Admission Checklist

• Admit to an Acute Care for Elders (ACE) unit if possible
• Medication reconciliation
  • Perform a thorough medication review
  • Discontinue meds with low therapeutic value, side effects and high fall/delirium. See section Prescribing in Geriatric Patients and utilize Beer’s criteria
• Mental status
  • At minimum, assess for alertness and orientation and compare to baseline. Consider Mini-Cog or MOCA if time permitting
• Functional status, ADLs and IADLs
  • Assess for frailty, fall risk, durable medical equipment needs (Ex. Walker, commode, shower chair/bench, wheelchair)
  • Order PT/OT if necessary
  • Encourage out of bed for most of the day, sitting for all meals
  • Use vision aids, hearing aids
  • Assess home safety (Ex. Stairs, clutter, railing)
• Nutrition
  • Protein calorie malnutrition is very prevalent among admitted elders. Poor nutrition increases mortality and reduces wound healing
  • Order culturally appropriate mechanical soft diet with vitamin D and multivitamin
  • Perform bedside swallow evaluation and assess need for dentures. Consider aspiration precautions and speech therapy evaluation
  • Order nutrition consult and provide nutrition supplements if necessary
• Social support and signs of abuse/neglect
  • Depression and loneliness are common among elders. Assess social support and perform mental health/depression screening
  • Assess for signs of elder abuse/neglect (physical, emotional, financial, sexual). Involve social workers or Adult Protective Services if necessary
  • Document decision makers, caregivers in chart
• Delirium prevention
  • Orient daily
  • Order melatonin QHS, promote good sleep/wake cycles
  • Avoid nighttime vitals, lab checks, glucose checks
  • Avoid chemical restraints, physical restraints, tethering devices and urinary catheters if possible
  • Use glasses, dentures, hearing aids/pocket talkers
  • Liberalize visitors and encourage family to bring pictures, comforting items to the hospital
  • Use CAM or CAM-ICU if concerned for delirium
• Pain management
  • Pain is undertreated in older adults.
  • Start with acetaminophen ATC as foundation of pain regimen. Use multimodal pain regimen. Start and titrate opioids slowly for more severe pain. Always give bowel regimen with opioids
  • Consider scheduling pain medicines for elders post-surgery rather than PRN
• Bowel and urinary function
  • Constipation and urinary retention are common causes of delirium
  • Treat constipation with sennosides, polyethylene glycol, suppositories, enemas PRN
  • Urinary retention - Encourage self-voiding and use external catheters if possible. Avoid indwelling urinary catheters
• Code status and goals of care (See section Palliative Care)
  • Ask about existing advance directives, document surrogate decision maker, reaffirm goals/code status, contact primary care provider
  • Consider palliative care consult and hospice referral if indicated

Discharge Checklist

• Disposition and DME
  • Start discharge planning early and involve the patient’s support system in disposition decision-making (e.g. home, rehab, SNF)
  • Order appropriate durable medical equipment
• Medication reconciliation
  • Review medication changes carefully with the patient and family
  • Provide the patient with an updated medication list on discharge
• Complete POLST form prior to discharge if changes were made
• Vaccinations
  • Give influenza and pneumococcal vaccinations if appropriate
• Schedule appropriate outpatient follow up
• Send discharge summary with updated medication list to the primary care provider for care coordination

Outpatient Follow Up Resources at UCSF

• Moffitt-Long Hospital
  • UCSF Care at Home Program for homebound elders: 415-514-3577
  • If no existing PCP, consider referral to UCSF Center for Geriatric Care or Over 60 Health Center in Berkeley
• SFVA
  • Refer to telehealth, home based primary care, geriatric medicine clinic
  • Consult with ACE team
• SFGH
  • Consult with ACE team