What measures decrease hospitalizations in geriatrics?

From the Guidelines

To decrease hospitalizations in geriatric patients, implementing a comprehensive geriatric assessment and management approach, as outlined in the "Geriatric 5Ms" framework, is crucial. This framework, which includes considering the patient's mind, mobility, medications, what matters most to the patient, and multicomplexity, provides a structured approach to managing the care of older adults 1. The Geriatric 5Ms framework is supported by recent evidence, which highlights the importance of a comprehensive approach to geriatric care 1.

Key components of this approach include:

• Regular comprehensive geriatric assessments to identify risk factors early
• Optimizing medication regimens through deprescribing unnecessary medications, using appropriate dosing for age-related physiological changes, and implementing medication reconciliation at all care transitions 1
• Implementing specific interventions such as pneumococcal and influenza vaccinations, fall prevention programs with home safety evaluations, and early management of chronic conditions
• Establishing transitional care programs with follow-up within 7 days of hospital discharge, and implementing telehealth monitoring for vital signs and symptoms
• Providing home-based primary care for homebound elderly and advance care planning discussions to align care with patient preferences

These measures work by addressing the unique vulnerabilities of older adults, including polypharmacy risks, reduced physiological reserve, and complex care coordination needs, ultimately preventing complications that commonly lead to hospitalization 1. By prioritizing a comprehensive and patient-centered approach to geriatric care, healthcare providers can reduce hospitalizations and improve the quality of life for older adults.

From the FDA Drug Label

The primary endpoint was the time to first occurrence of one of the following events: hospitalization for angina pectoris, coronary revascularization, myocardial infarction, cardiovascular death, resuscitated cardiac arrest, hospitalization for heart failure, stroke/TIA, or peripheral vascular disease. A total of 110 (16. 6%) and 151 (23.1%) first events occurred in the amlodipine besylate tablets and placebo groups, respectively, for a hazard ratio of 0.691 (95% CI: 0.540 to 0.884, p = 0. 003). Table 1 below summarizes the significant composite endpoint and clinical outcomes from the composites of the primary endpoint Clinical Outcomes N (%) Amlodipine (N=663) Placebo (N=655) Risk Reduction (p-value) Composite CV Endpoint 110 (16.6) 151 (23.1) 31% (0.003) Hospitalization for Angina* 51 (7.7) 84 (12.8) 42% (0.002) Coronary Revascularization* 78 (11.8) 103 (15.7) 27% (0.033)

The measures that decrease hospitalizations in geriatrics are:

• Amlodipine besylate tablets which showed a 31% risk reduction in the composite CV endpoint and a 42% risk reduction in hospitalization for angina, as seen in the CAMELOT study 2.
• The use of amlodipine in patients with documented coronary artery disease resulted in fewer hospitalizations for angina and revascularization procedures.
• Standard care that included aspirin, statins, beta-blockers, nitroglycerin, anti-coagulants, and diuretics may also contribute to decreased hospitalizations.

From the Research

Measures to Decrease Hospitalizations in Geriatrics

Several measures can help decrease hospitalizations in geriatrics, including:

• Comprehensive geriatric assessment (CGA) based care, which aims to meet the needs of frail patients with a multidisciplinary approach and intervention that includes physiological, psychological, and social domains 3
• Effective multimorbidity management, physical activity, nutritional support, preventing cognitive frailty, avoiding polypharmacy and anticholinergic drug burden, immunization, social support, and reducing the caregiver burden 3
• Identifying pre-frail and frail older adults using an instrument with high validity and reliability, which can be a practically applicable screening tool 3
• Standardizing CGA across healthcare settings to promote greater health system integration and coordination 4
• Using CGA-based assessment tools, such as the Resident Assessment Instrument (RAI) Minimum Data Set, to identify patients at higher risk of in-hospital death and adverse outcomes 4, 5
• Optimizing treatment by increasing the number of drugs taken in cases where under-treatment has been identified, and discontinuing unnecessary or inappropriate medications 6
• Periodically reviewing medications, particularly as the risk or presence of multiple co-morbidities increases 6

Benefits of Comprehensive Geriatric Assessment

The benefits of CGA include:

• Reducing morbidity, mortality, and rehospitalization in older adults 3, 5
• Improving quality of care and reducing hospitalization events in long-term care facilities 4
• Identifying patients at higher risk of in-hospital death and adverse outcomes, such as those with functional dependence, malnutrition, and poor social support 5
• Reducing the risk of unplanned hospital admissions in community-dwelling, frail, older people 7

Implementation of Comprehensive Geriatric Assessment

CGA can be implemented in various settings, including:

• Hospitals, where it can be used to assess patients at admission and identify those at higher risk of in-hospital death and adverse outcomes 5
• Long-term care facilities, where it can be used to improve quality of care and reduce hospitalization events 4
• Community settings, where it can be used to reduce the risk of unplanned hospital admissions in community-dwelling, frail, older people 7