Death by Bedrest: The Perils of The Hospital

Transcription

1 Death by Bedrest: The Perils of The Hospital Mindy Fain, MD Professor of Clinical Medicine Director, Arizona Reynolds Program of Applied Geriatrics Section Head, Geriatrics & Gerontology University of Arizona College of Medicine Death by Bedrest Hospitalization is a major risk for older adults Bedrest often leads to multi-system complications Vulnerable elderly may spiral into irreversible functional decline and death 1

2 Death by Bedrest Overview Focused systems Usual Aging Impact of Bedrest Outcomes Selected syndromes Summary Death by Bedrest Functional Decline is Common QOL, Costs, and Prognosis Related to Process of Care bedrest.. Bedrest and Deconditioning Functional loss is life-changing 1. CJ Brown, et al. J Am Geriatr Soc 57: , 2009; 2. Creditor MC. Ann Intern Med 1993; 118: Bedrest Happens! Why? 2

3 Bedrest Happens! Response to Acute Illness Belief System: Bedrest is Restorative Meet Expectations: Stay in Bed Response to Environment: Limiting Interventions: Immobilizing Assure Interaction: Staff Cumulative Effects of Bedrest Hoenig and Rubenstein, J Am Geriatr Soc 1991; 39: Death by Bedrest: Deconditioning due to Bedrest Musculo-Skeletal CardioVascular Pulmonary Skin Renal Neurologic Gastrointestinal Other Iatrogenic Illness Death by Bedrest: Deconditioning due to Bedrest Other Iatrogenic Illness Infections Procedure-related Medication Effects Medication Errors Overdiagnosis/ Underdiagnosis 3

4 Death by Bedrest Selected Organ Systems and Syndromes Usual Aging Impact of Bedrest Clinical picture Outcomes Interventions Death by Bedrest: Musculo-Skeletal Deconditioning Usual Aging: Musculo-skeletal System Reduced Muscle Mass Reduced Muscle Strength Reduced Muscle Strength Aerobic Capacity Cartilage Strength Tendon Flexibility Bone Density 4

5 Impact of Bedrest: Musculo-skeletal System Strength >1% daily Muscle atrophy Aerobic Capacity Joint ROM Contractures Accelerated bone loss 1. Creditor MC. Ann Intern Med 1993; 118: Kortebein P et al. JAMA 2007; 297: What does musculo-skeletal deconditioning look like? Mrs. Cole is an 82 year old woman with atherosclerotic coronary artery disease, diabetes mellitus, and chronic kidney disease, admitted for treatment of an exacerbation of heart failure. Now back at home seven days later following successful treatment, she can no longer prepare meals or bathe alone. She is very tired and weak. Outcomes and Interventions Bad Clinical Outcomes Falls and Fractures Prolonged Rehabilitation Supervised Settings Interventions Early mobilization to standing Positioning, ROM, exercises 5

6 Death by Bedrest: CardioVascular Deconditioning Usual Aging: Cardiovascular Changes Impaired Thirst Baroreceptor sensitivity Plasma volume Total body water LV compliance Maximum heart rate Response to b agonists CO w/ exercise Impact of Bedrest: Cardiovascular System Plasma volume Baroreceptor s. Venous compliance Cardiac output Resting heart rate Creditor MC. Ann Intern Med 1993; 118:

7 What does cardiovascular deconditioning look like? Mr. Fuller is an 85 year old man with a known hypertension and venous stasis, admitted for treatment of cellulitis. On day 2, the nurse says, Time to sit up in a chair and stand today! He sits up with assistance, sways a bit, and feels quite dizzy. He looks around the hospital room and says, Not today!. Outcomes and Interventions Bad Clinical outcomes Dehydration, Orthostasis Fatigue, dyspnea, falls Delirium Interventions Early mobilization to standing Exercise (isotonic > resistance) Avoid or correct dehydration Death by Bedrest: Pulmonary Deconditioning 7

8 Usual Aging: Pulmonary Changes Ribcage expansion Lung Elasticity + Recoil Alveolar l surface area Hypoxic drive Drop in PaO2 Function & # of cilia Impaired cough Janssens JP et al. Eur Respir J 1999; 13: Impact of Bedrest: Pulmonary System Ribcage expansion Ventilation V/Q mismatch p02-8mmhg Further Impaired cough What does pulmonary deconditioning look like? Mrs. Ortiz is a 79 year old woman with diabetes and hypertension admitted for evaluation of chest pain and palpitations. p An acute MI is ruled-out. On day 3 the nurses observe that she appears congested and has a low grade fever. A CXR reveals a new right lower lobe infiltrate. 8

9 Outcomes and Interventions Bad Clinical outcomes Pneumonia Delirium Myocardial ischemia Interventions Early mobilization to standing Maintain adequate p02 Aspiration precautions. Pulmonary hygiene Death by Bedrest: Aging Skin + Bedrest Usual Aging: Skin Epidermis, Dermis Vascular supply Subcutaneous fat Cellular turnover Moisture content 9

10 Impact of Bedrest: Skin Vulnerable to: Pressure>32mmHg Shear Friction Moisture Pressure sores can develop in hours What does this look like? Mr. Gainey is an 87 year old man with heart failure and mild dementia living with his 86 year old wife. At home, he is cued to void q2h. While hospitalized for pneumonia, he becomes delirious at night; soft restraints and diapers are used. He begins to complain of pain when sitting, and on exam has a sacral pressure sore. Outcomes and Interventions Bad Clinical outcomes: Pain, immobility, wound & bone infection Prolonged hospitalization & rehabilitation Interventions: Identify Risk: cognition, mobility, and incontinence Avoid immobilization, moisture, pressure & shear. Careful Positioning. 10

11 Death by Bedrest: The Perils of the Hospital Deconditioning due to Bedrest MusculoSkeletal CardioVascular Pulmonary Skin Renal Neurologic Gastrointestinal Other Iatrogenic Illness Infections Medication Effects Medication Errors Falls Procedure-related Overdiagnosis/ Underdiagnosis Death by Bedrest: Polypharmacy and Adverse Medication Events Perils of the Hospital: Medications Most frequent hospital iatrogenic event Elderly are more sensitive Multiple drugs increase risk Routine administration may lead to errors 11

12 Perils of the Hospital- Usual Aging: Kidneys Kidney size Number of glomeruli Renal tubule changes Renal blood flow GFR Mean CrCl rate Often normal serum creatinine Martin JE and Sheaff MT. J Pathol 2007; 211: What does polypharmacy look like? Mr. Valle is an 85 year old man admitted to the hospital for treatment of heart failure caused by atrial fibrillation. His first night he receives a sleeping pill (diphenhydramine) and some other routine medications (cimetidine, lorazepam). At 2 am the nurses find him agitated, pulling at his IV line, unable to answer simple questions. Death by Bedrest: Misdiagnosis in the Elderly 12

13 What does misdiagnosis look like? Mrs. Shaw is an 86 year old woman admitted from home for treatment of pneumonia. Although she had been living ao alone, she is now often confused, wet the bed, and fell in the bathroom. This patient with dementia, falls and urine incontinence is referred to a nursing home for long term care. Misdiagnosis in the Elderly Delirium Dementia Functional urinary incontinence chronic urinary incontinence Misdiagnosis in the Elderly Over/Under Diagnosis: Complex medical problems Adverse medication effects Atypical presentation Attributing symptoms to old age Limited contact in busy hospital 13

14 Hazards of Hospitalization Hospitalization can often be a life altering event for the elderly Bedrest superimposes multi-organ complications unrelated to the reason for admission Vulnerable older persons may spiral into irreversible functional decline and death The downward spiral is global and insidious, often attributed to old age Death by Bedrest: Some Solutions Avoid Acute Hospitalization Support Interventions That Reduce Problems Plan for Rehabilitation 14