Navigating the Frailty Pathway with My Older Trauma Patients
Next Generation is a Brigham Clinical & Research News column penned by students, residents, fellows and postdocs. If you are a Brigham trainee interested in contributing a column, email us. This month’s column is written by Orly Nadell Farber, MD, an intern in the Department of Surgery.
In my first week as an intern on the trauma service, I found myself sitting in front of a patient’s wife and daughter, struggling to explain delirium. With my shiny new “Doctor” badge dangling around my neck and palm-sized pager clipped to my waistband, I tried to reassure my patient’s family: “He’s confused. Sometimes, this just happens to older people in the hospital.”
“But will it get better?” his daughter asked, her puffy eyes focused on her father who, over the course of two days after emergent abdominal surgery, no longer recognized her and no longer remembered her name — or even his own. My heart sank, both from the pain in her voice and the realization that I didn’t know the answer to her question.
“I hope so.”
In my medical school classes, I was taught that delirium, unlike its steadfast counterpart dementia, waxes and wanes. It’s characterized by fluctuating changes in attention, cognition or consciousness. But working in the hospital as a student, I first came to realize that, while “waxes and wanes” is the correct answer on an exam, in reality delirium sometimes only waxes. Patients get more and more disoriented, agitated or lethargic.
Outside of the hospital, delirium is relatively infrequent in the general population (1–2 percent), but during a hospital admission, the rates skyrocket (14–24 percent). Broken down even further by looking only at older patients who have undergone surgery, the prevalence climbs to anywhere from 15 to 53 percent. There’s something about the confluence of hospitalized experiences — undergoing anesthesia, being bed-bound and in pain, waking up and sleeping at odd hours, taking new medications — that renders people vulnerable to confusion.
While the exact concoction of events that contributes to delirium remains murky, a group of surgical clinicians and researchers at the Brigham has shown that there are ways to prevent its onset. Under the leadership of trauma surgeon Dr. Zara Cooper and geriatrician Dr. Samir Tulebaev, this group showed that identifying not only elderly patients but also those who are frail goes a long way. Once a patient has been flagged as frail on admission, residents in the Emergency Department or interns with the trauma service are tasked with initiating a series of orders to direct geriatric-focused care.
Some of the orders are shockingly simple: Nurses should ensure that patients are sitting in a chair (as opposed to in bed) for all meals, and nurse assistants shouldn’t wake patients up at midnight just to take their blood pressure. Some orders require consultants: All elderly patients should be seen by nutritionists and physical therapists, and those who are frail should be evaluated by a specialized geriatrician. Critically, all frail patients with prolonged hospital stays should have a family-centered conversation with the geriatric surgery team to discuss patients’ goals, prognoses and barriers to care.
Inputting these orders with a few clicks on the computer triggers an interdisciplinary team to spring into action, and the outcomes are life-changing: reducing patients’ risk of developing delirium and decreasing the likelihood that they’ll return to the hospital after discharge. On paper, this data would have impressed me, but seeing the impact in person was astonishing. In my two months on the trauma service, I cared for frail patients who were hospitalized because they had fallen out of bed or down the stairs, had been in car crashes or had suffered from infections requiring operations. I was always nervous for these patients. Their health was more tenuous to begin with, but I was reassured because the frailty pathway provided them extra support so that often they returned home without difficulty or complication.
Of course, that wasn’t always the case. One weekend I was on call covering patients I had barely met before when an elderly woman began to deteriorate. She was short of breath and in pain. I got a page that her family wanted to stop any extreme measures to save her life and focus instead on her comfort. While preparing to speak with her family, I browsed her chart and found a geriatrics note documenting an hour-long conversation with the patient and her family. Her wishes and theirs were made clear well before this acute event, and I was able to draw on that conversation when I approached them on my own. Even when things don’t go as planned, geriatric-centered care strives to ensure that patients’ wishes are honored, and their dignity preserved.
As I now continue my training working with different surgical services, my biggest takeaway from the trauma team is that some of the best surgical care can be found in simple acts, like leaving patients undisturbed to sleep while recovering from an operation. Sometimes the best approach to healing is uncovered in honest conversations with families. I’m proud to be part of an institution that’s at the forefront of surgical technique and practice and at the forefront of surgical geriatric care — striving not only to operate successfully on older, frail patients, but also to spare them and their loved ones the delirium and the heartbreak it leaves in its wake.