PHILADELPHIA — Eight basic rules for making the rounds on older, hospitalized patients can help identify problems that the house staff may not focus on, Dr. Evelyn C. Granieri said at the annual meeting of the American College of Physicians.
It takes only 10 minutes to complete all eight assessments, said Dr. Granieri, a geriatrician at Columbia University, New York, who said she has been doing inpatient rounds almost daily for 17 years.
The eight rules are as follows:
1. Review all medications. Do this every day you visit the patient. Consider how changes in body weight and renal function may affect the appropriate dosage. “Older adults in the hospital are very dynamic in terms of their status,” she noted.
Also, keep in mind that medication changes are a major precipitant of delirium in older adults. On average, patients come into the hospital on about eight drugs and leave on about nine, but five of those medications are new, Dr. Granieri said.
The rate of cognitive impairment in hospitalized elderly over age 70 is as high as 75%, and so the discharge plan for medications needs to be “as simple as possible,” she said. Complex drug regimens are bound to fail, and may even precipitate an emergency department visit or rehospitalization. “Don't send patients home on b.i.d., t.i.d., and q.i.d. regimens. Try and do a q.d. or b.i.d. at the very most. This is very important,” she advised.
2. Perform a cognitive assessment. The best screening test is simply asking the patient to draw a clock showing a specific time. Give the instructions just once, and be ruthless in judging the results: “It's either right or it's wrong,” Dr. Granieri said. She related the story of a patient, who happened to be a practicing physician in his 70s, who drew and numbered the clock correctly but then added three hands pointing at 2, 4, and 5 and circled those numbers to indicate 2:45. As a physician, she said, “he had perfected the art of being vague.”
The clock test is a good early screen, but “it's not a diagnostic, it's an unmasking tool,” she noted. It's critical to unmask the impairment because a patient who can't draw a clock won't be able to take medications correctly or drive a car.
3. Look for pressure ulcers. Check the skin daily because a pressure ulcer can develop in as little as 2 hours. With the current shortage of hands-on nursing care, doing this screen faithfully has become even more crucial. On admission, 2%–10% of patients have pressure ulcers, but 10%–20% have them on discharge, she noted.
4. Check functional status. “One of the first things that I now do on frailer people, or people over the age of 75,” is immediately get a physical therapy and occupational therapy consult. This guarantees that the patient will get out of bed and be checked for ambulation. Also, the therapists often notice skin breakdown, incontinence, and inability to follow directions.
In bedridden patients, significant loss of muscle mass starts after 3 days, but it takes 9–12 days to begin rebuilding muscle with help from physical therapy.
But even without a consult, “you can look at them and see. You can tell if someone is getting out of bed. You can ask them to swing their legs around and stand,” she said.
5. Assess for gait dysfunction and fall risk. “It's incredible that many patients are discharged from the hospital without any test of their gait and ambulation,” Dr. Granieri said.
To prevent falls in the hospital, get rid of the Foley or Texas catheter. These are seldom needed but often overused, potentially causing falls as well as increasing the risk of urinary tract infections and resistant bacteria.
Little can be done to prevent falls in the hospital. “At the risk of sounding pessimistic, it's tough—there's no good answer.” A few environmental changes may help: Make sure that the beds are lowered, that there's enough light, and that each patient has a bedside commode.
6. Determine if your patient is eating and drinking. If a patient comes in malnourished, this can't be cured during a 5-day hospital stay. But during rounds, be sure the patient's food tray is close enough to reach, use a feeding program if available at the hospital, and check swallowing ability at least once (or be sure the nurse checks).
“Aspiration pneumonia—especially for people who are hospitalized who may be delirious or [have] cognitive impairment or infections—is deadly,” she noted.