Standardizing Optimal

Care
for Older Adults
Christine Conroy Melissa Mattison, MD Kim Sulmonte, RN,
Kristeller, RN, MS Associate Director, MHA
Geriatric Clinical Hospital Medicine Director,
Nurse Specialist Divisions of Operations, Quality
Coordinator, Gerontology and Safety
Geriatric Resource & General Medicine Patient Care
Nurse Program and Primary Care Services
 Objectives
1. Describe the unique hazards of
hospitalization faced by older patients
2. Implement a daily bedside delirium
screen for hospitalized elders
3. Standardize existing resources to
ensure established strategies to
mitigate functional decline are
performed daily
 Outline
1. Introductions
2. Older patients vulnerabilities
3. Case example
4. Overview of the GRACE program at
BIDMC
5. What we’ve learned
6. Discussion
7. Q & A
 Introductions
• Melissa Mattison, MD, SFHM
• Christine Conroy Kristeller, APRN-
BC, MSN, CWCN
• Kim Sulmonte, RN, MHA
 About our hospital….
• 621 licensed beds
• 6,100 Full-Time Equivalent Employees (Excluding
Research)
• Approximately 5,000 births a year
• Level 1 Trauma Center and roof-top heliport
• In 2009….
– 41,125 Inpatient Discharges
– 532,237 Outpatient Visits
– 53,270 Emergency Department Visits
– 318,335 Radiology Visits
– 532,000 Outpatient Clinic Visits
 Introductions
• Melissa Mattison, MD, SFHM
• Christine Conroy Kristeller, APRN-
BC, MSN, CWCN
• Kim Sulmonte, RN, MHA
• Participants
“For many older persons,
hospitalization results in functional
decline despite cure or repair of the
condition for which they were
admitted. Hospitalization can result in
complications unrelated to the
problem that caused admission or to
its specific treatment for reasons that
are explainable and avoidable.”

Creditor, MC Annals of Internal Medicine. 1993;118:219-223.

Hazards of Hospitalization of the Elderly
“For many older persons,
hospitalization results in functional
decline despite cure or repair of the
condition for which they were
admitted. Hospitalization can result in
complications unrelated to the
problem that caused admission or to
its specific treatment for reasons that
are explainable and avoidable.”

Creditor, MC Annals of Internal Medicine. 1993;118:219-223.

Hazards of Hospitalization of the Elderly
“The factors that contribute to a cascade to
dependency are identifiable and can be avoided
by modification of the usual acute hospital
environment by de-emphasizing bed rest,
removing the hazard of the high hospital bed with
rails, and actively facilitating ambulation and
socialization. The relationships among physicians,
nurses, and other health professionals must
reflect the importance of interdisciplinary care
and the implementation of shared objectives.”

Creditor, MC Annals of Internal Medicine. 1993;118:219-223.

Hazards of Hospitalization of the Elderly
“The factors that contribute to a cascade to
dependency are identifiable and can be avoided
by modification of the usual acute hospital
environment by de-emphasizing bed rest,
removing the hazard of the high hospital bed with
rails, and actively facilitating ambulation and
socialization. The relationships among physicians,
nurses, and other health professionals must
reflect the importance of interdisciplinary care
and the implementation of shared objectives.”

Creditor, MC Annals of Internal Medicine. 1993;118:219-223.

Hazards of Hospitalization of the Elderly
DeFrances CJ, Lucas CA, Buie VC, Golosinskiy A. 2006 National Hospital Discharge Survey. National health statistics reports;
no 5. Hyattsville, MD: National Center for Health Statistics. 2008.
Covinsky KE., et al. JAGS 2003;51:451-458
Covinsky KE., et al. JAGS 2003;51:451-458
 Aging + Hospitalization

Normal
Characteristics
physiologic
of typical
changes of hospitalization
aging

Functional disability
Loss of independence
Physiologic Changes with
Age
• Most organs lose some functional capacity
• Metabolism of medications/drugs changes
– Due to the loss of water content and increase in fat
content with age
• Kidney has decreased excretory function
• Less “physiologic reserve” to withstand
stressors

Turnheim, K., Drugs Aging. 1998;13(5):357-79

 Drug Dosage in the
Elderly
• Optimal therapeutic plasma concentrations have
not been established for most drugs in the elderly

• Increased Central Nervous System (CNS)

vulnerability
– Especially to drugs that can affect brain function
• Opioids, anticonvulsants, psychotropics, anesthetics
– Resulting in confusion, sedation, or agitation

Turnheim, K., Drugs Aging. 1998;13(5):357-79

 Hospitalization is
associated with:
• Bed rest and decreased mobility
• Sleep deprivation
• Poor nutritional intake
• Tethering (IV lines, telemetry
leads, urinary catheters, oxygen
tubing)
• Multiple medications (often new)
 Vulnerabilities of
Patients ≥ 65
• More vulnerable to decline due to:
– Delirium (acute confusional state)
– Deconditioning (loss of muscle strength, balance)
– Orthostatic hypotension (BP drop with standing)
– Decubitus ulcers
– Medication side effects

• ~40% of those ≥ 85 yrs are discharged to SNF

National statistics Outcomes by patient and hospital characteristics for All discharges.
Agency for Healthcare Research and Quality. 2006; http://hcupnet.ahrq.gov/HCUPnet.jsp.
 Delirium is associated with:
• Increased morbidity and mortality when POA
• High rate of mortality at 1 year
o
Delirium
Delirium is common(!)
during hospitalization  30-50%
• Impacts
1 in 5 patient’s
(20%) ability to participate
patients 65 and in
older
post-operative recovery
Half (50%)
• Increased length of high(LOS)
of stay risk patients
• Loss of function/independence
• Aspiration/Feeding difficulties

McCusker J et al in Arch Intern Med. Feb 25 2002;162(4):457-63

Marcantonio ER et al. J Am Geriatr Soc. Jun 2005;53(6):963-9.
 Case Example
• An 82 year old man fell at home while
intoxicated, sustained R ankle fracture
• Post ORIF, had an extended ICU stay secondary to
ETOH withdrawal and delirium
• He was treated with benzodiazepines long past
the 48 hour window for alcohol withdrawal
• He was treated with doses of neuroleptics higher
than recommended for an older adult
 Case Example
(continued)
• Patient fell out of a chair 23 days after
admission
• He was suffering ongoing delirium
• Sustained a C1-C2 fracture requiring
hard cervical collar for 3 months
• Required an additional ICU stay
• Discharged to LTC facility 14 weeks
after admission
 Lessons Learned
• Need education about alcohol withdrawal
• Equipment modifications
– removed 4 inch high foam chair cushion from hospital
inventory
• Need education about risks for delirium (e.g.,
benzodiazepine toxicity) and how to recognize
when a patient suffers from delirium
• Understand competing priorities related to
patient care
 Our Patient and
Diazepam
• In a 20 year old, the half life* of the
parent compound (diazepam) = 20 hrs
• The half-life increases by about 1 hr for
each year of age thereafter
• Diazepam half-life in our patient = 80
hrs 
• He had approximately 5% of active
drug remaining in his system the day
*Half life = time it takes for half of the substance to be rendered inactive
he fell.
 Single Dose of Diazepam

Young Adult Older Adult

Greenblatt DJ, Allen MD, Harmatz JS, Shader RI: Diazepam disposition determinants. Clinical
Pharmacology and Therapeutics 27:301–312, 1980
Courtesy of John Marshall, PharmD, Clinical Coordinator, BIDMC Pharmacy
 Our Patient and
Diazepam
• Diazepam also has an active
metabolite, desmethyldiazepam. 
• The half-life of desmethyldiazepam
– ~ 100 hrs in healthy young patients 
– ~ 250 hrs for an 82 year old patient
• Our patient had well over 50% of
maximum desmethyldiazepam
concentrations the day he fell.
 Our Patient and
Diazepam
• Yet diazepam has an active metabolite,
desmethyldiazepam. 
• The half-life of desmethyldiazepam
If any liver
– ~ 100 hrs in healthy young patients  dysfunction,
– ~ 250 hrs for an 82 year old patient half life can be
5 times longer
• Our patient had well over 50% of
maximum desmethyldiazepam
concentrations the day he fell.
 Delirium
• Delirium was a large factor in this
patient’s fall
• Looking at other examples within our
institution, we found similar cases
• Unrecognized delirium likely:
– leads to falls with injury, longer LOS etc.
• Delirium is often NOT recognized by
clinicians
Inouye SK. Delirium in older persons. N Engl J Med. Mar 16 2006;354(11):1157-1165.
 Complexity of Care
Physician Care

Effects of Medication
Illness Side Effects
Physical
Therapy
Nursing Care
Tethering
Devices
Immobility

Occupational
Speech
Therapy
Therapy

Sleep
Deprivation
• Goal: To standardize the care of all older
patients at the BIDMC by addressing
common, unique needs of vulnerable
elders
• Identifies delirium (confusion) as soon as it
develops
• Implements programs to maintain function
and prevent delirium
• RNs, MDs, software developers,
Pharmacy, PT/OT worked together to
create a novel, new, comprehensive,
and multi-tiered program
• Hospital leaders championed idea
• Culture of institution facilitated work
• Approximately 12 months from idea to
start of program
Three Main Features
1. Computer modifications
2. Pharmacy system changes
3. Bedside GRACE checklist
 GRACE Educational Roll-Out for
Nurses and Physicians
Medicine 4/27/10
Nursing
House Staff POE and IPA
In-Services
Education changes
hospital-wide

Oct Nov Dec Jan Feb Mar Apr May Jun Jul
2010

11/10/09 4/6/10
Bedside POE and IPA Surgical,
checklist for changes Neurology,
11R, Fa2, 5S(11R), Urology, etc.
CC7 Fa2, CC7 House Staff
and APC
Education
 Rollout
• Phase 1 - November 2009
– Rollout of Bedside GRACE Checklist to Medical units
for patients 80 and older for 3 inpatient medical units
• Phase 2 - April 2010
– Bedside GRACE Checklist and POE Rollout to ALL
units (except Inpatient Psychiatry, ICUs, Oncology)
for 80 and older
• Phase 3 – Winter, 2011
– Expansion to include subset of vulnerable 65-79 year
olds
• Phase 4 - Summer, 2011
– Special protocols for subset of GRACE patients
• Advanced Dementia Service
– Expansion to other hospitals/affiliates
• Nursing Initial Patient Assessment:
– Now screen for delirium on admission
– Generates GRACE nursing care plan
automatically
– Prompts RN to print GRACE bedside
checklist
Delirium Kits
• Pharmacy modifications
– Beers medication warning system alerting
providers when ordering a potentially
inappropriate medication
– Standardized “pages” within CPOE for:
• Analgesic dosing
• Antipsychotic
Mattison ML, Afonso dosing
KA, Ngo LH, Mukamal KJ, Arch Intern Med. 2010 Aug 9;170(15):1331-6. Preventing
potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry
warning system.
In all cases delirium, look for potential causes such as infection, pain, myocardial
infarction or medication effect.

Prior to treating with medications , employ non-pharmacologic treatment: Family at

bedside, d/c tethers including foley and telemetry as possible, provide assistive
devices, i.e., glasses and hearing aids.

Antipsychotics should only be used in delirious patients for definite indications such as
agitation or paranoia that is a danger to self or others or interferes with necessary care
or causes marked distress.

Please consider consulting Geriatrics or Psychiatry for patients that are too agitated to
comply with recommended treatment or therapy.

NOTE: Patients with Lewy Body Dementia, Parkinson’s Disease, or Parkinsonian

dementia do not tolerate antipsychotics well. PLEASE consider consultation with
Geriatrics or Psychiatry to guide management.
• Bedside GRACE checklist
– One checklist per day
– goes in vital signs book/clipboard at
bedside
– Use 1 copy of form each day
– RN responsible for completing the form
 Feedback
• “I think it’s a great program and I feel it
 has really helped our patients.” – Nurse
on Med/Surg Unit

• “I read [about GRACE] in the Boston

Globe, and want to say Bravo, it is
about time!” – Daughter of patient from
BIDMC
 What we’ve learned…
• It takes time to get used to new forms
• There are “too many forms”
– “The form just seems to be added paperwork.”
• We need to focus on making it easy for
staff to do the right thing at the right time
for the right patient, at the point of care
 Next Steps
• Ongoing Education
– Workshops
• Provide Tools
– Expand Delirium Kits to ICUs
• Expand to other populations
– < 80 with other comorbidities
• Improve work flow
– Incorporate better into existing
documentation
 Discussion
– At your institution, do you have any
programs designed to standardize care
of older patients?
– What have we forgotten?
– Do you use standard order sets or care
plans?
– What successes have you had?
– What obstacles? How did you
overcome them?
 Wrap-Up Discussion
• What have we learned?
• What are we doing well?
• What can we improve?
• How can we work together?
 Question and Answer

Christine Conroy Kristeller, RN, MS

ckriste1@bidmc.harvard.edu

Melissa Mattison, MD, SFHM

mmattiso@bidmc.harvard.edu

Kim Sulmonte, RN, MHA

ksulmont@bidmc.harvard.edu