Problems Due to Hospitalization

Hospitals are a place where people go expecting to get better, at least eventually. However, when many older people leave the hospital, they are in worse shape than before they became ill. Many older people cannot care for themselves when they are ready to be discharged from the hospital. Some of these people leave the hospital only to go to a nursing home. Part of the reason for the decline in function is that older people tend to have serious and debilitating disorders when they enter the hospital. However, part of the reason is just being in a hospital.

In the hospital, older people who already have problems caring for themselves tend to decline even more, as do those whose mental function is impaired, who are depressed, or who are undernourished. 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. Sometimes mistakes are made in hospitals. For example, the wrong drug may be given. Also, many hospitals do not adequately deal with the needs of older people.

Problems Due to Bed Rest

Staying in bed for a long time, as is sometimes necessary in a hospital, can cause many problems. Examples are weak muscles, stiff joints, blood clots, dizziness, weak bones, pressure sores, constipation, kidney stones, incontinence, infections, and depression.

When muscles are not used, they become weak. This effect may be greater in older people because muscles may already be weak. Older people tend to lose muscle tissue (a condition called sarcopenia) if they do not stay active. Staying in bed can make muscles and the tissues around them (ligaments and tendons) stiff. Stiffness can result in joints that are permanently bent (a contracture). A vicious circle may result: Staying in bed because of a disorder or surgery makes moving difficult, resulting in weak muscles and stiff joints, which make movement (including standing and walking) even more difficult.

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 slow-moving blood. Blood clots sometimes travel from the leg veins to the lungs and cause blockage of an artery in a lung (pulmonary embolism). Pulmonary embolism can be life threatening. Also, if blood moves slowly from the leg veins, the heart may not be able to pump enough blood to the brain when a person stands up. Then, standing up may make the person feel dizzy or light-headed—a disorder called orthostatic hypotension.

When bones do not bear weight regularly (that is, when a person does not spend enough time standing or walking), bones become weak and more prone to fractures.

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 and a sore (bedsore or pressure sore) forms. 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 incontinent. Being undernourished makes the skin thin, dry, inelastic, and more likely to tear or break. Being incontinent exposes the skin to urine, which irritates it. Pressure sores usually occur on the lower back, tailbone, heels, elbows, and hips. Pressure sores can be serious and can result in discharge to a nursing home rather than home.

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.

When people are restricted to bed rest or are too weak or ill to get out of bed by themselves, urinating and having bowel movements become complicated. Such people need a bedpan or urinal or someone's help getting to a toilet. Often, the needed help is delayed. Thus, these functions take more time than they usually do and require planning. A delay getting to the toilet may result in leakage of urine (a type of urinary incontinence called functional incontinence) or of stool (fecal incontinence).

When getting to the bathroom is delayed, the bladder may become overstretched because urine accumulates and stretches it. When the bladder is overstretched, a catheter is often inserted into the bladder to drain urine. Bacteria are more likely to enter the bladder when a catheter is inserted, making urinary tract infections more likely.

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 or coughing forcefully may become difficult. If mucus accumulates in the airways, coughing may not be forceful enough to clear the mucus out. Thus, people are more likely to become short of breath and to develop pneumonia and lung infections.

Depression is common among people who stay in bed for a long time. One reason is that bed rest results in so many other problems. Also, staying in bed may make people feel helpless and useless. They have less contact with other people, which may contribute to depression.

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. People are encouraged to get out of bed as soon as they can. If they 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.

If a person has difficulty moving, staff members periodically change the person's position in bed. This measure helps prevent pressure sores from forming and mucus from accumulating in airways. The person's 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.

Deep breathing and coughing exercises can help keep breathing muscles from weakening.

Undernutrition

Generally, older people are more susceptible to undernutrition for many reasons. For example, they may have a disorder or take a drug that interferes with the way the body uses some nutrients or may cause the appetite to decrease. Food may be unfamiliar and unappetizing. Some people are put on a restricted diet, such as a low-fat or low-salt diet. 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). Also, eating in a hospital bed with a tray may be 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. Even if water can be reached, older people may not drink enough because they tend to feel thirsty less quickly or less intensely than younger people. As a result, older people may become dehydrated in the hospital. If dehydration becomes severe, they can become confused, making them less likely to eat and drink.

Undernutrition is a serious problem. 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.

Hospital staff members can make sure that restrictive diets are changed as soon as possible and can check how much a person eats each day. Letting the staff members know what foods are preferred or not eaten can also help prevent undernutrition. Hospital diets can be modified to some degree. Family members may bring in the person's favorite foods. Having family members present at meals helps, because people tend to eat more when they eat with others. 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 can also regularly offer the person something to drink.

For people who cannot take food by mouth, a fluid containing nutrients can be given through a tube inserted into the stomach or a vein (intravenously). Such feedings may be necessary for a short time or indefinitely. If a person cannot take food by mouth (even if only temporarily), family members should check with staff members to make sure adequate nutrition is provided.

Loss of Independence

In hospitals, staff members do many of the tasks people normally do by themselves, largely because doing so is easier. People are brought food and are bathed. When people have to go to another location for a test or treatment, they are often taken by wheelchair. However, if older people do not continue to care for themselves, they tend to lose the ability to do so.

Family and staff members should encourage older people to do as much as possible for themselves. The more people do for themselves, the more likely they are to return home.

Confusion and Decline in Mental Function

Being ill or taking drugs for pain can make anyone somewhat confused. But in older people, an illness or a drug may cause sudden, noticeable confusion (delirium). Delirium is more likely because of changes that occur as people age.

The hospital environment can also contribute to confusion. Without their personal effects and clothing, people may feel as if they are losing their identity. They are in a strange place without familiar landmarks and usual routines. In their residence, these landmarks and routines help them compensate for various problems, such as impaired vision or memory loss.

Often, hospitals provide little stimulation (such as sights, sounds, and interaction with other people). A person 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. They may be unable to get their bearings in an unfamiliar, dimly lit room. The many tests and the complicated equipment may be overwhelming. Forgetting to bring eyeglasses or hearing aids can add to a person's confusion and disorientation.

Intensive care units (ICUs) can be even more confusing. People in ICUs are alone, often with no windows or clocks to help them orient themselves. The constant beeping of electronic monitors, constant bright light, and frequent interruptions to take blood, change intravenous (IV) tubes, or 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.

If family members notice that an older person becomes unusually confused while staying in a hospital, they should tell staff members. Delirium can usually be cured if its cause (a disorder, drug, or stressful situation) is corrected.

Staff and family members can help keep the person oriented. If the person wears glasses or a hearing aid, they can make sure the person has these items. They may also need to help the person use these items. For example, they may need to clean the lenses of the glasses or change the battery in a hearing aid. Adequate lighting in the room can help orient a person. Staff and family members can encourage the person to get out of bed, walk regularly, and do as many usual daily activities as possible. Talking with the person about what is going on outside the hospital helps keep the person's mind active. Explaining tests and treatments helps the person understand what is happening and why. Making sure the person eats, drinks, and sleeps enough also helps.

Incontinence

In the hospital, many people 65 and older lose control of their bladder or bowels (urinary or fecal incontinence). In these cases, incontinence often results from the environment rather than from the person's physical condition. For example, older people may have trouble getting out of bed because the bed is too high. A disorder or surgery may make walking difficult. Equipment such as IV or oxygen lines, heart monitors, and catheters may be in the way. Thus, getting to a toilet may take more time. The alternative—bedpans—may be hard to use or uncomfortable. Help may be needed. People who have dementia 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 in coming. Such delays may result in incontinence. Also, some drugs and disorders can make incontinence more likely to develop.

Staff members can set up regular times to help a person go to the toilet. Placing a toilet chair (commode) by the bed is sometimes useful. Having access to a urinal is helpful for men.

Falls

Conditions in a hospital can increase the risk of falling, particularly for older people. Bed rest can make muscles weak. It can cause people to feel dizzy or light-headed when they stand. They 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.

If people who are hospitalized or their family members realize what can cause falls in a hospital, they can take steps to prevent falls. 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. Bed rails are usually unnecessary.

Most falls occur when people get out of bed. So family or staff members should make sure people can get out of bed safely. People may need to be shown how high the hospital bed is. They also need to be careful and move slowly when getting out of bed. Wearing slippers or shoes with nonskid soles helps prevent falls. Knowing where the toilet is and how to get there can prevent missteps and bumping into furniture. People should be shown how to call for help.

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 to 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.

Side Effects of Drugs

Generally, but particularly in the hospital, older people experience more side effects from drugs than younger people. The main reason is that older people tend to take more drugs. During one stay in a hospital, older people may take 6 to 12 different drugs. Drugs may be given to help with sleep. But these drugs may make older people more likely to fall or become confused. In the hospital, new drugs may be started, and old ones discontinued. When older people are discharged, half of the drugs they are taking may be new to them.

Older people who are entering the hospital or their family members can talk with staff members about reviewing the drugs being taken. Making sure older people take drugs as instructed is also important. Before discharge, older people or family members should make sure they completely understand the instructions for taking the prescribed drugs.