Hospitalization

Almost half of adults who occupy hospital beds are >= 65 years; this proportion is expected to increase as the population ages. Hospitalization can magnify age-related physiologic changes and increase morbidity (see Table 11-3).

The outcome of hospitalization appears to be poorer with increasing age, although physiologic age is a more important predictor of outcome than chronologic age. Outcome is also better in patients hospitalized for elective procedures (eg, joint replacement) than in those hospitalized for serious conditions (eg, multisystem organ failure). The cost of hospital care to Medicare yearly is > $100 billion, representing 30% of health care expenditures for hospital care in the USA.

About 75% of persons >= 75 who are functionally independent when admitted to hospitals from their homes are not functionally independent when discharged; 15% of persons >= 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 an illness is treatable or appears uncomplicated, patients may not return to prehospitalized functional status. For example, in one study of patients who had hip fracture repair, only 20% returned to their preoperative functional level.

The hospital environment can be designed to reduce significant functional decline among elderly patients. Many successful models for acute care geriatric units have been implemented nationwide over the past decade; each differs in patient mix, targeting, and physical characteristics. A particularly successful model is Acute Care for the Elderly (ACE) intervention, a program of patient-centered care designed to prevent dysfunction.

A geriatric interdisciplinary team can help optimize care of elderly patients. The team members--geriatricians, nurses trained in gerontology, physical and occupational therapists, social workers, pharmacists, and other health care practitioners--work together to meet the complex needs of elderly patients. The clinical nurse specialist typically co-chairs the team along with the geriatrician; facilitates communication; provides assessment, case management, and related interventions for the patient; serves as a teacher and counselor for the staff, patients, and families; identifies ethical and compliance issues and the need for patient and family conferences; and monitors quality improvement in gerontologic nursing.

Some hospitals have implemented primary care nursing, in which one nurse has around-the-clock responsibility for a particular patient, just as an attending physician does. The primary care nurse administers the team's care plan, monitors response to nursing and medical care, supports health promotion, and serves as a teacher and counselor for patients, staff, and family members.

Nurses often make decisions that markedly affect patient outcomes. For example, disruptive patients may be calmed when placed in the hall near the nursing station; this allows for environmental stimulation as well as for close observation. Changing roommates can be critical when a wide functional disparity exists between two acutely ill patients.

Important considerations for the hospitalized elderly patient follow and are summarized by the acronym ELDERS (see Table 11-4). Hospitalization is necessary only when the patient cannot receive appropriate treatment in any other environment. The health care practitioner should promptly identify patients who can benefit from medical care in another environment (eg, at home). Acute hospital care should only be of sufficient duration to allow successful transition to home care, a skilled nursing facility, or an outpatient rehabilitation program.

Directives

Many elderly persons have strong opinions about health care options, and many have already taken such steps as making funeral arrangements and preparing wills. Patients should be asked to document their choice of health care proxy and other advance directives during routine office visits. It is best when these directives are brought to the hospital as soon as possible. However, if advance directives or assignment of a proxy was not obtained prior to hospitalization for severe illness, the clinician should make every effort to determine the patient's prior wishes. Efforts should also be made to reaffirm patient choices during acute hospitalization.

Nutrition

Hospitalized elderly patients can become malnourished quickly, or they may have been malnourished on admission. Under the best of circumstances, a patient's appetite and eating habits are markedly affected by an acute hospitalization. Prolonged hospitalization exacerbates this problem and often results in significant nutritional loss. Malnourishment is a serious problem because a malnourished patient cannot fight off infection, maintain skin integrity, heal surgical wounds, or undergo successful rehabilitation.

Many factors contribute to malnutrition in the hospitalized elderly. Meal scheduling, use of medications, and changes in environment may 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 the tray, utensils, and water out of easy reach is difficult, particularly when bed rails and restraints limit movement. Often, by the time someone arrives to help feed a patient, the food has cooled and is even less appetizing. In addition, if dentures are left at home or misplaced, chewing can be difficult. Labeling dentures helps prevent them from being lost or discarded with the food tray.

Aging is accompanied by a decrease in taste and smell, which can affect appetite and make dietary changes even less tolerable. Also, because thirst perception decreases with age, severe dehydration may occur, leading to stupor and confusion. These states further reduce a hospitalized patient's ability to eat and drink.

Physiologic changes of aging place elderly patients at greater risk of undernutrition, including mild to severe vitamin and trace mineral deficiencies. Marasmus (a state of borderline nutritional compensation with decreased muscle and fat stores but normal organ function and protein levels) may occur and, with the stress of an acute hospitalization, may rapidly lead to kwashiorkor (hypoalbuminemic protein-energy malnutrition).

Patients with preexisting nutritional abnormalities should be identified when admitted and be given appropriate treatment. Physicians and staff members should anticipate nutritional deficiencies in elderly patients. Preventive measures include rescinding restrictive dietary orders as soon as possible and monitoring nutritional intake daily. Hospital staff should confer with the patient and family regarding food preferences and attempt to tailor a reasonable diet specific to each patient's lifelong habits, ethnic food choices, and ability to chew and swallow. Because eating is a social as well as physical activity and because people eat more and better when they eat with others, it is beneficial for family members to join the patient at mealtimes.

Patients should be fed adequately at all times. For patients too sick to swallow, parenteral nutrition or gastrointestinal tube feedings may be given temporarily or permanently. Oral fluid orders should be explicit. If a medical condition does not require fluid restriction, the patient benefits from a fresh and readily accessible bedside water pitcher or other fluids. Family members, friends, and staff members also can regularly offer the patient a drink.

Morbidly obese patients have an entirely different set of problems and present certain challenges, nutrition-related and otherwise. For example, these patients may experience difficulty in undergoing diagnostic tests and procedures, as well as in rehabilitation and independence in activities of daily living. Counseling, along with strict dietary control and behavior modification techniques after hospital discharge, is often the best approach to address a lifetime of habitual overeating.

Mental Status

Mental status in the aged may be clouded by the proverbial three "D's": dementia, delirium, and depression. A confused and acutely ill elderly patient may show evidence of one or all three of these disorders. Clinicians must always remember that not all ill elderly patients develop confusion, and its presence requires a thorough evaluation and diagnosis.

Confusion may be due to a specific disorder; however, age-related changes and acute illness can cause confusion that may be exacerbated by the reduced visual and auditory input in a hospital setting. 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 intensive care unit, the constant light and noise can result in agitation, paranoid ideation, and mental and physical exhaustion for the patient.

Family members can be asked to bring missing eyeglasses and hearing aids. A wall clock and calendar can help to keep patients oriented. The use of physical restraints is discouraged. Tying down agitated patients invariably increases their level of agitation. In addition, the use of physical restraints has been shown to increase the risk of physical injury, including death. Bed rails and chairs sometimes serve as restraints. The use of bed rails increases the risk of falls and injury. When risk of falling is thought to be significant, beds should be kept low to the ground unless elevation is needed temporarily for examinations or procedures.

Drugs

Adverse drug reactions occur in up to 36% of hospitalized patients and are usually associated with polypharmacy, which increases as patient age increases. In some cases, the cause may be related to changes in pharmacokinetics and pharmacodynamics that occur with aging. Drug distribution, metabolism, and elimination vary widely among elderly patients. Therefore, drug doses should be carefully titrated, creatinine clearance of renally excreted drugs calculated for dose adjustment, serum drug levels measured, and patient responses observed.

Important is the number of drugs given to an elderly patient: 6 to 12 different drugs during a single hospitalization are not unusual. Also, nearly half of the drugs given to the elderly by the time of their discharge are new to the patient. Maintaining a daily list of drugs prescribed and received can help prevent adverse drug reactions and interactions.

Patients may have difficulty sleeping in the hospital. However, use of hypnotic drugs should be minimized because of tachyphylaxis and increased risk of falls and delirium. Short-acting benzodiazepines are generally best. Antihistamines have adverse anticholinergic effects on bladder and bowel function, cognition, and blood pressure and should not be used for sedation.

Incontinence

More than 40% of hospitalized patients >= 65 become incontinent of urine or stool, many within a day of hospital admission. The environment may be unfamiliar, the path to the toilet may be unclear, an illness or injury may impair ambulation, the height of the bed may be intimidating, or bed rails may be a barrier. Equipment such as IV lines, nasal oxygen lines, cardiac monitors, and catheters act as restraints. Bedpans may be uncomfortable, especially for postsurgical patients or patients with chronic arthritis. Psychoactive drugs may diminish the perception of a need to void, inhibit bladder or bowel function, and impair ambulation. Patients with dementia or neurologic disease may be unable to use the call bell to request toileting assistance. Anticholinergic drugs, opioids, and constipation may lead to overflow urinary incontinence, and diuretics may precipitate urge incontinence.

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

With appropriate diagnosis and treatment, continence can be reestablished, and nursing home placement avoided.

Skin Integrity

Pressure sores often develop in elderly hospitalized patients. With aging, the epidermis and dermis become thinner, vascularity decreases, epidermal turnover slows, and subcutaneous fat is lost. Direct pressure may cause skin necrosis in as few as 2 hours if the pressure is greater than the capillary perfusion pressure of 32 mm Hg. During a typical emergency department visit, the time elderly patients spend lying on a hard stretcher is often longer than that needed for pressure sores to start developing. 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 illness may contribute to pressure sore development.

Immediately placing patients on a prevention and treatment protocol helps decrease morbidity. Such protocols should be typically initiated upon admission, followed daily by the patient's primary care nurse, and reviewed at least weekly by an interdisciplinary team. Pressure sores may be the only reason a patient is discharged to a nursing home rather than to the community.

Falls

One of the most clinically important manifestations of the change in autonomic function that occurs with age is baroreceptor insensitivity. This insensitivity, combined with age-associated decreases in body water and plasma volume (which can be exacerbated by dehydration), results in a tendency toward orthostatic hypotension.

Bed rest has many pitfalls. It reduces muscle strength and aerobic capacity and accelerates bone loss. Bed rest also decreases plasma volume, peripheral vascular resistance, and baroreceptor sensitivity, all of which increase the risks of orthostatic hypotension and syncope. Sedatives and the intense hypotensive effects of some antihypertensive drugs can further contribute to the possibility of syncope or falls.

Among hospitalized elderly patients, > 60% of falls occur in the bathroom; often, patients strike hard objects. Some patients fall while getting out of high hospital beds, sometimes while climbing over the bed rails. High beds are for the staff's convenience, not the patient's. Patients do not fall out of bed in the hospital any more than they fall out of bed at home. They are injured as they climb in and out of high beds. Because all types of physical restraints pose a significant risk of injury, bed rails should be removed or kept down in most cases. The best alternatives to the use of physical or chemical restraints are careful analysis of risk factors and their modification, diagnosis and treatment of factors contributing to agitation or falling, and close observation by health care practitioners.

Rehabilitation

Rehabilitation is often needed by patients who have become deconditioned because of prolonged bed rest, which is seldom warranted. With complete inactivity, muscle strength decreases by 5% per day, and reduced muscle strength often leads to falls. Even young men on bed rest lose muscle strength at a rate of 1.0 to 1.5% per day (10% per week). Inactivity contributes to muscle shortening and changes in periarticular and cartilaginous joint structure, both of which contribute to limitation of motion and development of contractures. The most rapid changes occur in the legs. Bed rest also markedly decreases aerobic capacity, substantially reducing maximum oxygen uptake.

For an older person who has diminished physiologic reserves but who still can perform daily activities, such as walking, toileting, and bathing, the accelerated losses of muscle strength and aerobic capacity after even a few days of bed rest may result in a prolonged loss of independent function. Even if the loss is reversible, rehabilitation requires extensive and expensive intervention because reconditioning takes longer than deconditioning.

In the elderly, bed rest can also cause bony demineralization. Many elderly persons, particularly thin white women, are osteoporotic when admitted, and a prolonged stay accelerates bone loss. In older adults, bed rest can cause vertebral bone loss 50 times faster than in younger adults. The loss incurred from 10 days of bed rest takes 4 months to restore. The loss may be due to lack of weight bearing and the general negative nitrogen balance caused by immobilization.

Unless prohibited for a specific reason, activity, particularly walking, is encouraged; assistance with walking by physicians, nurses, and family members throughout the day is recommended, not only by therapists at scheduled times. Hospital orders should emphasize the need for activity. If immobilization is necessary or results from prolonged illness, procedures to prevent deep vein thrombosis are recommended unless contraindicated.

Realistic goals for rehabilitation at home can be determined by the patient's prehospitalization activity level and current needs.

Socialization

Socialization during treatment for an acute illness promotes recovery. A growing number of hospitals have rooming-in programs, in which a family member sleeps in a reclining chair or bed in the patient's room. These programs may disrupt staff routines and protocols; however, if properly supervised, they provide better one-on-one care and relieve staff members of some caregiving tasks. They also allay patient anxiety, particularly in delirious or demented patients, and allow family members to participate actively in the patient's recovery.

Discharge Planning and Transfers

Early, effective discharge planning shortens the hospital stay, decreases the likelihood of readmission, identifies less expensive care alternatives, facilitates placement of equipment (eg, hospital bed, oxygen) in the patient's home, helps increase patient satisfaction, and may prevent placement in a nursing home. As soon as the 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 hours of admission. Nurses are vital in helping physicians determine when discharge is safe and which setting is most appropriate.

Patients being discharged to their homes need detailed instructions about follow-up care, and family members or other caregivers may need training to provide care. Failure to teach them how to give drugs, implement treatment, and monitor recovery increases the likelihood of adverse outcomes and of readmission. Writing down follow-up appointments and drug schedules may be helpful for 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.

When patients are discharged to a nursing home or to another hospital, it is recommended that a written summary be sent with the patient and a copy faxed to the receiving institution. The summary must include information about the patient's mental and functional status, the times the patient last received drugs, known drug allergies, advance directives, and family contacts. The summary should contain complete, accurate information, including resuscitation status, cognitive and physical function, drugs, follow-up appointments and studies, and the names and phone numbers of a nurse and physician who can provide additional information. It is helpful when the patient's nurse calls the receiving institution to review the information shortly before the patient is transferred.

Likewise, when a patient is transferred to the hospital from a nursing home, important transfer information includes the patient's cognitive and physical function, resuscitation status, drugs, drug allergies, and family support. A written copy of the patient's medical and social history should accompany the patient during transfer and may be sent via fax to the receiving hospital to ensure that no information gaps occur. Written confirmation of advance directives is often required by the receiving hospital.

Effective communication between staff members of institutions helps ensure continuity of care. For example, a nurse caring for a hospitalized patient can call the nurse who will care for the patient after discharge.