Strategies to Ensure a Safe and Successful Hospitalization for the Older Adult

Jeffrey D. Schlaudecker, MD and Rachel Hart, MD

/>Adults over the age of 65 account for 48 percent of all hospital admissions. Compared to younger hospitalized adults, they are more likely to be admitted with higher acuity and disease burden, require a longer length of stay, are twice as likely to suffer from adverse events and have higher 30-day readmission rates. For frail older adults, small problems can lead to significant declines in health, physical function and independence. Critically important for a safe and successful hospitalization is a focus on the prevention of iatrogenic complications and further frailty, optimal hospital design, a medication review and effective transitions of care out of the hospital.</p> <p><strong>Hospital Design</strong></p> <p>Just as children’s hospitals underwent design changes decades ago to reflect the needs of young patients, today some hospitals are working to meet the unique needs of older adults. The Nurses Improving Care for Health System Elders (NICHE) program and Acute Care for the Elderly (ACE) units are two specific programs that are aimed at improving the care of older adults in the hospital.</p> <ul> <li>In 1992, New York University launched the NICHE program with the aim of creating a better care environment for the hospitalized older patient by improving nursing practice. NICHE provides resources, project management mentoring and evidence-based clinical protocols to over 300 participating hospitals.</li> <li>ACE units are a model of comprehensive inpatient geriatric care incorporating: 1) hospital environment modifications; 2) minimization of adverse effects of hospitalization; 3) early discharge planning and 4) patient-centered care protocols. The benefit of ACE units has been expanded hospital-wide. The concept of a mobile acute care for the elderly (MACE) unit is an added component, which can distribute excellence in geriatric care throughout a hospital, rather than solely in one centralized ACE unit.</li> </ul> <p>In addition to a redesign of care processes and procedures tailored to older hospitalized adults, the physical environments of hospitals are being redesigned to enhance geriatric-oriented care provision. Innovative hospital designs that focus on the needs of older adults and their families have begun to improve the hospital campus, the unit, the room and the amenities available in each of these.</p> <p><strong>Medication Review</strong></p> <p><strong></strong>Polypharmacy and inappropriate prescribing are common problems for older adults. Multiple medications for multiple chronic illnesses may be necessary, but can cause increased risk for drug-drug interactions and adverse drug side effects. Medications often inappropriate for older adults include sedating medications, muscle relaxants and drugs causing orthostatic blood pressure problems. These medications can lead to falls and increased confusion.</p> <p>Problems can also arise when the list of medications isn’t properly reconciled as patients move within areas of the hospital and between the community and the hospital. Medications appropriate in one setting may not be appropriate in all settings. Sedating medications can help stabilize a patient on a mechanical ventilator, but can cause serious consequences for a mobile patient working with physical therapy. Discharge medication reconciliations completed too quickly can lead to duplications, inaccuracies and continued use of medications that are no longer indicated.</p> <p>When determining medication appropriateness and safety, the medication itself, the dosage, likely effectiveness, drug-drug interactions, drug-disease interactions, unnecessary duplications and the duration of treatment must all be considered.</p> <p><strong>Unintended Consequences</strong></p> <p>Iatrogenesis is “any unintended consequence of well-intended healthcare interventions.” While many hospital-based interventions are necessary even appropriate care can carry a risk of harm, such as delirium, falls and infections. Iatrogenesis affects one in three older adults in the hospital, but over 50 percent of cases can be prevented. Implementing prevention strategies can prevent iatrogenic diseases, some of which are highlighted below:</p> <ul> <li>Delirium is a syndrome of an acute confusional state. It is distressing, increases cost and length of hospital stay, and can be a marker of a serious underlying medical illness. Delirium prevention involves multiple components including orientation and cognitive exercises, early mobilization, preventing hunger, thirst, pain and avoiding sensory deficits by ensuring patients have their eyeglasses and hearing aids.</li> <li>Falls can cause injury, loss of independence and even death for older adults. A falls assessment should be done on admission to recognize and manage risk factors. These risk factors are mechanical, such as decreased mobility from severe arthritis; physical, such as poor vision; cognitive, such as dementia causing someone to forget to use a walker; or environmental, such as an indwelling urinary catheter or tubing for oxygen. Prevention strategies should begin upon hospital admission and may include therapy-oriented exercise problems for gait limitations, medication modification to prevent hypoglycemia or hypotension, avoiding use of medical tethers such as urinary catheters or central lines which limit patient mobility, and environmental modification such as bed alarms, padding and lowering beds.</li> <li>Older adults are more prone to skin injury. Prevention for pressure ulcers includes proper skin moisturization, and optimal hydration and adequate nutrition. Avoidance of shearing or pressure damage includes repositioning immobile patients at least every two hours.</li> <li>Sleep deprivation leads to autonomic and biochemical processes that can prevent healing. Hospitalization can exacerbate sleep difficulty. Avoiding night-time awakenings for blood draws, avoiding the scheduling of activating medications or diuretics at nighttime and creating a routine schedule to contrast the day and night can provide more restful sleep.</li> <li>Constipation is experienced by more than 40 percent of older adults. It can contribute to pain, decreased appetite and complications like fecal impaction and bowel obstructions. The care team should avoid or correct for medications that can lead to constipation. As an example, all post-op patients on opioids should have a bowel regimen in place.</li> </ul> <p><strong>Transition of Care</strong></p> <p>Care transitions occur any time a patient moves from one level or location of care to another. This can include admission from the emergency department or intensive care unit to a medical floor, discharge to a skilled nursing facility and discharge from the hospital or other facility to home. With each transition, a patient may gain a new set of providers and with the possibility of disrupted continuity. The key to a safe transition is quality communication. Several essential components of safe transitions must be identified and followed. Information should be transferred to the new providers in a timely and accurate way, and patients and families should be educated as partners on the health care team about the illness and the expectations at the next level of care. </p> <p>The ideal discharge involves active advanced planning starting on the first day of hospitalization. The plan to be shared at discharge includes a current problem list, an accurate list of medications and scheduled follow-up appointments, completed advance directives, baseline physical and cognitive function notes, and family and health care professionals’ contact information. [<em>Editor’s note:</em> an earlier Eldercare Voices column describes one promising model that involves <a href=social-worker led interdisciplinary teams in transitional care.]

Conclusion

Hospitalizations can be potentially hazardous for the older adult. With appropriate planning, hospital care can be targeted to limit adverse events from medications, iatrogenic complications and maintain both functional status and independence.

Jeffrey D. Schlaudecker, MD, is a geriatrician-hospitalist and the Kautz Family Foundation Endowed Chair of Geriatric Medical Education at the University of Cincinnati. Rachel Hart,MD, is a geriatric medicine clinical fellow at The Christ Hospital/University of Cincinnati program.