Older adults have a much greater chance of being admitted to the hospital than any other age group in the United States. People aged 65 years and older make up 13% of the U.S. population but account for 36% of hospital admissions for acute care and nearly half of hospital spending for adult care. This trend is expected to increase rapidly as the population continues to age and the needs of the older adult become more complex. There are currently 35 million people over the age of 65. By 2030 (when the Baby Boomers retire), that number is projected to reach 70 million.
What does all this mean?
Our health-care system needs to improve the way we care for these people – especially when they are hospitalized. Right now, the system is capable of destroying the most independent older patients, ultimately forcing them into rapid decline and subsequent rehabilitation placement.
How does this happen?
For many older people, hospitalization results in functional decline despite cure or repair of the condition for which they were admitted. Hospitalization can result in complications unrelated to the problem that caused admission or to its specific treatment for reasons that are explainable and avoidable.
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Usual aging is often associated with functional change, such as a decline in muscle strength and oxygen capacity; gait instability; reduced bone density; diminished appetite and thirst; and a tendency toward urinary incontinence. Hospitalization and bed rest superimpose such factors as enforced immobilization, reduction of blood volume, accelerated bone loss, and sensory deprivation (hearing and visual); any of these factors may thrust vulnerable patients into a state of irreversible functional decline, further contributing to a cascade toward dependency.
These hospital-induced complications are identifiable and can be avoided through modification of the usual acute hospital environment by de-emphasizing bed rest, moderating medications, monitoring fluid intake, and actively facilitating socialization. The relationships among physicians, nurses, and other health professionals must reflect the importance of interdisciplinary care and the implementation of shared objectives.
Improving care in the hospital setting
All health-care providers must realize that the needs of the older population are uniquely different than that of their younger counterparts. Older adults are more sensitive to immobility, environmental changes, medications, and procedures. It is important to recognize these sensitivities and address them individually.
Bed rest/immobility: Prolonged bed rest causes deleterious effects on all systems in the body including cardiovascular; respiratory; digestion; urination; skin; and circulatory, muscular and mental status. Prolonged bed rest also causes medication complications and toxicity attributable to decreased clearance.
Psychological considerations: Hospitalized elderly patients are at increased risk of developing acute changes in mentation. Delirium, a sudden, fluctuating change in mental function, is one often under diagnosed condition. While there can be multiple causes of delirium, side effects from medications, environmental changes, sensorial deprivation and isolation, dehydration, electrolyte imbalance, and constipation are among the most common. Hospitalized elderly with delirium have a tenfold increase in risk of death if left untreated, have longer lengths of stay, and often need referral to rehabilitation centers. Delirium is reversible if recognized early and the causative agent is removed. Such telltale statements from families as, “They were fine until they came in here,” should alert you to an acute change that may signal delirium.
Medication: Polypharmacy is a major problem among the elderly. Anything more than three drugs is considered polypharmacy and warrants review. A good rule of thumb is to check medications monthly, and try to eliminate at least one from the list. Too often I see a 98-year-old on aspirin. Question consistently how much good the medications are doing for the patients and what the risks and benefits are of continuing or discontinuing.
Diet: Dietary changes come with every hospitalization, and more often than not, the food is tasteless. Normal aging produces a decrease in taste sensation, which increases the chances of protein-calorie malnutrition. Restrictions on dietary salt and sugar restrictions should be closely scrutinized as to whether they are necessary. An 88-year-old on a salt-restricted diet is more prone to atrophy, muscle wasting, and protein loss from not eating than they are from an exacerbation of CHF from a small amount of salt.
Common sense needs to prevail when it comes to ordering a diet for these elderly infirmed patients. All elderly patients entering the hospital should have serum albumin and pre albumin drawn to assess overall nutritional status.
Toileting: Foley catheters should be outlawed. If a patient is not admitted with a Foley, they should not have one when hospitalized. Foleys cause incontinence by damaging the detrusor muscle and eliminating normal bladder contractions that occur when voiding. If a patient is ambulatory, nursing staff should get them up and have them ambulate to the bathroom.
The other obvious issue with Foleys is the risk of infection. These infections cause increased length of stay, poorer outcomes, and can lead to full-blown sepsis in an already compromised host. Unless there are confirmed retention issues or precise intake and outputs need to be monitored to the ml, these devices should not be used. They are merely a convenience for staff.
