From Hospice to Assisted Living: 87-Year-Old Woman with Altered Mental Status

When an 87-year-old woman presented to Cleveland Clinic Fairview Hospital with an altered mental status, she was found to have hypothermia and was managed in the intensive care unit.

A geriatrics team led by Cleveland Clinic geriatric consultant Luke Kim, MD, was consulted for the patient’s altered mental state. Among hospitalized older adults, change of mental status is quite common; about 50% of ICU and 20% of regular nursing floor patients experience this change of mentation. And in older adults, disease presentations are not typical, so rather than present with pain or fever, they present with altered mental status in setting of infections. Dr. Kim suspected a urinary tract infection.

“Younger patients with UTIs tend to present with more obvious symptoms,” Dr. Kim says. “They’re often treated for the infection right away. But, in older populations, the infection often isn’t noticed or treated until the patient becomes seriously ill.”

UTIs are among the most commonly diagnosed infections in older adults. For women over age 65, the incidence rate of UTIs is over 10 percent. The incidence rate increases to almost 30 percent for women over age 85.

Patient couldn’t eat or swallow, placed on hospice

Although her temperature began to rise with antibiotics, the 87-year-old remained in critical care. Because the woman was still incoherent and unable to make medical decisions, those fell to her daughter and medical power of attorney. The woman couldn’t eat or swallow and her daughter declined the use of a feeding tube.

“In a span of four days, while she was not able to eat or communicate properly, I noticed her attention was improving daily,” says Dr. Kim. As her clinical condition improved, she was transferred to regular nursing floor. However, her daughter still wanted her to be on hospice care, rather than have a feeding tube placed for her dysphagia.

Swallow test helps determines next steps of care

To determine the next steps of care management, a Cleveland Clinic Fairview Hospital speech therapist wanted to do a modified barium swallow test. This procedure determines whether food or liquid is entering a person’s lungs.

Although hospice care was still the course of action, Dr. Kim advocated for a modified barium swallow test, as the patient’s cognition improved. As he assessed the 87-year-old’s medical capacity daily, she regained her decision-making ability, and she wanted to have feeding tube placed if necessary.

Patient transitions to rehabilitation facility

The swallow test showed that she was able to have food safely and did not require a feeding tube. But during this hospitalization, the patient’s physical strength declined, and she required a skilled nursing facility for rehab. She recognized it was no longer safe for her to live alone and agreed to move into an assisted living facility following rehabilitation.

Geriatrician consultants like Dr. Kim strive to coordinate care in a seamless manner to achieve better patient outcomes. They do this by assessing the cognitive capacity, physical capacity and long-term trajectories of older adults. Because of Dr. Kim and the geriatric team’s careful attention, this patient avoided unnecessary hospice and was able to regain her physical and mental strength.