Core Competencies

Care of the Older Patient. 2017 Hospital Medicine Revised Core Competencies

© 2017 Society of Hospital Medicine

Persons aged 65 years or older represent only 14% of the US population, yet account for more than 34% of hospital discharges.1-4 The population aged 65 years and older is growing at a faster rate than the total population, and the number of persons in this group is projected to double by 2050.1-4 Because of decreased physiologic reserves, changes in pharmacokinetics of medications, and decreased functional capacity of organ systems, the hospitalized older patient is at risk for many poor outcomes. Such outcomes include cognitive and functional decline, prolonged length of stay, higher rates of readmission, and increased risk of death. Because of clinically significant functional decline experienced during hospitalization, more than 28% of older patients are discharged to nursing care facilities rather than home.1 These outcomes have profound medical, psychosocial, and economic effects on individual patients, families, and society. In addition to disease-based management, care of the older inpatient must be approached within a specific psychosocial and functional context. Hospitalists must engage in a collaborative, interprofessional approach to optimize care provided to older patients, beginning at the time of hospital admission and continuing through all care transitions. Hospitalists should lead initiatives that improve the care of older patients.

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KNOWLEDGE

Hospitalists should be able to:

  • Describe common complications related to hospitalization in older patients.

  • Describe physiologic changes with aging that create increased vulnerability to adverse events during hospitalization.

  • Describe patient-specific, environmental, and iatrogenic risk factors for complications in hospitalized older patients.

  • Describe the high-risk medication classes that lead to most unplanned emergency department visits and emergency hospitalizations in older patients.

  • Describe the medical, psychosocial, and economic impact of hospitalization on older patients and their families.

  • Describe interventions shown to improve outcomes in hospitalized older patients.

  • Describe postacute care options that can enable older patients to regain functional capacity.

  • Identify all forms of delirium.

  • Describe the impact of delirium on patients’ functional and cognitive recovery from the acute illness.

  • Recognize that agitation is a symptom of a disease, often delirium, and that the underlying cause must be addressed to ensure adequate care.

  • Appreciate the risks and complications associated with restraint use.

  • Summarize the costs and implications of the intersection between healthcare finance and obtaining resources to compensate for functional deficits in older patients.

SKILLS

Hospitalists should be able to:

  • Elicit a thorough medical history and perform a physical examination to identify patient-specific risk factors for complications during hospitalization.

  • Perform a focused cognitive and functional assessment of older patients.

  • Formulate multidisciplinary care plans for the prevention of delirium, falls, and functional decline.

  • Investigate and appropriately address underlying contributors to delirium.

  • Provide nonpharmacologic alternatives (for example, behavioral plans) for the management of agitation and insomnia while minimizing exposure to potentially inappropriate medications.

  • Avoid prescribing, whenever possible, medications associated with low benefit and/or increased risk of adverse drug reactions in older patients.

  • Assess the complications and potential adverse effects associated with polypharmacy and work to avoid unnecessary medication exposure.

  • Incorporate unique characteristics of older patients into the development and communication of therapeutic plans.

  • Perform a social assessment of the patient’s living conditions and support systems and tailor the healthcare plan to each patient’s unique needs.

  • Formulate and communicate safe multidisciplinary plans for care transitions for older patients with complex discharge needs.

  • Connect elderly patients with social services early in the hospital course to provide institutional support, which may include referral for insurance and medication benefits, transportation, mental health services, and substance abuse services.

  • Communicate effectively with primary care physicians and other postacute care providers to promote safe, coordinated care transitions.

  • Educate patients and families about individual measures and community resources that can reduce potential complications after discharge.

  • Recognize signs of potential elder abuse and use designated mechanisms to report suspected abuse or neglect.

  • Lead, coordinate, and/or participate in multidisciplinary patient safety initiatives to reduce common complications experienced by older patients during hospitalization.

  • Lead, coordinate, and/or participate in hospital initiatives to improve care transitions and reduce postacute care complications in older patients.

ATTITUDES

Hospitalists should be able to:

  • Promote a team approach to the care of the hospitalized older patient, which may include physicians, geriatricians, psychiatrists, nurses, pharmacists, social workers, and rehabilitation services.

  • Establish and maintain an open dialogue with patients and families regarding care goals and limitations, palliative care, end-of-life concerns, and advance care plans.

References

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