(Editor’s note: In this first part of a two-part series on elderly patients, we discuss problems that cause delirium in and unanticipated hospitalization of seniors. In next month’s issue, we discuss more specifics about the problems, as well as solutions from experts in the field.)
An elderly lumpectomy patient was supposed to change her gauze, but instead, she removed the sterile strips holding the wound closed. She had to return to the surgeon.1 Another elderly ambulatory surgery patient was supposed to take four opioid pills a day, but she misunderstood and took four pills in an hour. She ended up in the emergency department.1
Reports are growing of such incidents. The number of elderly patients in outpatient surgery is increasing, and so are the complications, lengths of stay (LOS), and hospital readmissions, according to two just-published studies.
In a study published in the August issue of the Journal of the American Geriatrics Society (doi: 10.1111/jgs.13537), age was shown to be an independent risk factor for ambulatory surgical complications, which was not previously known. The study examined data from 53,667 patients who underwent ambulatory surgery in academic medical centers. The information was obtained for 2012 from the American College of Surgeons National Surgical Quality Improvement Project database. This database extracts information from more than 400 participating community and academic hospitals. Data are collected for acute care hospitals and freestanding surgery centers.
Over 30 days, seniors were 54% more likely to be readmitted to the hospital compared to patients younger than 65 years, after accounting for differences in other medical problems, the study reports.
“It’s not because they are sicker; it’s because they are older and have trouble understanding their discharge instructions and medication dosing, which often are not clearly explained,” said Gildasio De Oliveira Jr., MD, lead author of the study, assistant professor at the Center for Healthcare Studies at Northwestern University Feinberg School of Medicine, and a physician at Northwestern Memorial Hospital, both in Chicago, in a released statement.
The study suggested an answer: “Interventions to improve transitions of care for older adults after ambulatory surgery are needed.” The need for such interventions is likely to increase as economic pressures to reduce healthcare costs lead to even more complex surgeries in an ambulatory setting, the authors said. About 9 million ambulatory surgeries annually are performed on patients 65 and older.
Sharon K. Inouye, MD, MPH, professor of medicine at Harvard Medical School and director of the Aging Brain Center at Institute for Aging Research, Hebrew SeniorLife, both in Boston, says, “In the outpatient setting, we know outpatient surgery is dramatically increasing, and more and more patients who are more and more frail are undergoing surgery as day surgery.” Delirium is seen frequently, and that’s the reason patients end up getting admitted, Inouye says. “It’s not uncommon after, for example, cataract, urologic, even procedures considered minor, such as ortho procedures, that we are seeing increasing numbers of delirium patients.”
Inouye was an author of a study in JAMA Surgery which found that among patients 70 years or older having elective surgery, major complications contributed significantly to a prolonged length of stay (doi:10.1001/jamasurg.2015.2606).
The study included patients who underwent elective major orthopedic, vascular, or abdominal surgical procedures at two large academic medical centers. Of the 566 participants, 47 (8%) developed major complications and 135 (24%) developed delirium. The researchers found that delirium alone contributed significantly to all adverse outcomes. Delirium exerted the highest attributable risk of adverse outcomes compared with all other adverse events.
The authors wrote, “Delirium is not consistently considered a major postoperative complication. However, given its prevalence and clinical effect, delirium should be considered a leading postoperative complication for predicting adverse hospital outcomes.”
Delirium contributed significantly to several adverse accounts, including LOS and readmissions. That report is backed up by some just-released statistics from the Pennsylvania Patient Safety Authority in Harrisburg. According to an article in the September Pennsylvania Patient Safety Advisory, more than 400 events of patients experiencing delirium in hospitals were reported over a 10-year period, and 64 of those incidents resulted in patient harm. (To access the article, go to http://bit.ly/1RbTTC9.)
Michelle Feil, MSN, RN, CPPS, Patient Safety Authority analyst, said in a released statement, “The Authority has seen a nearly seven-fold increase in the number of delirium-associated patient safety events reported over the past decade, with an average of sixteen events reported per quarter in 2014, compared with two and a half per quarter in 2005. This increase could represent an increase in the number of these events that are occurring. But it is probably also the result of heightened awareness and improved recognition of delirium.”
Falls were the most common type of event, followed by reports of adverse drug events.
Some of the common risk factors for developing delirium were age 65 or older, male gender, pre-existing cognitive impairment, depression, and severe illness. Other common factors that can increase the chances of a patient experiencing delirium include surgery requiring sedation, sudden or severe illness or medical condition (stroke, infection, or substance withdrawal, for example), certain medications (sedatives and narcotics, for example); and environmental factors, such as sleep deprivation, Feil said.
Evidence-based guidelines and risk reduction strategies help identify and prevent delirium in patients, Feil said.
Problems and solutions
Another issue with elderly patients is that they might have difficulty understanding medication doses. According to Northwestern University, 44% of seniors have low health literacy.1
Medications should be given in large-print written format and reviewed verbally with the patient and the caregiver, Inouye says. “Any new medications should be reviewed in detail, along with their side effects and potential interactions,” she says. Provide printed information on the new medications, Inouye advises. “The primary care physician or next facility assuming care should be notified about all medication changes that have been made,” she says.
With a patient at high risk for delirium, determine if any medications need to be changed or avoided, Inouye advises. “Certain meds are at a very high risk of causing delirium in older patients,” she says. The Beers Critical Medications list spells out medications to avoid with elderly patients who are at very high risk for precipitating delirium. It can be accessed for free at http://bit.ly/1or0n0a.
REFERENCE
- Paul M. Northwestern University. Seniors at high risk for readmission after ambulatory surgery. Medication errors and confusion about post-surgical care lead to costly readmission. Aug. 10, 2015. Web: http://bit.ly/1FDDLb0.
