B. Gryglewska, T. Grodzicki innovative hospital friendly hospital for elderly patients

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Process of ageing is observed all over the world. Elderly patients suffer from many diseases and are frequently hospitalized. However, hospital treatment is associated with many hazards. Immobility, …

Process of ageing is observed all over the world. Elderly patients suffer from many diseases and are frequently hospitalized. However, hospital treatment is associated with many hazards. Immobility, infections, falls, drug adverse reactions are the most serious. Applications of new technologies may help to reduce that risk and improve the effectiveness of treatment. Moreover. hospital will be more friendly for elderly patients.

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  • Hostile environment- raised beds, cluttered halls, poor orientation, poor lighting. Depersonalization- pt= case, routine wake ups Iatrogenesis- foleys, restraints, diagnostic procedures Medical illness, effectsof hospitalization, psychosocial aspects of each contribute to mood, negative expectations (pt and family) with combined impact on functional status.
  • Relate to multidisciplinary needs in terms of potential interventions.
  • 2-12% of patients will have a fall in the hospital. From Coussement J, et al. Interventions for Preventing Falls in Acute and Chronic Care Hospitals: A systematic review and meta-analysis. JAGS 2007;56:29-36 Inpatient fall cost and LOS from Bates DW et al. Serious Falls in Hospitalized Patients: Correlates and Resource Ulilization. AJM 1995;99:137-143
  • Risk Factors from Oliver D, et al. Risk Factors and Risk Assessment Tools for Falls in Hospital In-patients: A Systematic Review. Age and Ageing 2004;33:122-130 Psychotropics are most associated with falls with a pooled odds ratio of 1.73- From Leipzig RM et al. Drugs and Falls in Older People: A systematic review and Meta-analysis I. Psychotrophic Drugs. JAGS 1999;47:30
  • It would be impossible to memorize all drug interactions, even the small number presented here. Fortunately, there are aids to help health care providers to prevent drug interactions, such as the one shown here. The slide shows a pocket version of a much larger CYP P450 drug interaction table available at www.drug-interactions.com . This table includes a listing of the six major cytochrome P450 isozymes involved in drug metabolism and many of the drugs that are metabolized by them. We recommend using this or another table as a quick reference for an initial screen for potential drug interactions. If two drugs are metabolized by the same cytochrome P450, it is very possible that competitive inhibition could lead to higher-than-usual levels of either or both of the drugs. If a drug is metabolized by a specific cytochrome P450 and is taken with an inhibitor or inducer of that enzyme, an interaction is also likely. The following are examples of how to use this card. If a patient is taking amiodarone and requires a statin agent to decrease cholesterol (follow the red indicators above), the card shows that amiodarone is an inhibitor of CYP2D6 and CYP3A. Also note that lovastatin, atorvastatin, and simvastatin are metabolized by CYP3A, and that if it is administered with amiodarone (an inhibitor of CYP3A), a toxic level of the statin may occur. The result may be an adverse reaction (rhabdomyolysis or liver toxicity). The best choice among statins in this case would be pravastatin because it is not metabolized by CYP3A. Another example can be seen if a transplant patient were taking tacrolimus and asks to take St. John’s wort (follow blue indicators above). As seen on the card, St. John’s wort induces CYP3A4. The concomitant administration of St John’s wort with some protease inhibitors can result in the induction of CYP3A4, increased metabolism, and sub-therapeutic levels of the protease inhibitor.
  • Central nervous system depressants
  • This graph shows that alcohol-based handrub is better than handwashing at killing bacteria. Shown across the top of this graph is the amount of time after disinfection with the hand hygiene agent. The left axis shows the percent reduction in bacterial counts. The three lines represent alcohol-based handrub, antimicrobial soap, and plain soap.

Transcript

  • 1. Innovative hospital Friendly hospital for elderly patients Dr Barbara Gryglewska Prof. Tomasz Grodzicki Department of Internal Medicine and Geriatrics University Hospital, Cracow INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 2. Life expectancy INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 3. Data GUS 2009 Life expectancy in Poland 80,1 71,5 13,5% ≥65 y . 5, 161 5 mln 62,3% female INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011 INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 4. Chronic Disease Age—A Major Risk Factor Older Adults are More Likely to Have Multiple Chronic Conditions INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011 INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 5. Chronic disorder 1 Chronic disorder 2 Complication… Age Birth Health QoL Wellbeing Ideal ageing Hospitalization INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011 Intervention Well-being perspective Prevention & cure
  • 6. Data NFZ 2009 Hospitalizations in the elderly - Poland INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 7. Hospitalizations in the elderly - Poland Data NFZ 2009 INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 8. Hospitalizations in the elderly University Hospital, Cracow INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 9. The Dysfunctional Syndrome INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011 Functional Older Person Acute Illness / Possible Dysfunction Hospitalization Hostile Environment Depersonalization Bedrest Starvation Medicines Procedures Depressed Mood Physical Impairment Dysfunctional Older Person Palmer et al. Clin Ger Med 1998
  • 10. INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011 Decrease of functional capacity during hospitalization Sager i wsp 1996
  • 11. Cascade to Dependency INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011 Creditor. Ann Int Med. 1993. INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 12. Hazards of Hospitalization Falls Delirium Immobilisation Insomnia Infections Adverse drug reactions INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 13. Inpatient Falls
    • 2-12% of patients will have a fall in the hospital
      • 30% with minor injury, 4% with major injury
      • Associated increased hospital charges ($4233)
      • Associated increased length of hospital stay (12 days)
    JAGS 2007;56:29-36 INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 14. Risk Factors of Falls
    • Prior fall history
    • Gait instability
    • Lower limb weakness
    • Confusion
    • Drugs ( >3)
      • Sedative/hypnotics
    • Urinary incontinence
    Oliver D, et al.. Age and Ageing 2004;33:122-130 INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 15. Risk factors of falls in the elderly Koski K et al. Gerontology. 1998:44:232-238 LifeScience Open Space Session Kraków 2011 INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 16. Fall Prevention INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011   Fall Prevention Monitors Bed/Chair Sensor Pads Weight-Sensing Floor Mats Early Warning Seatbelts Pull-String Fall Monitors Motion Sensor Monitors
  • 17. DELIRIUM
    • Affects 20% of hospitalized patients over age 65
      • Up to 70-80% of older patients in intensive care
      • Up to 83% of older patients at the end-of-life
    • Affects 36.8% of postoperative patients
      • Cataract Surgery 1-3%
      • General Surgery 10-15%
      • Orthopedic Surgery 28-61%
    Miller MO. AAFP 2008;78:1265-1270 INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 18. D E L I R I U M
  • 19. Delirium Prevention Modifiable risk factor
      • Cognitive impairment 
      • Immobility 
      • Visual Impairment 
      • Hearing Impairment 
      • Dehydration 
      • Sleep deprivation 
    Prospective Intervention
    • Orienting communication
    • Early mobilization, reduce restraints
      • Visual aides, adaptive equip
    • Amplifiers, adaptive equip
      • Prevent and correct dehydration
    • Uninterrupted sleep, nonpharmacologic aides
    Inouye SK et al. NEJM 1999;340:669-676 Vidan MT et al..JAGS 2009;57:2029-2036 40% Relative Risk Reduction INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 20.
    • Prospective, observational design
      • ADR in the very elderly (≥80 years old)
      • Preventability, severity and type of ADR
    • 560 pts (mean 85 yrs; 63% female)
      • 1 in 8 experienced ADR
      • Majority serious (69%) some life-threatening(4%). No deaths.
      • 63% preventable
    Adverse Drug Reactions Inpatient Elderly Tangiisuran et al; J Nutr HealthAgeing.2009 INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 21. INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011 Patient Medicine Poly- Pharmacy Pharmaco- genetics Adverse Drug Reaction Cognitive impairment & adherence Environment Altered Drug Handling Altered Drug Response Physiological Decline Co-morbidities Recovery, Hospitalisation Disability Death
  • 22. www.drug-interactions.com INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 23. Most frequent sites of infection and their risk factors LOWER RESPIRATORY TRACT INFECTIONS Mechanical ventilation Aspiration Nasogastric tube Central nervous system depressants Antibiotics and anti-acids Prolonged health-care facilities stay Malnutrition Advanced age Surgery Immunodeficiency 13% BLOOD INFECTIONS Vascular catheter Neonatal age Critical care Severe underlying disease Neutropenia Immunodeficiency New invasive technologies Lack of training and supervision 14% SURGICAL SITE INFECTIONS Inadequate antibiotic prophylaxis Incorrect surgical skin preparation Inappropriate wound care Surgical intervention duration Type of wound Poor surgical asepsis Diabetes Nutritional state Immunodeficiency Lack of training and supervision 17% URINARY TRACT INFECTIONS Urinary catheter Urinary invasive procedures Advanced age Severe underlying disease Urolitiasis Pregnancy Diabetes 34% Hand hygiene is the single most important measure for control of nosocomial infections INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 24. Hosp Epidemiol Infect Control , 1999. INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011 Ability of Hand Hygiene Agents to Reduce Bacteria on Hands 0.0 1.0 2.0 3.0 0 60 180 minutes 0.0 90.0 99.0 99.9 log % Bacterial Reduction Alcohol-based handrub (70% Isopropanol) Antimicrobial soap (4% Chlorhexidine) Plain soap Time After Disinfection Baseline
  • 25. BladderScan® Bladder Volume Instruments Sanitation Problem in Hospitals Reducing invasive procedures LifeScience Open Space Session Kraków 2011 INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 26. Immobilisation Rehabilitation and Mobility Equipment LifeScience Open Space Session Kraków 2011 INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011
  • 27. Hazards of Hospitalization Can we change the h azards of h ospitalization for elderly patients? Yes, we can. INNOVATIVE HOSPITAL LifeScience Open Space Session Kraków 2011