Although older adults comprise just 12% of the total population in the United States, they represent a large proportion of all inpatients in hospitals. Given that the number of Americans older than 65 is expected to almost double by 2030, meeting the needs of this unique population during hospital stays is essential.¹
As adults age, their physiology changes in ways that can dramatically affect how they react to treatment in a hospital setting. These changes include a loss of muscle mass, decreased aerobic and ventilation capacity, decreased bladder function, possible cognitive decline, sensorial loss, and loss of bone density.² These "normal" aging processes often coexist with comorbidities and diseases that are far more commonplace among the older adult population, such as heart failure, diabetes, pressure ulcers, dementia and dehydration.
With current reimbursement demanding "sicker and quicker" discharges, it is easy to comprehend why older adults have such poor outcomes after hospitalization: functional decline, high readmission rates, high rates of skilled nursing home placement and a high 1-year mortality rate.³ During a hospital stay, older adults are more likely to experience complications such as sepsis, delirium, fractures, skin breakdown and loss of function.¹
Identifying and Adapting Care
Many models and processes can be incorporated into a care plan that is specific for the older patient. The first goal is to identify risk factors by performing a thorough geriatric assessment screening upon admission. An effective assessment should identify a broad range of elements, such as fall risk, nutrition status, polypharmacy, hearing and vision impairment, cognitive status and functional ability.
A study of existing assessment tools by Hoogerduijn et al4 found that the Katz index of independence in activities of daily living (Katz Index), the mini mental state examination, the complexity prediction instrument, the identification of seniors at risk, and the hospital admission risk profile are valid tools for this purpose. The research showed that these tools help identify significant predictors of decline, such as impaired cognitive status, depression and prolonged length of hospital stay.4
Simple adaptations can have a significant impact on older patients. For example, incorporating adequate oral care into daily routines can make eating easier and reduce infections. Patients should be provided with their dentures, hearing aids and glasses as needed. Fluid should be provided on a regular basis in a cup that is an appropriate size and weight for the patient.5
With careful monitoring of intake and output, the need for intravenous hydration is reduced and the patient is not hampered by lines and catheters. The environment should be uncluttered so that the patient can be assisted out of the bed as much as possible, if medically able. Large clocks and labeling of items like the remote control and telephone can help keep the patient oriented.5 Insomnia is often an issue, especially in a disruptive hospital setting, and it can have severe consequences in older adults. Interventions should address the fact that disturbed sleep often occurs due to noise, pain and a need to go to the bathroom. Providing regular rounding, adapting a flexible approach to medication administration, providing bedtime snacks, back rubs, warm drinks and stimulus control are all effective methods to reduce sleep difficulty.6
Inappropriate medication usage accounts for up to 30% of hospital admissions of geriatric patients.7 Older adults are more likely to experience significant morbidity and mortality related to pharmacokinetic changes in how they absorb, utilize and eliminate drugs. The Beers' criteria allow clinicians to cross-reference medications for interactions and identifies medications that are inappropriate for older adults. Considering that inappropriate prescribing occurs in 40% of community and nursing home residents, performing a thorough medication history should be a fundamental component of the admission assessment.7
Delirium and Dementia
One of the major problems that can occur with aging is delirium. It is often underrecognized by clinicians, and early warning signs can go undetected in as many as 67% of cases.2 Delirium is a cluster of multifactorial, transient symptoms that manifest as acute impairment in cognition and psychomotor behavior.8 It usually occurs as a result of a disease process outside the central nervous system, such as a urinary tract infection or pneumonia. It is preventable and reversible, but it is associated with increased mortality and suffering for the patient and increased hospital costs.8
The two most identifiable risk factors for delirium are advanced age and existing dementia. Other risk factors include dehydration, sleep deprivation, four or more medications, physical restraints, poorly managed pain, immobility and depression. A thorough geriatric admission assessment is essential for determining risk, prevention and intervention. Providing an appropriate environment will help prevent delirium.2,8 Examples may include reviewing medications, incorporating the assistance of family members, strict monitoring of vital signs and intake/output levels, avoiding overuse of catheters, and utilizing haloperidol for promotion of quality sleep in cases of hallucinations and severe agitation.2,9
Approximately 48% of all hospitalized patients older than 80 have a diagnosis of dementia. These patients can become disorientated and distressed in a hospital setting.9 Staff should be educated about simple steps to make the process as least disturbing as possible and to be aware of the unique needs of this population (e.g., anorexia and swallowing difficulties).9 Having a friend or family member stay with the patient is beneficial, as is assigning the same staff members to care for the patient as much as possible. Distractions and clutter should be eliminated; communication techniques such as good eye contact, simple sentences and face-to-face contact work best. Rest periods should be scheduled and visitors limited at this time. Predictable routine and familiar objects can also lower patient anxiety levels.1
Existing Working Models
Several models of care for hospital settings address the unique care needs of the geriatric patient. Acute Care for Elders (ACE) units offer individualized care for older patients in specially designed hospital units. The program serves 100,000 patients annually, with promising results. Recent research found that hospital stays for patients in these units was shorter, cheaper and had better functional status outcomes at discharge.1 An interdisciplinary team versed in geriatric needs provides care on units that are designed with safety, accessibility, stimulus control and ease of mobility in mind. The goals include having the patients out of bed for meals, ambulating twice daily, zero hospital-acquired pressure ulcers and zero restraint use. The Katz index was used at admission and discharge and overall, outcomes were measurably better when compared to similar patients on other hospital units.1,3
Nurses Improving Care for Healthsystem Elders (NICHE) is an international program designed to help hospitals improve the care of older adults. It is based at the New York University College of Nursing and its principal goals are to help nurses identify, interpret and apply evidence-based practice to optimize both care outcomes and the patient/family experience. NICHE has a strong emphasis on interdisciplinary collaboration, geriatric-specific resources and creation of an elder-friendly hospital environment. Close to 400 hospitals and healthcare facilities in North America currently participate in a NICHE program. For less than $5,000 per year, hospitals can have complete access to the programs' proven model of care, webinars, tools and resources.10
The Hospital Elder Life Program (HELP) is similar in function, with a focus on preventing delirium. Using trained staff and volunteers, older adults are monitored for risk factors related to delirium, such as dehydration, sleep deprivation and sensory overload. By addressing these issues and others, such as providing adequate visual aids, hearing devices and therapeutic activities, delirium incidence has been greatly reduced.1,5,6
Innovation for the Future
The Hospital at Home model is designed to be carried out in the home as a substitute for acute hospital admissions. It is based on the belief that caring for older adults who meet qualifying parameters in their own homes will provide effective treatment that is more satisfying for the patient and family, less costly and has better outcomes. In this physician-led program, patients older than 65 receive hospital-level of care in their homes. Admission criteria are that patients must have one of the targeted diagnoses: community-acquired pneumonia, cellulitis, or an exacerbation of chronic obstructive pulmonary disease or heart failure.11
Physicians make daily visits and an on-call physician is available round the clock. A Medicare-certified home care agency provides nursing and ancillary care, with pharmacy support, therapy staff and durable medical equipment also available. Many diagnostic studies are also performed in the home. The patient is followed until discharge, at which time care reverts back to the primary care provider.11
Research indicates that this program is effective and provides patients and caregivers with satisfactory outcomes.10 In a study of three experimental Hospital at Home programs, patient satisfaction was high and costs averaged 32% less than inpatient stays.12 The program has also been employed successfully in a number of other countries, including New Zealand, Europe, Israel and Australia.11
Close Attention Needed
The healthcare industry must pay close attention to meeting the needs of the geriatric population. This group is the largest consumer of healthcare spending, and this will continue in the future. From 2009 to 2010, an estimated 10 million Medicare recipients were admitted to hospitals and Medicare paid acute care hospitals approximately $116 billion for fee-for-service inpatient care. This cost is growing an average of 2.1% a year.13 Adapting care to optimize cost efficiencies without jeopardizing outcomes is paramount. The models and methods described meet both economic and quality criteria.
Improving care for older adults does not have to involve complicated interventions or expensive equipment. The simple act of providing dementia patients with an activity kit containing items that distract from harmful actions or reduce agitation can make a big difference.5,8 Having a familiar face around can help keep older adults calm, receptive and on track with medical progress; the support of family members, friends and volunteers is integral to any good program.1,3,5,8
Recognizing risk factors upon admission and identifying areas for improvement through utilization of unit- and hospital-specific standards of care will lead to reduced decline during hospitalization.5 Older adults often do not have the ability to express their concerns and wishes, so it is essential that healthcare systems identify and meet their unique needs through use of interdisciplinary teams and targeted care. Many of the units described are inexpensive to start,3 but can result in vastly improved positive outcomes for the elderly patient, which should be a goal at the national level.
1. Kleinpell RM, et al. Reducing functional decline in hospitalized elderly. http://www.ahrq.gov/qual/nurseshdbk/docs/KleinpellR_RFDHE.pdf
2. Caring for the hospitalized elderly. Current best practice and new horizons. http://www.hospitalmedicine.org/AM/Template.cfm?Section=The_Hospitalist&Template=/CM/ContentDisplay.cfm&ContentFileID=1447
3. Greene A. Acute and post-acute care of the elderly: models for improving care. PowerPoint presentation by Adrienne Green, MD, University of California.
4. Hoogerduijn J, et al. Identification of older hospitalized patients at risk for functional decline, a study to compare the predictive values of three screening instruments. J Clin Nurs. 2010;19(9-10):1219-1225.
5. Balas MC, Casey CM. Comprehensive assessment and management of the critically ill. http://consultgerirn.org/topics/critical_care/want_to_know_more
6. Gilsenan I. Nursing Interventions to alleviate insomnia. Nurs Older People. 2012;24(4):14-18.
7. Barry PJ, et al. Inappropriate prescribing in the elderly: a comparison of the Beers criteria and the improved prescribing in the elderly tool (IPET) in acutely ill elderly hospitalized patients. J Clin Pharm Ther. 2006;31(6):617-626.
8. Conley DM. The Gerontological Clinical Nurse Specialist's role in prevention, early recognition, and management of delirium in hospitalized older adults. Urol Nurs. 2011;31(6):337-342.
9. Heath H. Improving quality of care for people with dementia in general hospitals. http://rcnpublishing.com/userimages/ContentEditor/1373367875414/Improving-dementia-care-quality.pdf
10. The NICHE program. http://www.nicheprogram.org/program_overview
11. Leff B, et al. Satisfaction with hospital at home care. J Am Geriatr Soc. 2006;54(9):1355-1363.
12. Graham J. Some patients can choose to be hospitalized at home.
13. Report to the Congress: Medicare Payment Policy. Hospital inpatient and outpatient services. http://www.medpac.gov/chapters/Mar12_Ch03.pdf
Sharon Bishop is a student in the adult-gero primary care nurse practitioner program at the University of Cincinnati. She has completed a disclosure statement and reports no relationships related to this article.