Just being in the hospital can cause certain problems, such as infections, pressure sores, and depression. Many hospital-related problems are caused by having to stay in bed for long periods. Others may result from being in unfamiliar surroundings or being given drugs to relieve pain or to treat a disorder. Sometimes one problem leads to another. When hospitalized, certain people—those who are confused, depressed, or undernourished or who are older—often become less able to take care of themselves. People who cannot adequately care for themselves are more likely to have longer stays in hospital and end up being sent to a nursing home after discharge.

If the person or family members anticipate problems, they should discuss preventive measures with staff members. For example, if communicating is a problem because English is not the person's first language or if hearing is impaired, family members should tell hospital staff members. Staff members can take measures to help, such as arranging for someone to translate.

Hospital-Acquired Infections

People who are admitted to the hospital are at risk of acquiring an infection there. Such infections are called nosocomial infections. In the United States, about 5% to 10% of people who are hospitalized get a nosocomial infection, and about 90,000 of these people die each year. The risk of infection is higher for infants, older people, and people with a weakened immune system.

These infections may be caused by bacteria or fungi. Bacterial and fungal infections can be dangerous and deadly.

Organisms that are acquired in hospitals are often resistant to many common antibiotics. The frequent use of antibiotics in hospitals encourages resistant strains to develop.

Hospital-acquired infections include pneumonia, urinary tract infections, infection of surgical incisions, and blood infections.

Lung Infections: People who stay in bed do not use their lungs as much, and the muscles that control breathing may weaken. Then, taking a deep breath may become difficult, and if mucus accumulates in the airways, people may not be able to cough forcefully enough to clear the mucus out. When mucus accumulates, bacteria cannot be cleared from the airways very well, and pneumonia may develop (see Pneumonia: Hospital-Acquired and Institution-Acquired Pneumonia).

The risk of lung infections is increased by the following:

• Using a ventilator, which makes the risk very high
• Having had antibiotic treatment previously
• Having other disorders, such as heart, lung, liver, or kidney disorders
• Being older than 70
• Living in a nursing home
• Having had abdominal or chest surgery

Deep breathing and coughing exercises can help prevent lung infections. These exercises can help keep the lungs open and prevent breathing muscles from weakening.

Urinary Tract Infections: Sometimes people in the hospital have a drainage tube placed in their bladder (urinary catheter). A catheter may be inserted when doctors need to closely monitor how much urine people produce—for example, in those who are critically ill. In the past, doctors placed urinary catheters in people who were incontinent. However, catheters significantly increase the risk of a urinary tract infection because they make it easy for bacteria to enter the bladder. Thus, to prevent urinary tract infections, doctors try to use these catheters as seldom as possible. When catheters are used, they must be carefully cleaned and regularly examined. If people are incontinent, diapers that are changed as often as needed are a better choice than a urinary catheter.

Prevention: General measures that hospital staff members use to help prevent hospital-acquired infections include the following:

• Frequent hand washing
• Frequent use of alcohol-based hand sanitizers
• Use of protective gear such as gloves and gowns when procedures are done

To prevent development of resistant bacteria, many hospitals have programs to limit the use of antibiotics.

Problems Due to Bed Rest

Staying in bed for a long time without regular physical activity can cause many problems.

Blood Clots: A leg injury, leg surgery, or bed rest may prevent people from using their legs. When the legs are not being used, blood moves more slowly from the leg veins to the heart. Blood clots are more likely to form in this slow-moving blood (see Venous Disorders: Prevention). Blood clots sometimes travel from the leg veins to the lungs and block a blood vessel. These clots, called pulmonary emboli, can be life threatening (see Pulmonary Embolism (PE)).

Pneumatic compression stockings may be used to prevent blood clots. Powered by an electric pump, these stockings repeatedly squeeze the calves and move blood into and through the veins. People at high risk of developing blood clots may be given an anticoagulant (such as heparin), which helps keep blood from clotting.

Constipation: When people stay in bed or are less active, stool (feces) moves more slowly through the intestine and rectum and out of the body. Thus, constipation is more likely to occur. Also, people may be taking drugs that cause constipation.

To prevent constipation, staff members encourage people to drink plenty of fluids, and extra fiber is included as part of meals or as a supplement. Stool softeners or laxatives may be prescribed.

Depression: Many people who stay in bed for a long time become depressed. Having less contact with other people and feeling helpless may also contribute to depression.

Pressure Sores: When people stay in one position in bed for too long, pressure is put on the areas of skin that touch the bed. The pressure cuts off the blood supply to those areas. If the blood supply is cut off too long, tissue breaks down, resulting in a pressure sore (also called pressure ulcer or bedsore—see Pressure Sores). Pressure sores can begin to form in as few as 2 hours. Pressure sores are more likely to develop in people who are undernourished or who leak urine involuntarily (are incontinent). Being undernourished makes the skin thin, dry, inelastic, and more likely to tear or break. Being incontinent exposes the skin to urine, which softens it, causing it to break open. Pressure sores usually occur on the lower back, tailbone, heels, elbows, and hips. Pressure sores can be serious, leading to infection that spreads to the bloodstream (sepsis).

If people have difficulty moving, staff members periodically change their position in bed to help prevent pressure sores from forming. The skin is inspected for any sign of pressure sores. Pads may be placed over parts of the body that are in contact with the bed, such as the heels, to protect them.

Weak Bones: When bones do not bear weight regularly (that is, when people do not spend enough time standing or walking), bones become weak and more prone to fractures.

Weak Muscles and Stiff Joints: When muscles are not used, they become weak. Staying in bed can make joints—muscles and the tissues around them (ligaments and tendons)—stiff. Over time, stiff joints can become permanently bent—called a contracture. A vicious circle may result: People stay in bed because of a disorder or surgery, resulting in weak muscles and stiff joints, which make moving (including standing and walking) even more difficult.

Prevention: Steps to prevent problems related to bed rest may seem bothersome or too demanding, but they are necessary for a good recovery. Moving as soon and as much as possible can help prevent most problems, including constipation. People are encouraged to get out of bed as soon as they can. If people cannot get out of bed, they should sit up, move, or do exercises in bed. Flexing and relaxing muscles in bed can help keep muscles from weakening. For people who cannot exercise on their own, a physical therapist or another staff member moves their limbs for them. Furnishings, such as handrails, grab bars in the bathroom, raised toilet seats, low beds, and carpeting, can make movement easier.

For children, hospitals frequently have playrooms to encourage activity and to prevent boredom or depression.

Undernutrition

People who are hospitalized may eat less for several reasons:

• Illness or drugs may cause loss of appetite.
• Food may be unfamiliar and unappetizing.
• Some people are on a restricted diet, such as a low-fat or low-salt diet, which they may not enjoy.
• Meals are served and removed at set times.
• People may be served foods they do not like or cannot eat for philosophical or religious reasons (for example, because the foods are not kosher).
• For some people, eating in a hospital bed with a tray is difficult.
• Some people need help or more time while eating. Often, by the time someone arrives to help with eating, the food has cooled and is even less appetizing.
• If dentures are left at home, are misplaced, or do not fit right, chewing can be difficult.
• Water may be difficult to reach from a hospital bed.

Undernutrition is a serious problem, particularly for older people and people who have chronic disorders. People who are undernourished cannot fight off infections. Sores and wounds heal more slowly, and recovery is less likely. Vitamin D deficiency is particularly common among people who are hospitalized. This deficiency increases the risk of fractures caused by falls.

Prevention: Hospital staff members can make sure that restrictive diets are changed as soon as possible and can check how much people eat each day. At hospital admission, people or their family members can let staff members know what foods are preferred or not eaten. Hospital diets can be modified to some degree. Family members may bring in favorite foods. Having family members present at meals helps because people tend to eat more when they eat with others. Family or staff members should make sure that people who wear dentures have and wear them.

A pitcher of fresh water should be placed within easy reach from the bed unless fluids must be limited because of a disorder. Family and staff members should encourage people to drink by regularly offering them something to drink.

If people cannot take food by mouth, a fluid containing nutrients can be given through a tube inserted into the stomach (through the nose or through a small hole in the wall of the abdomen—see Undernutrition: Tube feeding) or, less often, a vein (intravenously—see see Undernutrition: Intravenous feeding). Such feedings may be necessary for a short time until people can safely eat enough food by mouth. If people cannot take food by mouth (even if only temporarily), family members should check with staff members to make sure adequate nutrition is provided.

Confusion and Decline in Mental Function

Being ill, particularly when it involves taking drugs for pain or anxiety, can make anyone confused. The hospital environment adds to the problem. There, people give up their personal effects and clothing—marks of their identity—for a hospital gown. They are in a strange place without familiar landmarks and usual routines. Often, hospitals provide little stimulation (such as sights, sounds, and interaction with other people). People may be alone or with an uncommunicative roommate in a room that has blank white walls and bland, institutionalized furnishings. For most of the time, there may be no one to talk with. The only sound available may be that from a television.

Hospital procedures and schedules can be disorienting. For example, people may be awakened frequently during the night, depriving them of needed sleep. They may be unable to get their bearings in an unfamiliar, dimly lit room. The many tests and the complicated equipment may be overwhelming.

Intensive care units (ICUs) can be even more confusing. People in ICUs are alone, sometimes with no windows or clocks to help them orient themselves. The beeping of electronic monitors, constant bright light, and frequent interruptions to take blood, to change intravenous (IV) tubes, or to give drugs may interfere with sleeping. People who are tired are more easily confused and disoriented. Sometimes confusion is so severe that people develop a type of delirium called ICU psychosis (see Delirium and Dementia: Causes).

If people become unusually confused while staying in a hospital, family members should tell staff members. Delirium can usually be cured if its cause (a disorder, drug, or stressful situation) is corrected.

Prevention: Staff and family members can help keep people oriented by doing the following:

• Making sure that the lighting in the room is adequate
• Encouraging people to get out of bed, walk regularly, and do as many usual daily activities as possible
• Talking with people about what is going on outside the hospital to keep their mind active
• Explaining tests and treatments to help people understand what is happening and why
• Making sure people who wear glasses or a hearing aid have and wear these items
• Making sure that people consume enough fluids and food (dehydration can cause delirium)

Incontinence

In the hospital, people may involuntarily leak urine (urinary incontinence) or pass stool (fecal incontinence). In these cases, incontinence may result from the environment rather than from people's physical condition. The following may make incontinence more likely:

• Being restricted to bed rest
• Being given diuretics, which cause the bladder to fill quickly with urine
• Having trouble getting out of bed because the bed is too high or because people are weak or ill
• Having a disorder or having had surgery that makes walking difficult or painful
• Having equipment, such as IV or oxygen lines, heart monitors, and catheters, in the way

Thus, getting to a toilet becomes complicated and may take more time and planning than usual.

One alternative—bedpans—may be hard to use or uncomfortable. Help may be needed to use the bedpan or to get to a toilet. People who have dementia, who suddenly become confused, or who have had a stroke may be unable to use a call bell to request help. After the call bell is pushed, help may be delayed. Such delays may result in incontinence. Also, some drugs and disorders can make incontinence more likely to develop.

Prevention: Staff members can set up regular times to help people go to the toilet. Placing a toilet chair (commode) by the bed is sometimes useful. Lowering a bed or rearranging medical equipment may help. Having access to a urinal is helpful for men. Making sure people are familiar with the path from bed to toilet and making the toilet easy to identify may also help prevent incontinence.

Falls

Conditions in a hospital can increase the risk of falling, particularly for older people. After being in bed a long time (bed rest), leg muscles can become weak and less able to squeeze the leg veins and thus force blood toward the heart. Thus, blood pools in the legs when people stand up, causing blood pressure to drop and making people feel dizzy or light-headed (a disorder called orthostatic hypotension). Also, people may be given drugs that make them feel dizzy, drowsy, or confused. A bed may be too high or have rails, making getting out of bed more difficult. Lighting may be dim, so people may not see obstacles. People who are confused or disoriented are more likely to fall.

Because being in the hospital disrupts usual routines, parents who are staying in the hospital to care for a sick infant or small child may forget their usual precautions, such as keeping the crib rails up when the infant is in bed.

Prevention: If people who are hospitalized or their family members realize what can cause falls in a hospital, they can take steps to prevent them. For example, to counter weak muscles, people can get out of bed as soon as possible and exercise. Family or staff members can accompany people while they walk down hospital corridors until muscle strength is regained.

Most falls occur when people get out of bed. So family or staff members can help by doing the following:

• If a bed has rails or is too high, asking whether the rails are needed and whether the bed can be lowered
• Making sure people know how high the hospital bed is
• Encouraging people to be careful and move slowly when getting out of bed
• Making sure people are wearing slippers or shoes with nonskid soles
• Showing people where the toilet is and how to get there (to prevent missteps and bumping into furniture)
• Showing people how to call for help
• For infants and small children, making sure the crib rails are raised

Often, staff members try to identify and provide extra help to people who are likely to fall. Staff members may check on them at regular intervals or put them in rooms near the nursing station.

Family members can ask a doctor to check the drugs being taken and identify any that can increase the risk of falling. If such a drug is being used, family members can ask the doctor about possibly changing the drug or reducing the dose.

Spotlight on Aging
More than one third of people admitted to the hospital are older people. And at any time, almost half of people in the hospital are 65 or older. Almost half of older people seen in an emergency department are admitted to the hospital. When many older people leave the hospital, they are in worse shape than before they became ill. Part of the reason for the decline is that older people tend to have serious and debilitating disorders when they enter the hospital. Many hospitals do not adequately deal with the physical needs of older people. However, part of the reason is just being in a hospital, which can cause problems, regardless of age. Older people are more likely to already have or to develop these problems, and the consequences are more likely to be serious for the following reasons: Confusion: Changes that occur as people age make them more likely to become suddenly and noticeably confused (delirious—see Delirium and Dementia: Spotlight on Aging). Dehydration: Older people tend to feel thirsty less quickly or less intensely than younger people. They thus are inclined to drink less, especially when circumstances make getting water more difficult, as occurs in a hospital. Falls: Older people are more likely to fall and, if they fall, more likely to have a serious injury such as a broken bone. Incontinence: Older people may have particular difficulty getting out of a high hospital bed after they have had surgery, when they have a serious disorder, or when they have various equipment attached to them. As a result, they may not get to a toilet in time. Loss of independence: During a hospital stay, older people may become unable to take care of themselves because staff members provide this care (such as bathing). Loss of muscle tissue: When they spend a lot of time in bed or are immobilized, older people tend to lose more muscle tissue and lose it more quickly. Pressure sores: Older people are prone to pressure sores because they tend to have less fat under the skin and blood flow to the skin is decreased. If they develop pressures sores, they may be sent to a nursing home rather than their own home after they are discharged from the hospital. Side effects of drugs: Before entering the hospital, many older people are taking several drugs. In the hospital, more drugs may be prescribed. The more drugs people take, the greater the chance for side effects and drug interactions. Also, older people are more sensitive to the effects of certain drugs. Undernutrition: Physical age-related changes may reduce appetite or absorption of nutrients (see Undernutrition: Spotlight on Aging), as may certain disorders (including dental problems) and drugs. Many older people have difficulty bouncing back psychologically and physically from the experience of being in a hospital as well as from the disorder they have had. Preventive Strategies Some hospitals have developed strategies to prevent problems that can result when older people are hospitalized. These strategies are designed to help older people continue to function as well as they did before they became ill. An interdisciplinary team: This team consists of health care practitioners who work together to care for an older person. Team members evaluate the person's needs and coordinate the person's hospital care. Team members look for possible problems and correct or prevent them. A one-focus team: This team focuses on preventing and managing one specific problem, such as undernutrition or pressure sores. Such teams are often led by a nurse, who checks the person for the problem and develops a care plan. Geriatricians: These doctors are trained specifically to care for older people and can help prevent problems common among them. For example, geriatricians avoid prescribing drugs that are particularly likely to cause problems. Guidelines: Hospitals may also follow guidelines for care (protocols) developed specifically for older people. An assigned nurse: Sometimes one nurse is assigned to have primary responsibility for and to monitor a person's care. This nurse makes sure that other staff members understand the treatment plan for the person. Geriatric nursing units: These units are designed for older people and staffed with people trained in caring for older people. In these units, older people are encouraged to get out of bed as soon and as much as possible. They are encouraged to dress each morning, to follow their usual daily routine as much as possible, and to eat in a group dining room. If older people are going to be in the hospital a long time, they are encouraged to personalize their room with photographs, pillows, and other familiar items. Staff members encourage family members and friends to participate in care. Treatment How aggressively a disorder is treated in a hospital should not depend on age. Family members and older people should talk with a doctor to make sure options for treatment are based on the severity of the disorder, not on age. However, less aggressive treatments are sometimes appropriate for older people, depending on their wishes and outlook—that is, how the disorder is expected to progress and how long they are expected to live. Having advance directives, which state what sort of care people want, is particularly important for older people.

Last full review/revision February 2009 by Robert M. Palmer, MD, MPH