To address this problem, a number of interventions have been developed to smooth the transition to home. A central component of these interventions is intensive patient education and training before they go home. This sure seems like a great idea.
But, an innovative study from Geriatrician Lee Lindquist of Northwestern University suggests there may be an Elephant In The Room. What if the patient is confused and not able to understand much of this education and training. Lindquist's recent publication in the Journal of General Internal Medicine suggests this may be a surprising common problem.
Lindquist measured cognitive function at discharge, and one month later, in 200 older persons (average age of 83)discharged from a hospital medical service. What was remarkable about this study was that Lindquist specifically targeted patients believed to have normal cognitive function. She excluded patients who had a diagnosis of dementia, or were diagnosed with delirium during the hospitalization.
Remarkably, nearly one third (31%) of these subjects had abnormal congnitive function when they were discharged. Abnormal cognitive function was defined as a mini mental status exam (MMSE) score of less than 25. In most cases, this cognitive impairment was temporary. 58% of these patients tested normal one month later. Among those with cognitive impairment at discharge, MMSE score improved 4 points over the month. (A 4 point change on the MMSE is huge).
So this suggests that even when an older patient has no known cognitive problem, there is a very good chance there is significant cognitive impairment at the time of discharge. In this case, much of the discharge planning and education we do at discharge will be quite ineffective. We will need to extend the period of patient education and training into the home. As the authors note:
"Ultimately, patient self management may be better taught as an outpatient following discharge and not at the actual hospital discharge itself. Discharge interventions should incorporate screening of seniors for low cognition prior to discharge to provide optimal transitional care."
The study also warns us that the needs older patients will have for help when they go home may be greater than we usually anticipate. This study also teaches us that it is essential we view hospitalization of an elder as an integrated component of their health care rather than a discrete episode of care.
by: Ken Covinsky
Comments
Another theme that's been prominent is the importance of family in helping patients with medications. Often, the reason someone is "very confident" in taking their pills right is because of a family member. This suggests a very feasible target for education and support.
Perhaps with time, we can avoid creating such patient recollections of a hospitalization: "I think I just got through World War III!"
I work in a community-based geriatric program for frail older people. We're in touch with Transition as soon as one of our clients goes to the emergency room or into hospital, and they send us faxed information on the hospital stay and any medication changes when the person is discharged.
Nurses in this area used to really get to know their patients & look out for them. They were allowed to gradually get them back into a stable post-hospital situation.
There was a big growth in home health at one time and a subsequent growth in the field. But, between some unscrupulous providers to worked the system, and our every healthcare knowledgeable politicians who saw the big increase in money going to homehealth (what did they expect when people were pushed out of the hospitals sooner and homehealth was supposed to be the answer?) it has now turned into a place with an admission, 1 visit, and a discharge. Not enough time for these "befuddled" seniors to get back to their baseline.
One patient that I vividly remember was a woman with severe PVD who lived alone quite well. When I made my fist post-hospital visit, her sister was ready to send her to a Nursing Home because she was too confused to be alone. Seeing that she had been put on a sleeping pill in the hospital, I told her to not give her anything for sleep for a few days and give her a week to straighten out. Luckly, she listened to the homehealth nurse who really new her sister and this woman came out of her confusion and was back to her old self within a week. If she had gone to that Nursing Home, I would be my bottom dollar they would have restarted the sleeper and she would have ended her days befuddled, in a strange environment, without her beloved little dog...
We've lost an important cog in patient recovery with the loss of this kind of relationship in the home.
Not a perfect solution, but a step...and one that we take regardless of perceived cognitive function.