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Hospital Care and the Elderly

by Barbara Resnick, PhD, CRNP

A hospital may provide emergency medical care, diagnostic testing, intensive treatment, or surgery, which may or may not require admission. The elderly use hospitals more than younger patients; they have more admissions to the hospital from the emergency department and more and longer hospital stays, and they use more resources while in the hospital.

Emergency department care

In 2011, about 20% of people aged 65 to 74 and 27% of those ≥ 75 had at least one emergency department (ED) visit. Elderly patients tend to be sicker. More than 40% of elderly patients seen in an ED are admitted to the hospital; 6% go to ICUs. More than 50% are prescribed new drugs. The elderly may use the ED as a substitute for primary care or may come because they are not receiving adequate attention from their primary care physician. ED visits are often caused by a breakdown in the social structure of a frail elderly patient—eg, absence or illness of their caregiver may result in people calling an ambulance rather than going to their physician's office. However, in many cases, the reasons for coming are true emergencies.

A visit to an ED may create more stress for the elderly because there are typically no special accommodations for them (eg, quiet rooms, lower beds, extra pillows, indirect lighting).

Evaluation of the elderly usually takes longer and requires more diagnostic tests because many elderly patients do not present with clear-cut or typical symptoms and signs of a disorder (see Unusual Presentations of Illness in the Elderly). For example, MI manifests as chest pain in < 50% of patients > 80 yr. Instead, elderly patients may complain of feeling generally weak or just not feeling themselves.

Factors that are not apparent (eg, polypharmacy, adverse drug effects) may affect an elderly patient’s presentation. For example, a fall may result from elder abuse, an adverse drug effect (eg, oversedation), hazards in the home, physical problems (eg, poor vision), depression, or chronic alcoholism. Adverse drug effects account for at least 5% of hospital admissions for the elderly.

About 30 to 40% of elderly patients who come to the ED are cognitively impaired but do not have a diagnosis of dementia; in 10%, cognitive impairment consistent with delirium is unrecognized. When indicated (eg, if an elderly patient is having difficulty with orientation to person, place, or time), a standardized cognitive assessment (see Mental status) should be done in the ED. However, a standardized cognitive assessment is appropriate for any elderly patient coming to the ED. Cognitive impairment affects the reliability of the patient history as well as the diagnosis, increases the risk of delirium during a hospital stay, and must be considered when planning the patient’s disposition. Knowing whether onset of cognitive impairment is recent helps determine whether the impairment should be fully assessed in the ED. Cognitive impairment of recent onset may indicate sepsis, occult subdural hemorrhage, or an adverse drug effect.

Suicide risk, fall risk, incontinence, and nutritional and immunization status should be assessed in the ED so that follow-up care can be arranged.

Communication among practitioners

Good communication among ED physicians and patients, caregivers, primary care physicians, and staff members of long-term care facilities greatly enhances the outcome of elderly patients with complicated problems. Advance directives should be promptly and clearly communicated to emergency medicine practitioners. Baseline information from the patient’s personal physician facilitates assessment and management planning in the ED. Reports to the patient’s primary care physician should describe even simple injuries (eg, ankle sprain, Colles wrist fracture) because such injuries can dramatically affect functional ability and independence.

Disposition

Discharge planning may be complex because acute illness or injury may impair functional ability more in elderly patients (eg, a simple ankle sprain may be incapacitating unless patients have good support at home). Discharge planning may be improved when nurses, social workers, and primary care physicians are involved. It should include the following:

  • Functional status assessment (see Functional status)

  • Strategies to manage problems (eg, depression, alcoholism, impaired functional status) identified during the ED assessment

  • Determination of whether patients can obtain and take drugs as directed and can obtain the necessary follow-up care

  • Assessment of caregiver capabilities (eg, whether respite services are needed)

Many elderly patients are hospitalized after they are evaluated in the ED.

Occasionally, elderly patients are brought to the ED by a caregiver who refuses to take them home or who leaves, abandoning them in the hospital.

Hospitalization

Almost half of adults who occupy hospital beds are 65 yr; this proportion is expected to increase as the population ages. Hospital care costs Medicare > $100 billion/yr, representing 30% of health care expenditures for hospital care in the US.

Hospitalization can magnify age-related physiologic changes and increase morbidity.

Only seriously ill elderly patients who cannot be appropriately cared for elsewhere should be hospitalized. Hospitalization itself poses risks to elderly patients because it involves confinement, immobility, diagnostic testing, and treatments (particularly changes in drug regimens). When patients are transferred to or from a hospital, drugs are likely to be added or changed, leading to a higher risk of adverse effects (see Drug-Related Problems in the Elderly : Reasons for Drug-Related Problems). Treatment in hospitals can be dehumanizing and impersonal. Acute hospital care should last only long enough to allow successful transition to home care, a skilled nursing facility, or an outpatient rehabilitation program.

The outcome of hospitalization appears to be poorer with increasing age, although physiologic age is a more important predictor of outcome than is chronologic age. Outcome is better for patients hospitalized because of elective procedures (eg, joint replacement) than for those hospitalized because of serious disorders (eg, multisystem organ failure).

About 75% of patients who are 75 and functionally independent at admission are not functionally independent when they are discharged; 15% of patients 75 are discharged to skilled nursing facilities. The trend toward abbreviated acute hospital stays followed by subacute care and rehabilitation in a skilled nursing facility may explain why these percentages are high. However, even when a disorder is treatable or appears uncomplicated, patients may not return to prehospital functional status.

Improving outcomes

The following strategies can help reduce functional decline and improve care of elderly patients:

  • Geriatric interdisciplinary team: To identify and meet the complex needs of elderly patients and to watch for and prevent problems that are common among the elderly and that may develop or worsen during hospitalization (See also Geriatric Interdisciplinary Teams)

  • Primary care nurse (one nurse with around-the-clock responsibility for a particular patient) : To administer the team’s care plan, to monitor response to nursing and medical care, and to teach and counsel patients, staff members, and family members

  • Changes in the hospital environment, often made by nurses: Eg, to move disruptive patients into the hall near the nursing station or to change roommates for a patient

  • Rooming-in programs for a family member: To provide better one-on-one care, to relieve staff members of some caregiving tasks, to allay patient anxiety (particularly if patients have delirium or dementia), and to enable a family member to participate actively in the patient’s recovery

  • Good communication among practitioners: To prevent errors in and duplication of diagnostic procedures and treatments (particularly drugs)

  • Documentation of drug regimen: To state the indication for each new drug, to maintain a daily list of drugs prescribed and received, and thus to avoid using unnecessary drugs and help prevent drug interactions

  • Advance directives: To document the patient’s choice of health care proxy and health care decisions (see Advance Directives)

  • Early mobilization and participation in functional activity: To prevent physical deterioration due to decreased activity during illness and hospitalization

  • Discharge planning: To ensure that appropriate care is continued

  • Acute care of the elderly (ACE) units: To provide effective care for the hospitalized elderly by using most of the strategies listed above

Advance directives, if already prepared, should be brought to the hospital as soon as possible. Practitioners should reaffirm these choices during acute hospitalization. If directives were not documented, practitioners should make every effort to determine the patient’s wishes.

Problems common among the elderly require specific consideration during hospitalization, particularly after surgery (see Postoperative Care); many of them can be remembered using the acronym ELDERSS ( ELDERSS: Some Important Issues for the Hospitalized Elderly). In the hospital, elderly patients frequently experience nighttime confusion (sundowning), fracture a bone with no identifiable trauma, fall, or become unable to walk. Hospitalization may precipitate or worsen undernutrition, pressure ulcers, urinary incontinence, fecal impaction, and urinary retention. Such problems can prolong convalescence.

ELDERSS: Some Important Issues for the Hospitalized Elderly

Acronym

Issue

E

Eating (nutritional status)

L

Lucidity (mental status)

D

Directives for limiting care (eg, do not resuscitate)

E

Elimination (incontinence)

R

Rehabilitation (needed because of bed rest effects)

S

Skin care (to prevent and treat pressure ulcers)

S

Social services (discharge planning)

Adverse Drug Effects

Hospitalization rates due to adverse drug effects are 4 times higher for elderly patients ( 17%) than for younger patients (4%). Reasons for these effects include .

  • Polypharmacy

  • Age-related changes in pharmacokinetics and pharmacodynamics

  • Changes in drugs (intentional and unintentional) during hospitalization and at discharge (see Drug-Related Problems in the Elderly)

Prevention

Maintaining a daily list of drugs prescribed and received can help prevent adverse drug effects and drug interactions.

Because drug distribution, metabolism, and elimination vary widely among elderly patients, the following should be done:

  • Drug doses should be carefully titrated.

  • Creatinine clearance for renally excreted drugs should be calculated when doses are adjusted.

  • Serum drug levels should be measured.

  • Patient responses should be observed.

Certain drugs or drug categories should be avoided in the elderly (see Table: Potentially Inappropriate Drugs in the Elderly (Based on the American Geriatrics Society 2012 Beers Criteria Update)). Use of hypnotic drugs should be minimized because tachyphylaxis may occur and risk of falls and delirium is increased; measures to improve sleep hygiene should be tried before drugs (see Table: Sleep Hygiene). If drugs are necessary, short-acting benzodiazepines are usually the best choice. Antihistamines have anticholinergic effects and should not be used for sedation.

Bed Rest Effects

Prolonged bed rest, as can occur during hospitalization, causes deconditioning and is seldom warranted. The resulting inactivity has the following effects:

  • With complete inactivity, muscle strength decreases by 5% per day, increasing risk of falls.

  • Muscles shorten and periarticular and cartilaginous joint structure changes (most rapidly in the legs), limiting motion and contributing to development of contractures.

  • Aerobic capacity decreases markedly, substantially reducing maximum O 2 uptake.

  • Bone loss (demineralization) is accelerated.

  • Risk of deep venous thrombosis is increased.

After even a few days of bed rest, elderly patients who have reduced physiologic reserves but can still function independently may lose that ability. Even if the loss is reversible, rehabilitation requires extensive, expensive, and relatively lengthy intervention.

In elderly patients, bed rest can cause vertebral bone loss 50 times faster than in younger patients. The loss incurred from 10 days of bed rest takes 4 mo to restore.

Prevention

Unless prohibited for a specific reason, activity (particularly walking) should be encouraged. If assistance with walking is needed, therapists may provide it at scheduled times. However, physicians, nurses, and family members should also assist patients with walking throughout the day. Hospital orders should emphasize the need for activity.

If immobilization is necessary or results from prolonged illness, procedures to prevent deep venous thrombosis are recommended unless contraindicated.

Rehabilitation is often needed. Realistic goals for rehabilitation at home can be based on the patient’s prehospitalization activity level and current needs.

Falls

Age-related changes (eg, baroreceptor insensitivity, decreased body water and plasma volume) result in a tendency to develop orthostatic hypotension. These changes plus effects of bed rest and use of sedatives and certain antihypertensives increase risk of falls (and syncope).

Among hospitalized elderly patients, > 60% of falls occur in the bathroom; often, patients hit hard objects. Some patients fall while getting out of hospital beds. Patients are in a strange bed and in a strange environment, and they may easily become confused. Although bed rails may help remind elderly patients to call for assistance before attempting to get up, bed rails may also tempt patients to climb over or around them and thus may contribute to patient falls.

Prevention

Usually, bed rails should be removed or kept down. The best alternatives to the use of physical or chemical restraints are to identify, carefully analyze, and modify or correct risk factors for falling (including agitation) and to closely observe patients at risk. Using low beds and keeping pathways in rooms and hallways clear may also help reduce the risk of falls.

Incontinence

Urinary or fecal incontinence develops in > 40% of hospitalized patients 65, often within a day of admission. Reasons include

  • An unfamiliar environment

  • A cluttered path to the toilet

  • Disorders that impair ambulation

  • A bed that is too high

  • Bed rails

  • Hampering equipment such as IV lines, nasal oxygen lines, cardiac monitors, and catheters

  • Psychoactive drugs that may reduce the perception of the need to void, inhibit bladder or bowel function, or impair ambulation

  • Drugs that may result in urinary incontinence (eg, anticholinergic drugs and opioids, causing overflow urinary incontinence; diuretics, causing urge incontinence)

Bedpans may be uncomfortable, especially for postsurgical patients or patients with chronic arthritis. Patients with dementia or a neurologic disorder may be unable to use the call bell to request toileting assistance.

Fecal impaction, GI tract infection (eg, Clostridium difficile–induced colitis), adverse effects of drugs, and liquid nutritional supplements may cause uncontrollable diarrhea.

With appropriate diagnosis and treatment, continence can be reestablished.

Mental Status Changes

Elderly patients may appear confused because they have dementia, delirium, depression, or a combination. However, health care practitioners must always remember that confusion may have other causes, and its presence requires thorough evaluation.

Confusion may be due to a specific disorder (see Table: Causes of Delirium). However, it may develop or be exacerbated because the hospital setting exacerbates the effects of acute illness and age-related changes in cognition. For example, elderly patients who do not have their eyeglasses and hearing aids may become disoriented in a quiet, dimly lit hospital room. Patients may also become confused by hospital procedures, schedules (eg, frequent awakenings in strange settings and rooms), the effects of psychoactive drugs, and the stress of surgery or illness. In an ICU, the constant light and noise can result in agitation, paranoid ideation, and mental and physical exhaustion.

Prevention

Family members can be asked to bring missing eyeglasses and hearing aids. Placing a wall clock, a calendar, and family photographs in the room can help keep patients oriented. The room should be lit well enough to enable patients to recognize what and who is in their room and where they are. When appropriate, staff and family members should periodically remind patients of the time and place. Procedures should be explained before and as they are done.

Use of physical restraints is discouraged. For agitated patients, restraints invariably increase the level of agitation. Identifying and modifying risk factors for agitation and closely observing patients can help prevent or minimize it. Invasive and noninvasive devices attached to patients (eg, pulse oximeters, urinary catheters, IV lines) can also cause agitation; the risk:benefit ratio of these interventions should considered.

Pressure Ulcers

Pressure ulcers often develop in elderly hospitalized patients because of age-related changes in the skin. Direct pressure may cause skin necrosis in as few as 2 h if the pressure is greater than the capillary perfusion pressure of 32 mm Hg. During a typical ED visit, pressure ulcers can start developing while elderly patients are lying on a hard stretcher waiting to be examined. After short periods of immobilization, sacral pressures reach 70 mm Hg, and pressure under an unsupported heel averages 45 mm Hg. Shearing forces result when patients sitting in wheelchairs or propped up in beds slide downward. Incontinence, poor nutrition, and chronic disorders may contribute to pressure ulcer development.

Prevention

A protocol to prevent and treat pressure ulcers should be started immediately, at admission (see Pressure Ulcers : Prevention). It should be followed daily by the patient’s care providers and reviewed regularly by an interdisciplinary team. Pressure ulcers may be the only reason patients are discharged to a nursing home rather than to the community.

Undernutrition

In the hospital, elderly patients can become undernourished quickly, or they may be undernourished when admitted. Prolonged hospitalization exacerbates preexisting problems and often results in significant nutritional loss. Undernutrition is particularly serious for hospitalized patients because it makes them less able to fight off infection, maintain skin integrity, and participate in rehabilitation; surgical wounds may not heal as well.

Hospitalization contributes to undernutrition in several ways:

  • Rigidly scheduled meals, use of drugs, and changes in environment can affect appetite and nutritional intake.

  • Hospital food and therapeutic diets (eg, low-salt diets) are unfamiliar and often unappetizing.

  • Eating in a hospital bed with a tray is difficult, particularly when bed rails and restraints limit movement.

  • Elderly patients may need help with eating; help may be slow to come, resulting in cold, even less appetizing food.

  • The elderly may not drink enough water because their thirst perception is decreased, water is difficult to reach, or both; severe dehydration may develop (sometimes leading to stupor and confusion).

  • Dentures may be left at home or misplaced, making chewing difficult; labeling dentures helps prevent them from being lost or discarded with the food tray.

Prevention

Patients with preexisting nutritional abnormalities should be identified when admitted and be treated appropriately. Physicians and staff members should anticipate nutritional deficiencies in elderly patients.

The following measures can help:

  • Rescinding restrictive dietary orders as soon as possible

  • Monitoring nutritional intake daily

  • Conferring with patients and family members about food preferences and attempting to tailor a reasonable diet specific to each patient

  • Encouraging family members to join the patient at mealtimes because people eat more when they eat with others

  • Making sure patients are fed adequately at all times (eg, ensuring that meals are saved if patients are out of their unit for tests or treatment during mealtime)

  • Considering use of temporary parenteral nutrition or GI tube feedings for patients too sick to swallow

  • Giving explicit oral fluid orders (eg, providing a fresh and readily accessible bedside water pitcher or other fluids unless fluids are restricted; advising family members, friends, and staff members to regularly offer patients a drink)

Discharge Planning and Transfers

Early, effective discharge planning has many benefits:

  • Shortening the hospital stay

  • Reducing the likelihood of readmission

  • Identifying less expensive care alternatives

  • Facilitating placement of equipment (eg, hospital bed, O 2 ) in the patient’s home

  • Helping increase patient satisfaction

  • Possibly preventing placement in a nursing home

As soon as a patient is admitted, all members of the interdisciplinary team begin discharge planning. A social worker or discharge planning coordinator evaluates the patient’s needs within 24 h of admission. Nurses help physicians determine when discharge is safe and which setting is most appropriate.

To home

Patients being discharged to their home need detailed instructions about follow-up care, and family members or other caregivers may need training to provide care. If patients and family members are not taught how to give drugs, implement treatment, and monitor recovery, adverse outcomes and readmission are more likely. Writing down follow-up appointments and drug schedules may help patients and family members. At discharge, a copy of a brief discharge summary plan should be given to patients or family members in case they have questions about care before the primary care physician receives the official summary plan.

To another health care facility

When a patient is discharged to a nursing home or to another facility, a written summary should be sent with the patient, and a full copy should be sent electronically to the receiving institution. The summary must include complete, accurate information about the following:

  • The patient’s mental and functional status

  • Times the patient last received drugs

  • List of drugs being currently taken and the dosage

  • Known drug allergies

  • Advance directives, including resuscitation status

  • Family contacts and support status

  • Follow-up appointments and tests

  • Names and phone numbers of a nurse and physician who can provide additional information

A written copy of the patient’s medical and social history should accompany the patient during transfer and may be sent electronically to the receiving facility to ensure that there are no information gaps.

Effective communication between staff members of institutions helps ensure continuity of care. For example, the patient’s nurse can call the receiving institution to review the information shortly before the patient is transferred and can call the nurse who will care for the patient after discharge.

Resources In This Article

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