The typical geriatric patient
• Longer and more frequent hospitalizations
• Unique sensitivities to medications and stress
• Risk of functional decline during hospitalization
• Diminished ability to respond to stress and illness
• Multiple chronic illnesses
• Iatrogenesis (geriatric syndromes)
• Altered sleep/wake cycles
• Disorienting effects of environment
• Greater risk of nursing home placement
Geriatric Syndromes
• Delirium
• Sensory impairment
• Depression
• Pain
• Deconditioning
• Incontinence
• Pressure sores
• Malnutrition and dehydration
• Polypharmacy
The HELP Program
HELP is a research based program developed by Sharon Inouye, MD, MPH (1999) to prevent delirium, a complex problem in hospitalized elderly. Delirium is an acute but reversible confusional state associated with an underlying cause(s) that must be assessed and treated.
Delirium is considered a common geriatric syndrome that carries a high mortality rate, longer length of hospital stay, increased risk of dementia, and high rate of nursing home placement. Furthermore, delirium creates much distress for patients, families, and nursing staff.
Delirium:
• Complicates the hospital stay for 2.2 million persons.
• Involves >17.5 million inpatient days
• Estimated costs > $8 billion/yr—hospital costs only
Inouye SK et al., J Ger Med, 2000; 48:1697-1706
Inouye SK et al., NEJM, 1999; 340:669-76
However, despite its prevalence, delirium remains widely under-recognized and under-reported yet research has shown that at least 40 % of cases may be preventable (Inouye, 1999). The etiology of delirium is usually multifactorial and infections, medications, and metabolic problems (especially dehydration) are the most common causes. Delirium can be recognized based on the follow criteria in the Confusion Assessment Method (CAM):
1. Acute onset and fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness
Diagnosis requires (1), (2), and either (3 or 4)
Causes of delirium
Drugs/Depression/Disturbed sleep pattern
Any CNS acting agents, analgesics (including NSAIDS), antihypertensives, anti-parkinson drugs, digitalis, quinolone antibiotics, H2 blockers, anticholinergics, beta blockers, steroids, alcohol, and benzodiazepines. Many common drugs have anticholinergic activity (furosemide, digoxin, warfarin, prednisone, isosorbide, codeine. Often the cumulative effects of multiple drugs.
Endocrine
Most commonly dehydration, volume depletion, elevated BUN and, Creatinine, B12/folate deficiency, hypo/hyperglycemia, hypo/hyperthyroid, liver/renal failure, adrenal insufficiency, and electrolyte abnormalities.
Location change
Usually only in patients with dementia
Impaction of stool/retention of urine
Usually in patients with dementia
Respiratory/cardiac
Any cause of decreased oxygenation or perfusion of the brain, CVA, MI, PE, CHF, rhythm disturbance, hypotension.
Infections/Injury
Usually UTI or pneumonia, surgery
Unrelieved pain
Usually in patients with dementia/ after surgery
Malnutrition
Anemia
Risk factors for delirium
Advanced age
Dementia or cognitive impairment
Sleep deprivation
Vision/Hearing impairment
Poor nutritional intake/dehydration
Recent surgery
Severe illness
Immobility
Polypharmacy/psychoactive medication use
Prevention Strategies
Reality Orientation/Therapeutic Activities
Vision/Hearing Aids/ Adaptive Equipment
Mobilization
Non-pharmacologic approaches
Volume repletion
Sleep enhancement
Our HELP team
E. Dzielak, DO, Medical Director - Geriatrician
M. Manganiello, RN, MSN, CNN, DON
Nurse Practitioner: Soni Sandhaus, NP
Administrative Elder Life Specialist: Faith Harrell
Elder Life Nurse Specialist: Donna Valenti, RN,C
Volunteer Director:
Partnerships with dieticians, rehabilitation therapists and hospital chaplains
HELP Outcomes
–decreased psychoactive medication use