Michael Bogaisky, MD
Assistant Professor, Department of Medicine (Geriatrics)
As doctors, we expect to see our patients in the hospital get better. As their acute illness resolves, we assume that their physical function should also improve. This is what we usually see among our younger, more robust patients. However, for a significant proportion of patients, particularly those who are older or frailer, we often find that the trajectories of their acute illness and physical function diverge.
Too often when we treat older patients, we see that while their physiologic markers such as vital signs and blood counts recover between admission and discharge, their level of physical function fails to improve, or worsens. Studies have shown that one-third of older adults leave the hospital with less ability to perform basic activities of daily living such as walking, bathing, dressing, using the toilet, and feeding themselves—than they had before they were hospitalized.
The Hospital’s Role
A stay in the hospital can contribute in a number of ways to a decline in a patient's level of function.
- Immobility is the norm during hospitalization. Multiple factors contribute to immobility: the acute illness itself; tethers like Foley catheters, nasal cannulas (oxygen tubes), and IV drips; restrictive activity orders; lack of assistive mobility devices; lack of assistance by hospital personnel; and the traditional hospital design which encourages bed rest.
- Continued bed rest results in loss of muscle mass, which can significantly decrease muscle strength and aerobic capacity. Plasma volume decreases which increases risk of orthostatic hypotension (a drop in blood pressure) when assuming an upright posture. Orthostatic hypotension can lead to dizziness upon rising, which limits walking and increases risk of falling.
- Malnutrition is common. Approximately 40% of patients aged 70+ have evidence of moderate to severe levels of malnourishment at the beginning of their hospital admission. While in the hospital, older patients have been found to consume on average only 60-80% of their daily caloric requirements. This accelerates loss of muscle mass and impairs their ability to recover from their illness.
- Sleep deprivation is common. Routinized night-time interruptions, high ambient noise levels, and the loss of normal circadian activity patterns contribute to sleep loss. The featureless environment of the typical hospital room, lack of cues to the normal passage of time, and inadequate lighting levels lead to sensory deprivation. Along with sleep deprivation, sensory deprivation can contribute to the development of acute confused states such as delirium, which can have grave consequences including agitation and falls.
Elder Care Innovations
Some hospitals now have Acute Care for the Elderly (ACE) units that employ specially designed environments and interdisciplinary care teams to promote safe mobility, cognitive stimulation, improved nutrition, and preservation of function. Patients hospitalized on ACE units have shown to experience lower rates of functional decline, fewer falls, less delirium, and a higher likelihood of being discharged to home (rather than to a nursing home). ACE units also lower patient care costs and shorten lengths of stay in the hospital.
Another successful model of care is the Hospital Elder Life Program (HELP), originally tested in the Yale Delirium Prevention Trial by physicians and nurses at the Yale School of Medicine and subsequently disseminated to nearly a hundred hospitals throughout the United States and abroad. HELP uses nurses, physical therapists, and volunteers to deliver a multi-component intervention that includes:
- reorientation protocols and cognitively stimulating activities such as word games and group discussions of current events to prevent confusion
- vision and hearing aids to prevent confusion
- early mobilization protocols including walking or active range of motion exercises three times daily combined with eliminating use of immobilizing equipment such as bladder catheters and restraints.
- non-drug-based sleep enhancement including minimizing scheduled night-time awakenings by staff and noise reduction strategies to combat sleep deprivation
- nutritional protocols to prevent dehydration and malnutrition
The HELP program reduces loss of function, falls, and delirium in older adults.
The Health Provider’s Role
Even in hospitals with no specialized elder-care units or programs, healthcare personnel can have a dramatic effect on older patients’ ability to improve by focusing interventions on correctable risk factors:
- Ask patients or family members about their baseline level of function prior to their illness. Directly assess patients’ function on admission and periodically during the hospital stay.
- Test patients’ ability to turn in bed, sit, stand, and walk; evaluate their ability to feed themselves.
- Promote mobility through physical therapy; assistive devices at the bedside; removal of nasal oxygen tubes, IVs, and Foley catheters; give each patient an individualized “exercise prescription” and enlist nursing staff and family members to see that the prescription is followed.
- Support nutrition through liberalized diets and protein-calorie supplements, encourage family members to bring food from home, minimize harmful medications, avoid unnecessary no-food-or-drink orders, and provide feeding assistance when needed.
- Protect sleep by modifying the ordering of tests and medications during night-time hours (for example, requesting a 6 am rather than a 3 am blood draw, order finger-stick glucose tests before meals and at bedtime instead of every four hours); provide ear plugs; and avoid giving sedative hypnotics which may lead to confusion, falls, and worsened outcomes.
- Carefully monitor patients’ medications for risk of drug interactions and adverse side effects
- Engage nurses, physical therapists, pharmacists, and social workers early in the patients’ hospital stay.
These simple interventions can have a huge impact on the overall success of patients’ hospital stays and outcomes.
Dr. Bogaisky is the recipient of a grant from the U.S. Department of Health and Human Services Health Resources and Service Administration to provide training to interdisciplinary team members at Montefiore on the prevention of adverse events in hospitalized older adults.