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PERSPECTIVE
Hazards of Hospitalization of the Elderly
1 February 1993 | Volume 118 Issue 3 | Pages
219-223
For many older persons, 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.
Usual aging is often associated with functional change, such as a
decline in muscle strength and aerobic capacity; vasomotor
instability; reduced bone density; diminished pulmonary ventilation;
altered sensory continence, appetite, and thirst; and a tendency
toward urinary incontinence.Hospitalization and bed rest superimpose
factors such as enforced immobilization, reduction of plasma
volume, accelerated bone loss, increased closing volume, and
sensory deprivation. Any of these factors may thrust vulnerable
older persons into a state of irreversible functional decline.
The factors that contribute to a cascade to dependency are identifiable
and can be avoided by modification of the usual acute hospital
environment by de-emphasizing bed rest, removing the hazard of
the high hospital bed with rails, and actively facilitating
ambulation and socialization. The relationships among physicians,
nurses, and other health professionals must reflect the importance
of interdisciplinary care and the implementation of shared
objectives.
Hospitalization is a
major risk for older persons, particularly for the very old. For
many, hospitalization is followed by an often irreversible decline in
functional status and a change in quality and style of life [1]. A recent
study showed that of 60 functionally independent individuals 75 years
or older admitted to the hospital from their home for acute
illness, 75% were no longer independent on discharge, including 15%
who were discharged to nursing homes [2].
In many cases the decline cannot be attributed to the progression
of the acute problem for which they are hospitalized. Even when
the disease, such as pneumonia, is cured in a few days, or the
hip fracture repair is technically perfect and uncomplicated,
the patient may never return to the premorbid functional status.
Between 30% and 60% of patients with hip fractures are discharged
from the hospital to nursing homes; 20% to 30% of those persons
still reside in nursing homes 1 year later [3,4,5,6].
Only 20% of one large group of patients returned to their
preoperative functional level after repair of a hip fracture [7].
Some of the decline can be attributed to particular complications
of the disease itself or to its management. Adverse drug reactions
are an example of the latter. However, many elderly persons are
susceptible to other complications not directly related to the
illness or injury for which they were hospitalized or the specific
treatment of the problem.
Usual aging is associated with changes that increase susceptibility
to various stresses. Some of these changes represent loss of
reserve function and do not produce disability under ordinary
circumstances. However, the elderly are vulnerable and stand at
the threshold of functional disability, at risk of being projected
over that threshold when stressed.
| Interaction of Aging and Hospitalization
|
|---|
A
number of explainable factors associated with hospitalization and bed
rest, individually and collectively, thrust the elderly into
disability. They are described in detail by Harper and Lyles [8], Hoenig
and Rubenstein [1], and
Mobily and Kelly [9].
These factors initiate a cascade of events Figure 1 that
frequently culminate in diminished quality of life. I outline some of
the functional capacities that change with usual aging and that
are further modified by hospitalization, along with the functional
consequences of the interaction Table 1.
|
|
Muscle Strength and Aerobic Capacity
Muscle mass and muscle strength are reduced with aging, which may
reflect the progressive loss of reserve capacity associated with
reduction of physical activity with age. Aerobic capacity is also
progressively lost (maximum oxygen uptake, Vo2 max), and
research indicates that the loss is not cardiac in origin but the
result of reduced peripheral use of oxygen related to the diminished
muscle mass and strength as well as the capacity to respond to
exercise [10].
Muscle contractions of certain minimal force and frequency are
necessary to maintain strength. In the absence of any voluntary
contraction, muscle strength decreases by 5% per day. Young men
at bed rest lose muscle strength at the rate of 1.0% to 1.5% per day
(10% per week) [11].
Inactivity rapidly contributes to muscle shortening and changes in
periarticular and cartilaginous joint structure, which contribute to
a tendency toward limitation of motion and contracture. The most
rapid changes take place in the lower extremities [12]. Bed
rest markedly diminishes aerobic capacity with substantial reductions
in Vo2 max values.
For older persons who have diminished physiologic reserves but
still can attend to their ambulation, toileting, bathing, and
other daily functions, the accelerated loss of muscle strength
and aerobic capacity after a few days of bed rest may result in
future dependency in carrying out those activities. Even if
reversible, long periods of rehabilitation will be required because
reconditioning time is longer than deconditioning time [13].
Loss of muscle strength is also a major cause of falls in the
elderly and may contribute to the many falls that occur in the
hospital, particularly as the patients try to climb over the
rails of the usual high hospital bed.
Vasomotor Stability
With increasing age, one of the most clinically important manifestations
of alteration in autonomic function is baroreceptor insensitivity.
The resultant tendency toward syncope is increased by the
age-associated reduction in body water and plasma volume and may be
further increased by disease-associated dehydration.
Bed rest in the supine position results in loss of plasma volume
averaging about 600 mL [14]. This
loss contributes to the propensity for postural hypotension and
syncope already associated with usual aging.
Syncope under any circumstance can result in injury. The possibility
of injury is increased if syncope occurs while getting out of a
high hospital bed in a strange environment. Additional risk factors,
described next, compound the consequences.
Respiratory Function
The mechanics of respiration are altered with aging. Costochondral
calcification and reduction in muscle strength diminishes ribcage
expansion. The residual capacity increases and occupies a greater
proportion of total lung capacity [15]. The
closing volume increases and greater numbers of dependent alveoli
fail to ventilate as a result of airway closure [16]. The
combination of effects on pulmonary ventilation reduces arterial
oxygen tension (Po 2) so that a value of 70 to 75 mm Hg is
not uncommon in a 75-year-old person. This reduction in arterial
oxygen pressure produces little functional disability in a healthy
elderly person.
The supine position reduces ventilation even more by increasing
the closing volume [17] enough
to cause an additional fall in Po 2 of 8 mm Hg in a
healthy elderly person. The further reduction in Po 2 may
be sufficient to produce symptoms such as confusion in an elderly
person at the threshold of pulmonary insufficiency. It may also
contribute to the occurrence of syncope in persons already sensitized
by vasomotor instability.
Demineralization
Involutional loss of bone mineral begins in early adulthood, is
accelerated with the menopause, and varies in occurrence. Many
elderly persons, particularly thin, white women, are osteoporotic and
are at risk for fractures.
It has been shown that vertebral bone loss accelerates to 50 times
the involutional rate in healthy men on bed rest [18].
The loss incurred with 10 days bed rest required 4 months to
restore. Some of the loss is due to lack of weight bearing, but
the general negative nitrogen balance associated with immobilization
probably contributes to the problem.
The frequent falls that occur in hospitalized elderly, caused by
factors already described, have increased the likelihood of
fractures, particularly hip fractures.
Urinary Incontinence
With aging comes an increased tendency for urinary incontinence.
Bladder capacity is reduced. In older men, prostatic hypertrophy
is almost universal. Many women suffer relaxation of the pelvic
floor and also vaginal atrophy. Uninhibited contractions of the
detrusor muscle increase. However, only 5% to 15% of community-dwelling
elderly persons are actually incontinent [19]. Others
at risk are spared embarrassment by consciously and unconsciously
developing strategies for toileting at appropriate times.
Many hospitalized patients have difficulty implementing their
habitual strategies to avoid incontinence. The environment is
unfamiliar, and the path to the toilet may not be clear. The
high bed may be intimidating; the bed rail, an absolute barrier;
and the various “tethers,” such as intravenous lines, nasal
oxygen lines, and catheters, become restraining harnesses.
Psychotropic agents may reduce the perception of the need to
void.
About 40% to 50% of hospitalized persons over age 65 are incontinent
[19], many
within a day of hospitalization. The functional incontinence that
occurs in the hospital explains the discrepancy between incontinence
rates in community-dwelling and newly hospitalized patients.
Skin Integrity
With aging come changes in the skin: thinning of the epidermis and
dermis, reduction in vascularity, decrease in epidermal turnover, and
loss of subcutaneous fat. Direct pressure on the skin greater than
the capillary perfusion pressure of 32 mm Hg for as little as 2 hours
results in skin necrosis in anyone. After short periods of
immobilization, sacral pressures reach 70 mm Hg, and the pressure
under the unsupported heel averages 45 mm Hg. Unusual shearing forces
result from movement in a jacked-up bed or wheelchair.
Pressure sores occur frequently in hospitalized elderly patients
usually developing within hours of immobilization. The rate may
be accelerated in the case of the incontinent patient in a wet bed or
chair.
Sensory “Continence”
An increased propensity to confusion with minimal provocation
comes with aging. It can be partially explained by age-associated
reduction in sensory input. Frequency of visual loss is increased
as a result of presbyopia, cataract, and other eye problems.
Hearing loss is variable but common. However, there are undoubtedly
other factors related to the jumble of neurotransmitter,
neurophysiologic, and neuroanatomic changes that are described in the
literature and await explanation.
Sensory deprivation or overstimulation results in confusion and
delirium in normal people at any age if of sufficient intensity and
duration. Twenty-nine percent of young persons placed in a simulated
hospital room developed subjective sensory distortions after 2.5
hours [20].
The reduction of sensory input of all types that occurs with
immobilization can produce intellectual and perceptual disorders
[21]. It is
not surprising that an elderly person, admitted to a hospital bed in
a quiet room with subdued lighting, whose eyeglasses and hearing aid
were left at home, suffers delirium. If the sensory deprivation alone
were not enough, add the possibility that he or she awakens in a
strange bed after a period of anesthesia or coma.
Nutritional Status
Dietary habit is deeply ingrained. Age-associated loss of taste
and smell makes change in dietary habit even less desirable.
The sensation of thirst also diminishes with advancing age.
Problems with dentition are more common in the elderly as is
the dependence on dentures if nutrition is to be maintained.
Under the best of circumstances, hospital food is unfamiliar.
Therapeutic diets, such as those low in salt, are apt to make
food less appealing. Eating in bed is difficult with trays,
utensils, and water not easily accessible, particularly if bed
rails and restraints limit reach. A delay usually occurs between
the time when the tray of food is delivered to the room and
when someone arrives to help the patient–an interval long enough
to allow the food to cool and become even less appealing.
Malnutrition and dehydration can occur rapidly in hospitalized
patients of any age. Anorexia is a feature of many illnesses
for which patients are hospitalized. The addition of the factors
noted already put the elderly patient at particular risk. In
the 85-year-old patient whose thirst perception is decreased,
thirst may have to be compelling before he or she exerts the
effort to grasp a glass of water that is out of reach. If, as
is so often the case, dentures have been left at home or misplaced,
all the other problems become secondary.
| The Cascade of Interactions
|
|---|
As
illustrated in Figure 1, the
consequences of individual interactions between the effects of usual
aging and hospitalization are, in turn, likely to interact with each
other, producing additional tiers of disability in the cascade toward
dysfunction and the final common pathway to dependency.
Many factors contribute to the falls and fractures that are all
too common in hospitalized older persons. There is adequate
explanation for the frequent occurrence of delirium and its
consequences. The actual and perceived disability created by
fractures, delirium, pressure sores, and functional incontinence
all contribute to the frequency with which hospitalized older
patients are discharged to nursing homes.
Additionally, Medicare-imposed restraints on the length of
hospitalization grease the skids down the cascade toward the final
common pathway to the nursing home.
The End Result
|
|---|
A
high percentage of hospitalized elderly persons discharged to nursing
homes never return to their homes or community. In one study, 55% of
persons over age 65 who entered nursing homes remained for more than
a year [22]. Many of
the others were discharged to other hospitals or long-term-care
facilities or died. In another study, only 12% were eventually
discharged to home [23]. Even if
the intent is for a temporary stay until rehabilitation occurs or
arrangements can be made for home care, circumstances frequently
dictate otherwise. The family or other informal caretaker may
discover the advantage of respite during the separation. Available
helpmates may disappear from the scene. The apartment rental may have
lapsed. The spend-down for nursing home care may have left
insufficient funds to get started again. Perhaps the most important
fact is that many nursing homes do not have the resources to
rehabilitate their charges back to their prehospitalization levels of
function.
The ultimate outcome for many hospitalized elders is loss of home
and, ultimately, loss of place.
Recommendations
|
|---|
 Top Recommendations Author & Article InfoReferences |
|---|
The
negative effects of hospitalization begin immediately and they
progress rapidly. Hirsch and colleagues [24] have
shown that functional decline from baseline occurs by the second
day of hospitalization and improves little by discharge. The
techniques of formal geriatric assessment applied to each
hospitalized elderly patient should theoretically identify risk
factors that would predict the propulsion into the cascade to
dependency produced by hospitalization. Unfortunately, the typical
time frame for conduct of assessment is not consistent with the
speed with which deterioration can occur. By the time the
assessment team meets on Tuesday to discuss the patient who was
admitted to the hospital last Wednesday, the damage has already
been done. By the time the need for consultation is recognized,
the problems have evolved. Until assessment recommendations are
put into practice, additional time has passed. The risk should
be predicted before the assessment or consultation.
Although the formal assessment process provides a useful data base
for determining long-range patient management and for evaluating the
effects of intervention, the time it takes might actually delay the
initiation of care that is predictably beneficial and is unlikely to
be harmful in any case. If this premise is accepted, then the
hospital environment into which elderly persons are admitted should
be modified on the assumption that for many, hospitalization will
propel them over the “threshold of frailty.” It is essential that the
paradigm of acute hospitalization be adapted to the needs of the
hospital’s most frequent customer Table 2.
|
I know of no evidence that shows the therapeutic value of bed
rest. The “ambient” condition should be for the patient to be
out of bed except for a particular reason. High beds are for
the convenience of the staff, not the patient. Patients do not
fall out of bed in the hospital any more than they fall out of
bed at home. They are injured as they climb in and out of high beds.
Modified, less hazardous hospital beds are on the market and should
replace those in common use. Carpeting, which can provide safe
footing and which is easily maintained, is now available.
Not every patient needs an intravenous line, although it may
justify the hospitalization. The needs of many hospital patients
could be met with appropriate fluids placed where they can be
reached and offered on a timely basis. The availability of needed
dentures may obviate the need for enteral or parenteral nutrition.
Proper lighting, clocks, calendars, communal eating, daily dressing
and undressing in personal clothing, and other efforts to provide
reality orientation will provide therapeutic benefits no less
important than those prescribed for the condition causing the
hospitalization. Involvement by social services from the time
of admission rather than at the time of discharge will often
obviate the need for nursing home placement.
Most importantly, relationships among physicians, nurses, and
other health professionals need to reflect the interdisciplinary
care required by the elderly, even on acute care units. Mutual
objectives require expression beyond the simple writing of an
order by a physician and its execution by a nurse. Just as an
attending physician is responsible 24 hours a day for a particular
patient, so must there be a nurse with an equivalent relationship
to the patient. Doctor and nurse must work in partnership. They
must make rounds together on a daily basis and convey the shared
objectives to all members of the care team on all shifts. It is
essential that all personnel assigned to units on which elderly
patients reside understand the unique requirements for their
care and share in implementing the details of that care. Everyone
who has contact with the patient throughout the day, including
doctors, nurses, and family members, should offer encouragement
and assistance with ambulation, not just the physiotherapist
during the 15-minute formal session once or twice a day. “High
tech” medicine requires particular attention to “high touch”
care if its recipients are to enjoy its rewards.
A few studies [25,26,27,28,29]
of the effectiveness of specially designed units on the outcomes of
acute hospitalization of the elderly have been reported but not in
journals read by the clinicians who usually care for most of the
older patients. If the preliminary results are confirmed, then such
units should serve as models for rapid change in the pattern of care
offered by acute care hospitals.
Grant Support: In part by a National Institute on Aging Geriatric
Leadership Academic Award 5K07 AG-00413-03.
| Author and Article Information
|
|---|
| TopRecommendationsAuthor & Article Info References |
|---|
From the University of
Kansas Medical Center, Kansas City, Kansas.
Requests for Reprints: Morton C.
Creditor, MD, The Center on Aging, University of Kansas Medical Center, 3901
Rainbow Boulevard, Kansas City, KS 66160.
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| TopRecommendationsAuthor & Article InfoReferences |
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