Dr. Warren Wong
The hospital is a hard place for older patients. In a previous post, I described three awful things that happen too often. I was frequently asked to help care for frail older patients in the hospital. Based on these experiences, I came up with 8D's.
When you have an older loved one in the hospital, think of these 8 Ds:
- Delirium is a medical term for temporary confusion and change in consciousness. A third of patients aged 70 and older develop delirium during a hospital stay.
- Dementia, including Alzheimer’s Disease, is common in older patients. A hospital stay is likely to result in more confusion, distress and decline in function.
- Depression can develop during a hospital stay but rarely resolves quickly. It is often a long-term consequence of hospitalization.
- Deconditioning occurs rapidly during hospital stays. More than half of patients aged 85 and over leave the hospital more disabled than when they came in.
- Drugs. Patients are given too many medicines. An average of 8 medications are ordered at the time of discharge. Medications that are potentially inappropriate are given to one third of older patients. Resulting problems include adverse drug events, poor medication adherence, and drug interactions.
- Discharge Planning. Hospitalization can be very short or very long. In either case, it’s likely that an older patient will need more help. Frail patients end up discharged to nursing homes. Having a person go back home requires much more planning and effort.
- Dignity. Hospitals are designed to take care of acute diseases. A patient stays in bed and lets the hospital take care of the illness. I ask myself if dignity is maintained when a patient receives care. If my answer is no, I make suggestions. Families can do a great deal to help. They can remind staff that a patient is loved and should be treated with dignity.
- Decisions. As people age, full recovery is less likely. It is much harder to bounce back. A hip fracture may have long-term consequences. As a geriatrician, I talk with patients and families about what the future looks like. For some patients, death comes closer or is likely. For others I talk about next steps and prognosis. What are the likely results of interventions? What will life look like and how do we make it as good as possible. At these points in life, patients and families make important decisions.
These are the 8 Ds I reminded doctors in training to look for in frail, hospitalized patients. There is another D, the one hospitals focus on: Disease. Geriatricians think about the consequences of being in the hospital. Will hospitalization result in complications? What is the impact on physical, emotional, mental, and functional well-being? What social and caregiving issues need answers? Are the values of the patient and loved ones honored? What is the best care possible in this chapter of a person’s life? These questions are seldom if ever answered by just a pill. The goal is to find the best answer possible. I feel joy when I can help.
Look for future posts where I will discuss each of the 8 Ds in detail. Geriatricians use the 8 Ds to see things from the perspective of an older patient. What might the side effects of a hospital stay, treatments and drug prescriptions be? I have a request to caregivers, loved ones and family: Remember the 8 Ds so that your loved one receives the best care possible.