Early in her career, geriatrician Esther Oh noticed something alarming among her older patients.
“Family members would bring in their loved one and say, ‘Mom went into the hospital for a routine elective surgery and she was functioning normally. Now, after the surgery, she suddenly has problems with memory and needs our help. What happened?’”
Oh, who today is co-director of the Johns Hopkins Memory and Alzheimer’s Treatment Center, set out to investigate that question. She and others in the field ultimately landed on post-operative delirium as a culprit in this cognitive decline. This delirium, experienced by up to 50% of older adults who undergo surgery, is a state in which patients become agitated and confused, their perceptions and memory thrown off as they struggle to make sense of their world after surgery.
“We think that some older people can function normally by relying on a cognitive reserve. Then they go into the hospital and experience post-operative delirium, and this inflicts a hit to the brain, unmasking any underlying dementia process so that they can no longer compensate and they exhibit this acute decline,” says Oh, who was recently named Sarah Miller Coulson CIM Scholar.
The good news? In about 40% of patient cases, postoperative delirium can be prevented entirely, through careful teamwork of health care professionals, including physicians and nurses, as well as physical and occupational therapists. The interventions may range from close monitoring during surgery and anesthesia, to taking steps immediately after surgery to orient patients to their surroundings and get them up and moving as soon as safely possible. Oh is now leading a student/trainee “incubator” team, part of the CIM-supported Human Aging Project, to identify which patients are most at risk for developing post-operative delirium and to develop a sustainable model for prevention.
These efforts are just one part of an ambitious initiative now underway at Johns Hopkins Bayview Medical Center. The HAP initiative, created and led by Jeremy Walston, the Salisbury Family Foundation CIM Scholar, aims to transform the way health care is delivered to older adults by creating an “age-friendly” approach across the care spectrum — from the emergency department to primary care, from surgery to rehabilitation, from the memory center to home health care.
“Older people, many of whom are coping with multiple chronic health conditions, experience the bumps and challenges of our health care system in this country because it is so siloed,” says Cynthia Boyd, director of the Division of Geriatric Medicine and Gerontology. “At Bayview, we are part of a national initiative to break down those silos — to create a more seamless experience for older patients and make it much easier for them and their caregivers to navigate to get the care they need.
“It really is a paradigm shift,” says Boyd, the CIM Lavinia Currier Scholar.
As laid out by the Institute for Healthcare Improvement, the framework for an age-friendly health care system consists of “4Ms” that are aimed at making complex care more manageable:
Medication: Ensuring that patients are properly taking only the medications they need and avoiding potentially harmful drug reactions that can occur if communication between health care providers breaks down
Mentation: Providing a united effort to prevent, identify and treat anxiety, depression and delirium
Mobility: Ensuring that older adults move safely, avoiding falls, to maintain function
What Matters Most: Knowing and aligning care with each individual’s specific health outcome goals and care preferences, including end-of-life care
Boyd also adds a fifth “M” to the age-friendly initiative at Bayview: multi-complexity. “It’s so important for us as health care providers to see the whole person — as a unique individual with unique psychosocial needs.”
“At Bayview, we are part of a national initiative to break down those silos — to create a more seamless experience for older patients and make it much easier for them and their caregivers to navigate to get the care they need.” — Cynthia Boyd
She emphasizes that it’s not just the Division of Geriatric Medicine and Gerontology that is committed to this model. “There’s a real synergy across Bayview,” she says. “The Emergency Medicine Department was recently accredited as a geriatric ED, for example, and we have great partnerships with the Memory Center, the Johns Hopkins Bayview Medical Center leadership and the Department of Surgery, among other areas.”
Colorectal surgeon Susan Gearhart is an enthusiastic partner and has been leading efforts over the past few years to establish geriatric surgery pathways at Bayview — standards of care aimed at helping older patients get through surgery safely and to avoid unwanted outcomes, such as loss of independence.
Her team has zeroed in on preventing post-operative delirium by providing more individualized care. “Historically, most ‘standards of care’ were one size fits all,” says Gearhart. “Now these standards are becoming more personalized.”
For example, anesthesiologists are administering anesthesia to the level of sedation the individual patient actually needs, rather than to a standardized level. And to avoid dehydration, which can contribute to delirium, some patients are now allowed to have water right up until surgery.
“And we’re reducing the use of narcotics for pain control after surgery to provide just the amount that patient needs,” says Gearhart.
She notes that the nurses in the post-anesthesia care unit (PACU) are crucial to providing each older patient what they need to return to a normal state as soon as possible, largely by following the 4M’s. “They start from the minute the patient gets out of surgery to get them on a pathway home,” she says.
Gearhart elaborates: “Traditionally, patients in the PACU would be kept in bed on pain medications. Now our nurses turn down their fluids and get them out of bed as soon as possible, safely reducing the use of tethers like oxygen. Nurses also return patients’ glasses and hearing aids immediately, encouraging interactions with family members — and a return to normal sleep/wake cycles by turning off the TV and lights at night — to help patients get re- oriented as quickly as possible.”
Reducing hospital length of stay and improving outcomes require a high degree of communication and collaboration between all the members of the care team. Toward that end, Gearhart says, team members last year launched a weekly Zoom on Friday mornings to better prepare for patients coming in for surgery the following week. These meetings include nurse managers, as well as staffers from social work, the chaplains office, anesthesiology, geriatrics and other departments.
“We talk about our sickest, frailest patients and the steps we can take to provide the most effective care, such as placing them in rooms closest to the nursing station,” says Gearhart.
“Taken together, all of these steps are allowing our nurses to take care of their patients the way they’ve always wanted to take care of them.”
Geriatrician Michele Bellantoni, clinical director, Division of Geriatric Medicine and Gerontology, believes that the Bayview campus — with its robust array of programs, clinics and centers already in place to address the health needs of older patients — offers the ideal spot for establishing a seamless, age-friendly approach to health care.
“By coming together to collaborate on this initiative,” she says, “we will improve the lives of our older patients and teach the next generation of health care providers how to provide the very best care for older adults.”