalists prepared to offer evidence-based care to meet the specific challenges presented by older hospitalized patients? Can the research base help support hospitalists?

A recent article in the Journal of Hospital Medicine[1] describes an effort to address a dearth of evidence in this area through a "patient-centered research agenda" for improving the care of older hospitalized patients. The research agenda was assembled over the past 2 years by the Society of Hospital Medicine, the Association of Specialty Professors, and 17 partnering stakeholder organizations.

"We focused our work, informed by a framework from the Patient-Centered Outcomes Research Institute (PCORI), on trying to advance care for older adults," explains hospitalist Eduard Vasilevskis, MD, MPH, of the Division of General Internal Medicine and Public Health and Center for Quality Aging at Vanderbilt University, Nashville, Tennessee, and a member of the task force that developed the new agenda.

Significant unmet needs and concerns for older hospitalized patients include delirium, dementia, cognitive impairments, functional status, weight loss, depression, and advanced care planning. Often common geriatric syndromes go underrecognized, but they can have a profound effect on such outcomes as readmissions rates and mortality, Dr Vasilevskis said.

Medical research is most commonly done in nonhospital settings, and research trials often exclude older patients. "Our new research agenda supports increased research on geriatric syndromes in the acute care setting," he explained. "We want to see more published on geriatric syndromes."

The complexities of caring for this older population were described by Harlan Krumholz, MD, who coined the term "post-hospital syndrome"[2] to reflect acute changes in cognitive impairment and other symptoms that either have their onset or are worsened in the hospital. Although the post-hospital syndrome may be prevalent, "we don't know how much of that is avoidable," Dr Vasilevskis said.

He continued, "Hospitalists need to recognize that they are caring for the overwhelming numbers of geriatric patients and that these patients' needs are different. We also need to find new tools for recognizing their conditions, tools that are feasible, useable and lead to changes in care—which will lead to better outcomes."

More training in geriatric concepts is also needed, Dr Vasilevskis said. "As an example, we need to recognize the problems of polypharmacy, which is related to a number of other geriatric syndromes, and become experts at deprescribing. We are very good at adding prescriptions, but not as good at subtracting them."

A Geriatric Consult

Another study in the same issue of the Journal of Hospital Medicine[3] examined the impact of a geriatric consultation service on hospital readmissions and mortality outcomes for cognitively impaired older adults. The service utilized comprehensive geriatric assessments and multidisciplinary processes to recognize and modify risk factors that may lead to poor outcomes for hospitalized older patients. But it found that these services did not have an impact on 1-year postdischarge outcomes, suggesting that other models of care are needed to improve such outcomes.

The authors point out that the geriatric service that was studied did not involve unit cohorting of older patients. An approach to such cohorting that has shown positive impact is the acute care of the elderly (ACE) unit. One such unit at the University of Colorado Hospital is directed by hospitalist Ethan Cumbler, MD, FHM, FACP. "We use expertise derived from geriatrics and our institution's geriatricians, but hospitalists are primarily responsible for the care of these patients," he said. The unit has 21 beds and two active medical services.

It can be a challenge to concentrate these patients geographically in a busy hospital, but a lot can be gained from such concentration in terms of staff engagement, identification, professional collaboration, and expanded expertise from all providers on the ACE unit, Dr Cumbler said. There is also an opportunity to bundle identified best practices to address common geriatric needs.

"Our first step was to ask the hospital to designate one unit with a preference for elderly patients, aged 75 years or older. Then we asked the hospital medicine group to develop an emphasis in this area. For us and for the hospital, it was a low-risk commitment. But once you start doing that, the power of the model becomes apparent. Now they want us to expand to a third service and a bigger unit."

Previous research has shown that the ACE model of care can lower fall rates, delirium, and length of stay while reducing the risk that patients will end up in a nursing home 1 year after hospitalization,[4,5] Dr Cumbler said. "Those are the outcomes that good geriatric hospitalist care seeks to deliver."

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