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Acute ~ Hospital Care of the ^~ Elderly: Research and Policy Issues ..... . . .. , ~ . ~ Jerome Kowal Cicero stated, "Old age, especially an honored old age, has such great authority that it is of more value than all the pleasures of youth." The average life expectancy at that time was 25 years of age. The old three score and ten biblical life span has really become four score and ten in terms of functional life span. The question for modem medicine is how to make those last 20 years functionaBy useful in the face of increasing cost of medical technology. CAN WE DEVELOP NON-AGE-BASED OUTCOME CRITERIA FOR SELECTION OF PATIENTS WHO CAN BENEfIT FROM HIGH-TECH THERAPEUTIC INTERVENTION? Age and economic circumstances may affect decisions for thera- peutic interventions, without adequate regard for the underlying morbid condition and useful life expectancy of He individual. There is no question about the need for relatively simple highly technological inter- vention, such as lens implants for the management of severe sensory deficits. These benefits can never be objectively measured. At me other extreme, brain transplants would seem very impractical today, but they might provide the neurotransmitters to overcome early dementia or Park- insonism in the not too distant future. Another issue is the determination of the cost-effectiveness and utility of the newer diagnostic technologies (e.g., magnetic resonance imaging EMRIl, computerized tomography Ecrl, and positron emission tomography [PET] scanning) to reduce the poten- tial morbidity of invasive procedures and shorten hospitalizations. i24

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ACUTE HOSPITAL CARE: RESEARCH AND POLICY ISSUES 125 THE EFFICACY OF INTENSIVE CARE UNITS The report of the National Institutes of Health ~H) consensus development conference on intensive care medicine that took place in 1983 was not directed at the elderly, but some items were very pertinent to them. The conference addressed the empirical evidence that intensive care units (TCUs) caused a decrease in patient morbidity and mortality, and He kinds of patients most likely to benefit from intensive care. The consensus report recognized that He efficacy of ICUs had to take into account the nature of me patient population, He conditions and interven- tions being employed, and the alternative patient management systems to which comparisons can be made. ICUs have gone beyond their original purpose of dealing with postoperative patients, monitoring airway maintenance, and mechanical ventilation for reversible neurological disorders. In recent years, He criteria for admission to ICUs have become less stnngent. Patients are now being admitted for whom the achievable benefits are much less clear. However, the iatrogenic illnesses associated with ICU care, particularly in the elderly, may outweigh any potential benefit, as is true for some of the psychiatric effects it may have on elderly patients. In this case, less care may be better for some elderly patients. ICUs are best suited for treating acute,-reversible diseases in patients for whom the probability of survival without ICU intervention is low and the chance of a favorable outcome with ICU intervention is high. These patients need life support interventions for acute conditions. Pa- tients with septic or canogenic shock, however, have a lower potential for survival in an ICU. The ICU results, then, may be affected by patient selection. A third category is comprised of patients who are at risk of becoming cndcaDy in. The ICU is there to intervene, and the outcome depends on the risk. For example, admitting a patient with myocardial infarction and ventricular extra beats to the ICU, as contrasted with somebody admitted only with chest pain and a suspected myocardial infarction, can greatly affect the apparent success rate of ICU treatment. The question, then, is He allocation of ICU resources and disposi- tion of patients with very low probability of survival. Age may become a factor in the selection process independent of potential outcome. One analogy that I present to students is the following: If there is one ICU bed left and you have two patients a 50-year-old cirrhotic in shock and

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126 JEROME KOWAL bleeding with a prognosis of ~ or 2 years, and an 85-year-old with chest pain and ectopic beats but who otherwise is well who is likely to get that one last bed? The most appropriate use of the ICU would be for Lose patients who have the best chance of a favorable outcome, regardless of age. ICUs, however, are not gear toward care of the elderly (e.g., patients may not be adequately mobilized or fed appropriately). Another area of concern is the impact of ICUs on the hospitals. As more hospitals have pulmonary ICUs, cardiac ICUs, and gastrointestinal ICUs, less and less acute care is being rendered elsewhere. Patients are admitted to the general medicine wards, and the nurses are not equipped to handle problems that formerly were handled very well on such a service. If the ICUs become overloaded and patients spill over into the units, the nurses then must take care of the sick patients. The elderly patients who have special needs are neglected in favor of those patients who are creating the greatest stress among He personnel. SPECIALIZED UNITS FOR CARE OF THE ELDERLY The efficacy of specific interventions requires careful evaluation, but most ICU research has been directed at morbidity and mortality of specific diseases win very little emphasis on age. In contrast to that trend, In 1983 Dr. Louis Del Guercio and colleagues (l,2) established a special four-bed preoperative monitoring unit specifically for patients over 65 and others considered to be at high risk for chronic diseases. The patient is admitted directly to this preoperative monitoring unit the day before surgery. Swan-Ganz catheters are routinely inserted and cardiac outputs, intravascular pressures, and arsenal and mixed venous blood gases are measured and entered in a dedicated microcomputer for the recording of an automated physiologic profile. The patients are graded into four stages. Stage ~ is the normal range, and the patients may go directly to surgery. Stage 2 patients have mild functional deficits that could easily be corrected overnight win volume expansion to achieve optimum cardio- vascular performance. Stage 3 consists of patients with compromised ventricular pulmonary or oxygen-transpoIt function that requires correc- tion by physiologic fine tuning. This might entail combinations of blood volume expansion, inotropic drug therapy, afterload reduction, diuretics,

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ACUTE HOSPITAL CARE: RESEARCH AND POLICYISSUES 127 pulmonary therapy, and some part-time, total parenteral nutrition. Stage 4 includes those win functional deficits that are uncorrectable. The papers published by Dr. De} Guercio and his colleagues report that monitoring in this manner reduced the moronity rate of the Stage I, 2, and 3 patients to zero. The research team found that about 53 percent of their patients fen into Stage 2 and 3 and could be corrected and be in the operating room within a day and one-half of these monitorings. In addition, the staff could identify physiologic problems much more accu- rately Man could be estimated by the classic parameters used by anesthe- Biologists. By continuously monitoring patients during surgery, anesthe- siolog~sts were also able to measure the impact on the elderly patients' cardiovascular systems of simple procedures like transurethral prostatec- tomies. They found that this procedure can have profound effects on both the cardiovascular and sympathetic nervous systems. Although the hospi- tal had to absorb the cost of these interventions, they were able to improve the situation for their patients very dramatically, especially among the Stage 2 and 3 patients. Recognizing the problems that we have in intensive care units and on acute care wards in private hospitals (where we do not have geriatric evaluation units [GEUs] as in the Veterans Administration EVAl), the question anses, should we consider as a research protocol some type of acute care unit a genatlic therapeutic unitwith monitoring capability and staff particularly attuned to the elderly patient (3~? These units would not necessanly have the fun range of services of an ICU, but should be able to monitor and provide the kind of intensive nursing support specifi- cally needed by geriatric patients. Can units dedicated to meet the needs of frail elderly patients reduce the ia~genic decline which may be associated with acute tertiary care? CONFUSIONAL STATES IN THE ELDERLY An example of an important hospital complication Hat requires investigation is confilsion. Although acute confusional states are associ- ated with higher mortality, research into acute confusional states, particu- larly in the elderly, is virtually nonexistent and largely anecdotal in nature. The differences in clinical features between acute confusional states and dementia have been well delineated; both hypokinetic and hyperkinetic acute confusional states have been described. Most studies of acute confusional states deal with its prevalence and association with

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128 JEROME KOWAL medical conditions, with the prevalence running as high as 50 percent in some studies. Unfortunately, the underlying medical causes are compli- cated by psychological and environmental factors that may be as impor- tant as the underlying physiological conditions. How can we identify patients likely to need intervention? Predic- tors have included: age, mental status examination results, and pre-entry level of activity. Earlier studies hypothesized that acute confusional states develop as a result of a generalized cerebral insufficiency associ- ated with electroencephalogram (EEG) slowing, but even the pathogno- moruc aspect of BEG slowing has been refitted in recent years. A variety of mechanisms involving oxidative metabolism, acetylcholine levels, and high levels of circulating steroids have been hypothesized, but much still remains to be learned. DIAGNOSTIC-RELATED GROUPS Diagnostic-related groups (DRGs) pose a potential problem for only about 15 to 20 percent of the elderly hospitalized population. The need for intensive care in the home often negates the savings of shortened hospitalization. A problem for hospitals is that, under the current pay- ment system, they have little incentive to reduce post-hospital costs. But before condemning DRGs we need to determine whether the adverse effects of the short length of stays are counterbalanced by decreased iatrogenesis. DRGs are prejudiced against excessive screening and preclude comprehensive assessments. The system does not allow much room for dealing with psychosocial consequences of hospitalization. Hospitals are not offered reimbursement to cover the costs of geriatric evaluation units. One possibility is to direct some DRG funds toward demonstration proj- ects to determine whether certain classes of patients may be more effec- lively managed by an interdisciplinary approach, extending beyond the acute care unit. Perhaps DRGs could include the cost of allied health care personnel for early discharge planning. Inui (5) and his colleagues discussed various research techniques for identifying hospital patients who need early discharge planning for special dispositions. They set three realistic objectives for a screening process: (1) maximizing the number of patients requiring special disposi- tion, identification, and refenal to social work service for evaluation; (2) minimizing the number of inappropriate referralspatients not requiring

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ACME HOSPITAL CARE: RESEARCH AND POLICY ISSUES 129 special disposition toward social work service; and (3) minimizing ward nursing service efforts expended for screening and identification of pa- tients. Research methods are needed to identify the patient population that can gain the most from early discharge planning while avoiding unnecessary planning for patients who do not need it. We cannot plan discharges for everybody. If we did, we would risk staff burnout. In 1983, ~ undertook a study of We Medicare discharges from University Hospitals of Cleveland, in anticipation of starting me DRG system. We examined the lengths of stay of all the patients as related to the overall DRGs. An interesting finding was that, on average, patients age 70 and over averaged less than one day more man the cumulative means of aU DRGs per patient; these patients were discharged to their homes (51. Only 4 percent of patients were discharged to nursing home or rehabilitation centers, but they averaged ~ days longer. This 4 percent of the patient population accounted for 40 percent of all the excess days under me DRGs. We found no age difference in terms of the overall length of stay. Age differences were evident only among the patients being discharged to nursing homes. For example, 2 percent of patients age 65 to 70 went to nursing homes; 16 percent of patients age 85 and over went to nursing homes. We examined about 100 charts to see if we could formulate some predictors. We did notice that among the patients who were going to nursing homes, medical care was completed well before their hospitaliza- tion was finished. These patients used a number of administrative days for arranging placement to the nursing home, social worker interaction with the patient, and getting things in order. There is a great need to predict, early in the hospitalization, which patients are going to be faced with this situation. A repeat of He study using 1986 data, well into DRGs has shown similar results with a dramatic increase in nursing home referrals after a shorter length of stay. CONSULTATION TEAMS Many researchers have studied the efficacy of consultation teams. Campion at The Massachusetts General Hospital and venous Canadian investigators have written extensively on this subject (6,7~. From these studies, we can generalize that the efficacy of this activity seems to be in

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130 JEROME KOWAL lowenng the short-term readmission rate to the hospital and lowering the short-term mortality rate. From my observations, He greatest benefit of consultation teams appears to be related to rehabilitation. Patients who were referred early for rehabilitation improved over time. Where no rehabilitation was fac- to~ in, consultation teams seemed to have no impact whatsoever. How- ever, these differences disappear over time, so that by one year, most studies show virtually no differences in morality and morbidity between the patients who had been exposed to consultation teams and those who were not. These observations relate to a 3-year study by Hendrickson (4) in Denmark of interventions in patients' homes. The elderly population in a major suburb was divided in half; every elderly person in the target group had a social worker or nurse who visited once every 3 months to ask questions about how they were living; medical intervention was not part of the visit. The target group had 40 percent fewer hospitalizations during 3 years, had a higher survival rate, and actuary fared better in the home situation. The cost of the intervention was more than offset by the reduction in hospital utilization. GERIATRIC EVALUATION UNITS Geriatric evaluation units (GEUs) are prevalent in the VA. Unfor- tunately, because of the length of stay required and the kind of support needed, they are impractical in the private sector at the present time. As indicated earlier, a more appropriate approach would be the establisl~nent of demonstration "geriatric therapeutic units" where trained professionals study the potential efficacy of early intervention on outcomes of hospita~i- zation. from them. We are well behind the British in this area and have much to lean, Homer's Ulysses said to his fabler: "Warm beds, good food, soft sleep, and generous wine. These are He rights of age and should be Mine." In summary (in canny for the elderly in the acute hospital), we are on the threshold of recognizing the need for innovative approaches that may deviate considerably from what we have come to recognize as established procedures.

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ACUTE HOSPITAL CARE: RESEARCH AND POLICY ISSUES 131 REFERENCES 1. Del Guercio, L.R.M., Savino, J.A., and Morgan, J.C. Physiologic assessment of surgical diagnosis-related groups. Annals of Surgery 202(4):51~523, 1985. 2. Savino, J.A., and Del Guercio, L.R.M. Preoperative assessment of high-r~sk surgical patients. Surgical Clinics of North America 65(4):76~791, 1985. Rubenstein, L.Z., et al. The role of geriatric assessment units: An analytic review. JoumalofGerontology37:51~521, 1982. Hendrickson, C., et al. Consequences of assessment and intervention among elderly people: A 3 year randomized trial. British Medical Journal 289:1209-1212, 1984. Inui, T.S., Stevenson, K.M., Plorde, D., and Murphy, I. Identifying hospital patients who need early discharge planning for special dispo- sitions: A comparison of altemadve techniques. Medical Care 19~9~:922-929, 1981. 6. Campion, E.W., Bang' A., and May, M.~. Why acute-care hospitals must undertake long-tenn care. New England loumal of Medicine 308(2):71-75, 1983. 7. Campion, E.W. The meets of geriatric consultation. Joumal of the American Medical Association 257~17~:2337-2336, 1987.