The PPMC inpatient geriatrics team (from left to right): Megha Patel, MD, Mark Simone, MD, and Alyson Michener, MD
The patient, a man in his 80s suffering from dementia, had fallen outside the Penn Presbyterian Medical Center (PPMC) Emergency Department, where his wife was being treated, and had broken his jaw.
He was admitted to the trauma service, where after a few days, his condition had stabilized and he didn’t require surgery. But he wasn’t eating. Concerned he might need a feeding tube if he didn’t take in enough nutrients, his care team wondered if they could give him an appetite stimulant.
That’s when Mark Simone, MD, chief of Geriatric Medicine at PPMC and director of the Geriatric Surgical Co-Management Program, joined the case. The co-management program began in January 2019 to provide an additional layer of care for trauma patients aged 65 and older.
Simone was worried about the risks of delirium or other side effects from a stimulant. This is a common scenario: Certain classes of medications that cause no cognitive effects in younger patients carry increased risks of side effects in older adults due to the physiological changes of aging. Older, frailer adults are also more susceptible to medications that can be sedating or cause confusion leading to delirium.
The geriatrician talked to the patient and determined the man did not have any pain or physical reasons not to eat. But he was lonely, with his wife in a critical care unit in another part of the hospital. Simone helped arrange a video call with the man’s daughter, who was living out of state, and she stayed on the phone with him to encourage him to eat.
“His appetite suddenly, like magically, improved,” Simone said. “After that, the nurses helped arrange daily video calls during mealtimes with his daughter to improve his spirits and appetite. There was no longer a concern about his oral intake and becoming malnourished. He just needed the company of his daughter. Then he was able to be discharged.”
Simone likes to share this example when explaining the role of the three-year-old co-management program. Such programs, while still relatively rare, are becoming more prevalent in health systems as providers recognize that older hospital patients have a unique set of needs and risk factors. Geriatricians are experts in managing conditions commonly seen in older patients, including delirium, frailty, and the use of multiple medications.
“Older patients, especially those admitted with some sort of fall-related traumatic injury, are often by definition frail and in need of additional specialty care to help manage both their acute and chronic medical conditions while they’re in the hospital recovering from their surgical procedure or injury,” Simone said. “While the surgeons do a great job at managing the complex surgical needs and managing the injuries, often there are medical issues and geriatric syndromes that come up that our team can help manage.”
Providers can request a consultation from the three-member inpatient geriatrics team – Simone, Alyson Michener, MD, and Megha Patel, MD – to help them manage the physical, cognitive, social, and medical needs of elderly patients. Together, the specialist and surgical care team discuss the patient’s mental state and ways to reduce the use of potentially inappropriate medications, manage their other chronic illnesses, and minimize common complications. The specialists also help with discharge planning.
“Whenever a geriatric patient comes onto our service, they get a comprehensive review of all their medical care during their stay,” said trauma surgeon Jeremy W. Cannon, MD. “The co-management team assesses whether their outpatient medications may have contributed in some way to the injury – for example, a fall after a blood pressure medication adjustment – and whether all of their treatments are absolutely necessary in the setting of their injury or traumatic event, such as whether their blood thinners are truly necessary after suffering a brain injury.”
In addition to the co-management partnership with the trauma services, the geriatrics specialists offer consultations to any service in the hospital to address clinical questions when managing the syndromes common in hospitalized older adults.
Geriatric co-management programs show promise in important health outcomes like reduced lengths of stay, fewer complications, and better functional status, Simone said. The PPMC program is conducting a research project to study the impact of its service by comparing health outcomes before and after implementation of the program.
Lisa M. Walke, MD, MSHA, Penn’s chief of Geriatric Medicine, created two geriatric surgical co-management services at Yale University and saw firsthand the benefit to patients and caregivers and the high satisfaction of surgical colleagues. In the future, she says she would like to see the surgical co-management program extend to other surgical services with high volumes of older adults.
“For most surgical specialties, at least half of their operative patients are 65 years of age or older,” Walke said. “This will only increase as the number of older adults increases in the next 20 years. Pennsylvania already has a higher percentage of older adults than the national average.”
While the outcome data isn’t available yet, trauma providers at PPMC say they believe, intuitively, that partnering with geriatrics specialists has led to improvements for surgical patients.
“The thing that makes this work is that it’s truly co-management. We meet and discuss the patient’s care, review their labs, and get feedback on how to adjust certain medications. The geriatrics specialists also provide insight on the psychological and social factors because they can spend more time with the patient,” said nurse practitioner Adele Hamilton, DNP, CRNP, FNP-BC, AGACNP-BC.
Hamilton is responsible for the clinical management of all orthopedic trauma patients at PPMC and has worked with the co-management program since its inception. She said the geriatrics specialists have helped her team develop new pain-management protocols to minimize postoperative delirium in hip fracture patients, as well as facilitated conversations with family members about whether a surgery made sense for a patient at the end of their life.
“There’s more to the patient than that broken bone,” Hamilton said. “They’re able to help us keep that comprehensive perspective.”