{"id":1601,"date":"2013-10-11T09:50:46","date_gmt":"2013-10-11T09:50:46","guid":{"rendered":"http:\/\/jacobimed.org\/NS\/?page_id=1601"},"modified":"2013-10-11T09:50:46","modified_gmt":"2013-10-11T09:50:46","slug":"hazards-of-hospitalization-of-the-elderly","status":"publish","type":"page","link":"https:\/\/jacobimed.org\/old\/ambulatory\/mlove\/curriculumwomengeri-2\/the-geriatric-evaluation\/geriatrics-articles\/hazards-of-hospitalization-of-the-elderly\/","title":{"rendered":"Hazards of Hospitalization of the Elderly"},"content":{"rendered":"

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\n<\/span><\/p>\n

PERSPECTIVE<\/span><\/span><\/h4>\n

Hazards of Hospitalization of the Elderly <\/span><\/h2>\n

<\/a> Morton C.
\nCreditor <\/span><\/a>
\n<\/span><\/p>\n

1 February 1993 | Volume 118 Issue 3 | Pages
\n219-223<\/strong><\/span>
\n<\/span><\/p>\n

For many older persons, hospitalization results in
\nfunctional <\/sup>decline despite cure or repair of the condition for which
\nthey <\/sup>were admitted.Hospitalization can result in complications
\nunrelated <\/sup>to the problem that caused admission or to its specific
\ntreatment <\/sup>for reasons that are explainable and avoidable. <\/sup>
\n<\/span><\/span><\/p>\n

Usual aging is often associated with functional change, such <\/sup>as a
\ndecline in muscle strength and aerobic capacity; vasomotor
\n<\/sup>instability; reduced bone density; diminished pulmonary ventilation;
\n<\/sup>altered sensory continence, appetite, and thirst; and a tendency
\n<\/sup>toward urinary incontinence.Hospitalization and bed rest superimpose
\n<\/sup>factors such as enforced immobilization, reduction of plasma
\n<\/sup>volume, accelerated bone loss, increased closing volume, and
\n<\/sup>sensory deprivation. Any of these factors may thrust vulnerable
\n<\/sup>older persons into a state of irreversible functional decline. <\/sup>
\n<\/span><\/span><\/p>\n

The factors that contribute to a cascade to dependency are identifiable
\n<\/sup>and can be avoided by modification of the usual acute hospital
\n<\/sup>environment by de-emphasizing bed rest, removing the hazard <\/sup>of
\nthe high hospital bed with rails, and actively facilitating
\n<\/sup>ambulation and socialization. The relationships among physicians,
\n<\/sup>nurses, and other health professionals must reflect the importance
\n<\/sup>of interdisciplinary care and the implementation of shared
\nobjectives. <\/sup>
\n<\/span><\/span><\/p>\n


\n<\/span><\/p>\n

\n

\nHospitalization is a
\nmajor risk for older persons, particularly <\/sup>for the very old. For
\nmany, hospitalization is followed by an <\/sup>often irreversible decline in
\nfunctional status and a change <\/sup>in quality and style of life [1]<\/a>. A recent
\nstudy showed that <\/sup>of 60 functionally independent individuals 75 years
\nor older <\/sup>admitted to the hospital from their home for acute
\nillness, <\/sup>75% were no longer independent on discharge, including 15%
\nwho <\/sup>were discharged to nursing homes [2]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/p>\n

In many cases the decline cannot be attributed to the progression
\n<\/sup>of the acute problem for which they are hospitalized. Even when
\n<\/sup>the disease, such as pneumonia, is cured in a few days, or the
\n<\/sup>hip fracture repair is technically perfect and uncomplicated,
\n<\/sup>the patient may never return to the premorbid functional status.
\n<\/sup>Between 30% and 60% of patients with hip fractures are discharged
\n<\/sup>from the hospital to nursing homes; 20% to 30% of those persons
\n<\/sup>still reside in nursing homes 1 year later [3,4,5,6]<\/a>.
\nOnly 20% <\/sup>of one large group of patients returned to their
\npreoperative <\/sup>functional level after repair of a hip fracture [7]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/p>\n

Some of the decline can be attributed to particular complications
\n<\/sup>of the disease itself or to its management. Adverse drug reactions
\n<\/sup>are an example of the latter. However, many elderly persons <\/sup>are
\nsusceptible to other complications not directly related <\/sup>to the
\nillness or injury for which they were hospitalized or <\/sup>the specific
\ntreatment of the problem. <\/sup>
\n<\/span><\/span><\/p>\n

Usual aging is associated with changes that increase susceptibility
\n<\/sup>to various stresses. Some of these changes represent loss of
\n<\/sup>reserve function and do not produce disability under ordinary
\n<\/sup>circumstances. However, the elderly are vulnerable and stand <\/sup>at
\nthe threshold of functional disability, at risk of being <\/sup>projected
\nover that threshold when stressed. <\/sup>
\n<\/span><\/span><\/p>\n

<\/a><\/p>\n\n\n\n
Interaction of Aging
\n and Hospitalization <\/span><\/p>\n\n\n\n
<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

A
\nnumber of explainable factors associated with hospitalization <\/sup>and bed
\nrest, individually and collectively, thrust the elderly <\/sup>into
\ndisability. They are described in detail by Harper and <\/sup>Lyles [8]<\/a>, Hoenig
\nand Rubenstein [1]<\/a>, and
\nMobily and Kelly [9]<\/a>.
\n<\/sup>These factors initiate a cascade of events Figure 1<\/a> that
\nfrequently <\/sup>culminate in diminished quality of life. I outline some of
\nthe <\/sup>functional capacities that change with usual aging and that
\n<\/sup>are further modified by hospitalization, along with the functional
\n<\/sup>consequences of the interaction Table 1<\/a>.
\n<\/sup>
\n<\/span><\/span><\/p>\n

<\/a>
\n<\/span><\/span><\/p>\n\n\n\n
\n\n\n\n
\"<\/a>
View larger version<\/strong>
\n (53K):
[in this
\n window]<\/a>
[in a new window]<\/a>
  <\/span><\/td>\n		Figure 1
\n <\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 
<\/a>
\n<\/span><\/span><\/p>\n\n\n\n
\n\n\n\n
View
\n this table:<\/strong>
[in this
\n window]<\/a>
[in a new window]<\/a>
  <\/span><\/td>\n		Table 1. Interaction
\n of Aging and Hospitalization<\/strong>
\n <\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 
\n<\/span><\/span><\/p>\n

Muscle Strength and Aerobic Capacity<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Muscle mass and muscle strength are reduced with aging, which <\/sup>may
\nreflect the progressive loss of reserve capacity associated <\/sup>with
\nreduction of physical activity with age. Aerobic capacity <\/sup>is also
\nprogressively lost (maximum oxygen uptake, Vo2<\/sub> max), <\/sup>and
\nresearch indicates that the loss is not cardiac in origin <\/sup>but the
\nresult of reduced peripheral use of oxygen related to <\/sup>the diminished
\nmuscle mass and strength as well as the capacity <\/sup>to respond to
\nexercise [10]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/p>\n

Muscle contractions of certain minimal force and frequency are
\n<\/sup>necessary to maintain strength. In the absence of any voluntary
\n<\/sup>contraction, muscle strength decreases by 5% per day. Young <\/sup>men
\nat bed rest lose muscle strength at the rate of 1.0% to <\/sup>1.5% per day
\n(10% per week) [11]<\/a>.
\nInactivity rapidly contributes <\/sup>to muscle shortening and changes in
\nperiarticular and cartilaginous <\/sup>joint structure, which contribute to
\na tendency toward limitation <\/sup>of motion and contracture. The most
\nrapid changes take place <\/sup>in the lower extremities [12]<\/a>. Bed
\nrest markedly diminishes <\/sup>aerobic capacity with substantial reductions
\nin Vo2<\/sub> max values. <\/sup>
\n<\/span><\/span><\/p>\n

For older persons who have diminished physiologic reserves but
\n<\/sup>still can attend to their ambulation, toileting, bathing, and
\n<\/sup>other daily functions, the accelerated loss of muscle strength
\n<\/sup>and aerobic capacity after a few days of bed rest may result <\/sup>in
\nfuture dependency in carrying out those activities. Even <\/sup>if
\nreversible, long periods of rehabilitation will be required <\/sup>because
\nreconditioning time is longer than deconditioning time <\/sup>[13]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/p>\n

Loss of muscle strength is also a major cause of falls in the
\n<\/sup>elderly and may contribute to the many falls that occur in the
\n<\/sup>hospital, particularly as the patients try to climb over the
\n<\/sup>rails of the usual high hospital bed. <\/sup>
\n<\/span><\/span><\/p>\n

Vasomotor Stability<\/span><\/strong>
\n<\/span><\/span><\/p>\n

With increasing age, one of the most clinically important manifestations
\n<\/sup>of alteration in autonomic function is baroreceptor insensitivity.
\n<\/sup>The resultant tendency toward syncope is increased by the
\nage-associated <\/sup>reduction in body water and plasma volume and may be
\nfurther <\/sup>increased by disease-associated dehydration. <\/sup>
\n<\/span><\/span><\/p>\n

Bed rest in the supine position results in loss of plasma volume
\n<\/sup>averaging about 600 mL [14]<\/a>. This
\nloss contributes to the propensity <\/sup>for postural hypotension and
\nsyncope already associated with <\/sup>usual aging. <\/sup>
\n<\/span><\/span><\/p>\n

Syncope under any circumstance can result in injury. The possibility
\n<\/sup>of injury is increased if syncope occurs while getting out of <\/sup>a
\nhigh hospital bed in a strange environment. Additional risk <\/sup>factors,
\ndescribed next, compound the consequences. <\/sup>
\n<\/span><\/span><\/p>\n

Respiratory Function<\/span><\/strong>
\n<\/span><\/span><\/p>\n

The mechanics of respiration are altered with aging. Costochondral
\n<\/sup>calcification and reduction in muscle strength diminishes ribcage
\n<\/sup>expansion. The residual capacity increases and occupies a greater
\n<\/sup>proportion of total lung capacity [15]<\/a>. The
\nclosing volume increases <\/sup>and greater numbers of dependent alveoli
\nfail to ventilate as <\/sup>a result of airway closure [16]<\/a>. The
\ncombination of effects <\/sup>on pulmonary ventilation reduces arterial
\noxygen tension (Po 2<\/sub>) so that a value of 70 to 75 mm Hg is
\nnot <\/sup>uncommon in a 75-year-old person. This reduction in arterial
\n<\/sup>oxygen pressure produces little functional disability in a healthy
\n<\/sup>elderly person. <\/sup>
\n<\/span><\/span><\/p>\n

The supine position reduces ventilation even more by increasing
\n<\/sup>the closing volume [17]<\/a> enough
\nto cause an additional fall in <\/sup>Po 2<\/sub> of 8 mm Hg in a
\nhealthy elderly person. <\/sup>The further reduction in Po 2<\/sub> may
\nbe sufficient <\/sup>to produce symptoms such as confusion in an elderly
\nperson at <\/sup>the threshold of pulmonary insufficiency. It may also
\ncontribute <\/sup>to the occurrence of syncope in persons already sensitized
\nby <\/sup>vasomotor instability. <\/sup>
\n<\/span><\/span><\/p>\n

Demineralization<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Involutional loss of bone mineral begins in early adulthood, <\/sup>is
\naccelerated with the menopause, and varies in occurrence. <\/sup>Many
\nelderly persons, particularly thin, white women, are osteoporotic <\/sup>and
\nare at risk for fractures. <\/sup>
\n<\/span><\/span><\/p>\n

It has been shown that vertebral bone loss accelerates to 50 <\/sup>times
\nthe involutional rate in healthy men on bed rest [18]<\/a>.
\n<\/sup>The loss incurred with 10 days bed rest required 4 months to
\n<\/sup>restore. Some of the loss is due to lack of weight bearing, <\/sup>but
\nthe general negative nitrogen balance associated with immobilization
\n<\/sup>probably contributes to the problem. <\/sup>
\n<\/span><\/span><\/p>\n

The frequent falls that occur in hospitalized elderly, caused <\/sup>by
\nfactors already described, have increased the likelihood <\/sup>of
\nfractures, particularly hip fractures. <\/sup>
\n<\/span><\/span><\/p>\n

Urinary Incontinence<\/span><\/strong>
\n<\/span><\/span><\/p>\n

With aging comes an increased tendency for urinary incontinence.
\n<\/sup>Bladder capacity is reduced. In older men, prostatic hypertrophy
\n<\/sup>is almost universal. Many women suffer relaxation of the pelvic
\n<\/sup>floor and also vaginal atrophy. Uninhibited contractions of <\/sup>the
\ndetrusor muscle increase. However, only 5% to 15% of community-dwelling
\n<\/sup>elderly persons are actually incontinent [19]<\/a>. Others
\nat risk <\/sup>are spared embarrassment by consciously and unconsciously
\ndeveloping <\/sup>strategies for toileting at appropriate times. <\/sup>
\n<\/span><\/span><\/p>\n

Many hospitalized patients have difficulty implementing their
\n<\/sup>habitual strategies to avoid incontinence. The environment is
\n<\/sup>unfamiliar, and the path to the toilet may not be clear. The
\n<\/sup>high bed may be intimidating; the bed rail, an absolute barrier;
\n<\/sup>and the various “tethers,” such as intravenous lines, nasal
\n<\/sup>oxygen lines, and catheters, become restraining harnesses.
\nPsychotropic <\/sup>agents may reduce the perception of the need to
\nvoid. <\/sup>
\n<\/span><\/span><\/p>\n

About 40% to 50% of hospitalized persons over age 65 are incontinent
\n<\/sup>[19]<\/a>, many
\nwithin a day of hospitalization. The functional incontinence <\/sup>that
\noccurs in the hospital explains the discrepancy between <\/sup>incontinence
\nrates in community-dwelling and newly hospitalized <\/sup>patients.
\n<\/sup>
\n<\/span><\/span><\/p>\n

Skin Integrity<\/span><\/strong>
\n<\/span><\/span><\/p>\n

With aging come changes in the skin: thinning of the epidermis <\/sup>and
\ndermis, reduction in vascularity, decrease in epidermal <\/sup>turnover, and
\nloss of subcutaneous fat. Direct pressure on the <\/sup>skin greater than
\nthe capillary perfusion pressure of 32 mm <\/sup>Hg for as little as 2 hours
\nresults in skin necrosis in anyone. <\/sup>After short periods of
\nimmobilization, sacral pressures reach <\/sup>70 mm Hg, and the pressure
\nunder the unsupported heel averages <\/sup>45 mm Hg. Unusual shearing forces
\nresult from movement in a <\/sup>jacked-up bed or wheelchair. <\/sup>
\n<\/span><\/span><\/p>\n

Pressure sores occur frequently in hospitalized elderly patients
\n<\/sup>usually developing within hours of immobilization. The rate <\/sup>may
\nbe accelerated in the case of the incontinent patient in <\/sup>a wet bed or
\nchair. <\/sup>
\n<\/span><\/span><\/p>\n

Sensory “Continence”<\/span><\/strong>
\n<\/span><\/span><\/p>\n

An increased propensity to confusion with minimal provocation
\n<\/sup>comes with aging. It can be partially explained by age-associated
\n<\/sup>reduction in sensory input. Frequency of visual loss is increased
\n<\/sup>as a result of presbyopia, cataract, and other eye problems.
\n<\/sup>Hearing loss is variable but common. However, there are undoubtedly
\n<\/sup>other factors related to the jumble of neurotransmitter,
\nneurophysiologic, <\/sup>and neuroanatomic changes that are described in the
\nliterature <\/sup>and await explanation. <\/sup>
\n<\/span><\/span><\/p>\n

Sensory deprivation or overstimulation results in confusion <\/sup>and
\ndelirium in normal people at any age if of sufficient intensity <\/sup>and
\nduration. Twenty-nine percent of young persons placed in <\/sup>a simulated
\nhospital room developed subjective sensory distortions <\/sup>after 2.5
\nhours [20]<\/a>.
\n<\/sup>
\n<\/span><\/span><\/p>\n

The reduction of sensory input of all types that occurs with
\n<\/sup>immobilization can produce intellectual and perceptual disorders
\n<\/sup>[21]<\/a>. It is
\nnot surprising that an elderly person, admitted <\/sup>to a hospital bed in
\na quiet room with subdued lighting, whose <\/sup>eyeglasses and hearing aid
\nwere left at home, suffers delirium. <\/sup>If the sensory deprivation alone
\nwere not enough, add the possibility <\/sup>that he or she awakens in a
\nstrange bed after a period of anesthesia <\/sup>or coma. <\/sup>
\n<\/span><\/span><\/p>\n

Nutritional Status<\/span><\/strong>
\n<\/span><\/span><\/p>\n

Dietary habit is deeply ingrained. Age-associated loss of taste
\n<\/sup>and smell makes change in dietary habit even less desirable.
\n<\/sup>The sensation of thirst also diminishes with advancing age.
\n<\/sup>Problems with dentition are more common in the elderly as is
\n<\/sup>the dependence on dentures if nutrition is to be maintained. <\/sup>
\n<\/span><\/span><\/p>\n

Under the best of circumstances, hospital food is unfamiliar.
\n<\/sup>Therapeutic diets, such as those low in salt, are apt to make
\n<\/sup>food less appealing. Eating in bed is difficult with trays,
\n<\/sup>utensils, and water not easily accessible, particularly if bed
\n<\/sup>rails and restraints limit reach. A delay usually occurs between
\n<\/sup>the time when the tray of food is delivered to the room and
\n<\/sup>when someone arrives to help the patient–an interval long enough
\n<\/sup>to allow the food to cool and become even less appealing. <\/sup>
\n<\/span><\/span><\/p>\n

Malnutrition and dehydration can occur rapidly in hospitalized
\n<\/sup>patients of any age. Anorexia is a feature of many illnesses
\n<\/sup>for which patients are hospitalized. The addition of the factors
\n<\/sup>noted already put the elderly patient at particular risk. In
\n<\/sup>the 85-year-old patient whose thirst perception is decreased,
\n<\/sup>thirst may have to be compelling before he or she exerts the
\n<\/sup>effort to grasp a glass of water that is out of reach. If, as
\n<\/sup>is so often the case, dentures have been left at home or misplaced,
\n<\/sup>all the other problems become secondary. <\/sup>
\n<\/span><\/span><\/p>\n

<\/a><\/p>\n\n\n\n
The Cascade of
\n Interactions <\/span><\/p>\n\n\n\n
<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

As
\nillustrated in Figure 1<\/a>, the
\nconsequences of individual interactions <\/sup>between the effects of usual
\naging and hospitalization are, <\/sup>in turn, likely to interact with each
\nother, producing additional <\/sup>tiers of disability in the cascade toward
\ndysfunction and the <\/sup>final common pathway to dependency. <\/sup>
\n<\/span><\/span><\/p>\n


\n<\/span><\/span><\/p>\n

Many factors contribute to the falls and fractures that are <\/sup>all
\ntoo common in hospitalized older persons. There is adequate
\n<\/sup>explanation for the frequent occurrence of delirium and its
\n<\/sup>consequences. The actual and perceived disability created by
\n<\/sup>fractures, delirium, pressure sores, and functional incontinence
\n<\/sup>all contribute to the frequency with which hospitalized older
\n<\/sup>patients are discharged to nursing homes. <\/sup>
\n<\/span><\/span><\/p>\n

Additionally, Medicare-imposed restraints on the length of
\nhospitalization <\/sup>grease the skids down the cascade toward the final
\ncommon pathway <\/sup>to the nursing home. <\/sup>
\n<\/span><\/span><\/p>\n

<\/a><\/p>\n\n\n\n
The End Result
\n<\/span><\/p>\n\n\n\n
<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

A
\nhigh percentage of hospitalized elderly persons discharged <\/sup>to nursing
\nhomes never return to their homes or community. In <\/sup>one study, 55% of
\npersons over age 65 who entered nursing homes <\/sup>remained for more than
\na year [22]<\/a>. Many of
\nthe others were <\/sup>discharged to other hospitals or long-term-care
\nfacilities or <\/sup>died. In another study, only 12% were eventually
\ndischarged <\/sup>to home [23]<\/a>. Even if
\nthe intent is for a temporary stay until <\/sup>rehabilitation occurs or
\narrangements can be made for home care, <\/sup>circumstances frequently
\ndictate otherwise. The family or other <\/sup>informal caretaker may
\ndiscover the advantage of respite during <\/sup>the separation. Available
\nhelpmates may disappear from the scene. <\/sup>The apartment rental may have
\nlapsed. The spend-down for nursing <\/sup>home care may have left
\ninsufficient funds to get started again. <\/sup>Perhaps the most important
\nfact is that many nursing homes do <\/sup>not have the resources to
\nrehabilitate their charges back to <\/sup>their prehospitalization levels of
\nfunction. <\/sup>
\n<\/span><\/span><\/p>\n

The ultimate outcome for many hospitalized elders is loss of <\/sup>home
\nand, ultimately, loss of place. <\/sup>
\n<\/span><\/span><\/p>\n

<\/a><\/p>\n\n\n\n
Recommendations
\n <\/span><\/p>\n\n\n\n
<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
Top<\/span>
<\/a>Recommendations<\/span>
Author & Article Info<\/span>
<\/a>References<\/span>
<\/a><\/span><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

The
\nnegative effects of hospitalization begin immediately and <\/sup>they
\nprogress rapidly. Hirsch and colleagues [24]<\/a> have
\nshown <\/sup>that functional decline from baseline occurs by the second
\nday <\/sup>of hospitalization and improves little by discharge. The
\ntechniques <\/sup>of formal geriatric assessment applied to each
\nhospitalized <\/sup>elderly patient should theoretically identify risk
\nfactors that <\/sup>would predict the propulsion into the cascade to
\ndependency <\/sup>produced by hospitalization. Unfortunately, the typical
\ntime <\/sup>frame for conduct of assessment is not consistent with the
\nspeed <\/sup>with which deterioration can occur. By the time the
\nassessment <\/sup>team meets on Tuesday to discuss the patient who was
\nadmitted <\/sup>to the hospital last Wednesday, the damage has already
\nbeen <\/sup>done. By the time the need for consultation is recognized,
\nthe <\/sup>problems have evolved. Until assessment recommendations are
\n<\/sup>put into practice, additional time has passed. The risk should
\n<\/sup>be predicted before the assessment or consultation. <\/sup>
\n<\/span><\/span><\/p>\n

Although the formal assessment process provides a useful data <\/sup>base
\nfor determining long-range patient management and for evaluating <\/sup>the
\neffects of intervention, the time it takes might actually <\/sup>delay the
\ninitiation of care that is predictably beneficial <\/sup>and is unlikely to
\nbe harmful in any case. If this premise is <\/sup>accepted, then the
\nhospital environment into which elderly persons <\/sup>are admitted should
\nbe modified on the assumption that for many, <\/sup>hospitalization will
\npropel them over the “threshold of frailty.” <\/sup>It is essential that the
\nparadigm of acute hospitalization be <\/sup>adapted to the needs of the
\nhospital’s most frequent customer <\/sup>Table 2<\/a>.
\n<\/sup>
\n<\/span><\/span><\/p>\n

<\/a>
\n<\/span><\/span><\/p>\n\n\n\n
\n\n\n\n
View
\n this table:<\/strong>
[in this
\n window]<\/a>
[in a new window]<\/a>
  <\/span><\/td>\n		Table 2.
\n Recommendations for Modification of Physical and Functional
\n Environment<\/strong>
\n <\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 
\n<\/span><\/span><\/p>\n

I know of no evidence that shows the therapeutic value of bed
\n<\/sup>rest. The “ambient” condition should be for the patient to be
\n<\/sup>out of bed except for a particular reason. High beds are for
\n<\/sup>the convenience of the staff, not the patient. Patients do not
\n<\/sup>fall out of bed in the hospital any more than they fall out <\/sup>of
\nbed at home. They are injured as they climb in and out of <\/sup>high beds.
\nModified, less hazardous hospital beds are on the <\/sup>market and should
\nreplace those in common use. Carpeting, which <\/sup>can provide safe
\nfooting and which is easily maintained, is <\/sup>now available. <\/sup>
\n<\/span><\/span><\/p>\n

Not every patient needs an intravenous line, although it may
\n<\/sup>justify the hospitalization. The needs of many hospital patients
\n<\/sup>could be met with appropriate fluids placed where they can be
\n<\/sup>reached and offered on a timely basis. The availability of needed
\n<\/sup>dentures may obviate the need for enteral or parenteral nutrition.
\n<\/sup>Proper lighting, clocks, calendars, communal eating, daily dressing
\n<\/sup>and undressing in personal clothing, and other efforts to provide
\n<\/sup>reality orientation will provide therapeutic benefits no less
\n<\/sup>important than those prescribed for the condition causing the
\n<\/sup>hospitalization. Involvement by social services from the time
\n<\/sup>of admission rather than at the time of discharge will often
\n<\/sup>obviate the need for nursing home placement. <\/sup>
\n<\/span><\/span><\/p>\n

Most importantly, relationships among physicians, nurses, and
\n<\/sup>other health professionals need to reflect the interdisciplinary
\n<\/sup>care required by the elderly, even on acute care units. Mutual
\n<\/sup>objectives require expression beyond the simple writing of an
\n<\/sup>order by a physician and its execution by a nurse. Just as an
\n<\/sup>attending physician is responsible 24 hours a day for a particular
\n<\/sup>patient, so must there be a nurse with an equivalent relationship
\n<\/sup>to the patient. Doctor and nurse must work in partnership. They
\n<\/sup>must make rounds together on a daily basis and convey the shared
\n<\/sup>objectives to all members of the care team on all shifts. It <\/sup>is
\nessential that all personnel assigned to units on which elderly
\n<\/sup>patients reside understand the unique requirements for their
\n<\/sup>care and share in implementing the details of that care. Everyone
\n<\/sup>who has contact with the patient throughout the day, including
\n<\/sup>doctors, nurses, and family members, should offer encouragement
\n<\/sup>and assistance with ambulation, not just the physiotherapist
\n<\/sup>during the 15-minute formal session once or twice a day. “High
\n<\/sup>tech” medicine requires particular attention to “high touch”
\n<\/sup>care if its recipients are to enjoy its rewards. <\/sup>
\n<\/span><\/span><\/p>\n

A few studies [25,26,27,28,29]<\/a>
\nof the effectiveness of specially <\/sup>designed units on the outcomes of
\nacute hospitalization of the <\/sup>elderly have been reported but not in
\njournals read by the clinicians <\/sup>who usually care for most of the
\nolder patients. If the preliminary <\/sup>results are confirmed, then such
\nunits should serve as models <\/sup>for rapid change in the pattern of care
\noffered by acute care <\/sup>hospitals. <\/sup>
\n<\/span><\/span><\/p>\n

Grant Support: In part by a National Institute on Aging Geriatric
\n<\/sup>Leadership Academic Award 5K07 AG-00413-03. <\/sup>
\n<\/span><\/span><\/p>\n

<\/a><\/p>\n\n\n\n
Author and Article
\n Information <\/span><\/p>\n\n\n\n
<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
Top<\/span>
<\/a>Recommendations<\/span>
<\/a>Author & Article
\n Info<\/span>
References<\/span>
<\/a><\/span><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/a>From the University of
\nKansas Medical Center, Kansas City, Kansas.
Requests for Reprints: Morton C.
\nCreditor, MD, The Center on Aging, University of Kansas Medical Center, 3901
\nRainbow Boulevard, Kansas City, KS 66160. <\/span>
\n<\/span><\/span><\/p>\n

<\/a><\/p>\n\n\n\n
References <\/span><\/p>\n\n\n\n
<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n
Top<\/span>
<\/a>Recommendations<\/span>
<\/a>Author & Article Info<\/span>
<\/a>References<\/span>
<\/span><\/th>\n<\/tr>\n<\/tbody>\n<\/table>\n

<\/a>
\n<\/span><\/span><\/p>\n

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\n<\/span><\/span><\/p>\n

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\n<\/span><\/span><\/p>\n

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\n<\/span><\/span><\/p>\n

4.<\/strong> Palmer RM, Saywell RM Jr, Zollinger TW, Erner BK, LaBov AD, Freund
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\n<\/span><\/span><\/p>\n

5.<\/strong> Kellie SE, Brody JA. Sex-specific and race-specific hip fracture
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\n<\/span><\/span><\/p>\n

6.<\/strong> Furstenberg AL, Mezey MD. Community residence one year after hip
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\n<\/span><\/span><\/p>\n

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\n<\/span><\/span><\/p>\n

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\n<\/span><\/span><\/p>\n

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14.<\/strong> Vogt FB, Johnson PC. Plasma volume and extracellular fluid volume
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\n<\/span><\/span><\/p>\n

15.<\/strong> Druz WS, Sharp JT. Activity of respiratory muscles in upright and
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\n<\/span><\/span><\/p>\n

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\n<\/span><\/span><\/p>\n

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\n<\/span><\/span><\/p>\n

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\n<\/span>
<\/a>\n<\/p>\n

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<\/td>\n<\/td>\n\"Home<\/a><\/td>\n<\/td>\n\"N\"Home<\/a>
E. S. Fisher,
\n J. E. Wennberg, T. A. Stukel, and S. M. Sharp
Hospital
\n Readmission Rates for Cohorts of Medicare Beneficiaries in Boston and New
\n Haven<\/strong>
N. Engl. J. Med., October 13, 1994; 331(15):
\n 989 – 995.
[Abstract]<\/a>
\n [Full
\n Text]<\/a>

\n <\/span><\/td>\n		<\/td>\n<\/tr>\n
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<\/td>\n<\/td>\n\"Home<\/a><\/td>\n<\/td>\n\"N\"Home<\/a>
C. S.
\n Landefeld, R. M. Palmer, D. M. Kresevic, R. H. Fortinsky, and J.
\n Kowal
A Randomized Trial of Care in a Hospital Medical Unit
\n Especially Designed to Improve the Functional Outcomes of Acutely Ill
\n Older Patients<\/strong>
N. Engl. J. Med., May 18, 1995;
\n 332(20): 1338 – 1344.
[Abstract]<\/a>
\n [Full
\n Text]<\/a> [PDF]<\/a>
<\/span><\/td>\n		<\/td>\n<\/tr>\n
\n
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<\/td>\n<\/td>\n\"Home<\/a><\/td>\n<\/td>\n\"N\"Home<\/a>
E. W.
\n Campion
The Value of Geriatric Interventions<\/strong>
N.
\n Engl. J. Med., May 18, 1995; 332(20): 1376 – 1378.
[Full
\n Text]<\/a>

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D. E. Henley,
\n B. Starfield, T. A. Parrino, G. L. Snider, W. S. Colucci, C. T. Sawin, M.
\n K. Magill, M. Babitz, M. P. Silver, M. W. Rich, G. A. Corey, J. H. Burack,
\n V. A. Portnoi, W. L. Adams, M. Weinberger, E. Z. Oddone, W. G. Henderson,
\n and H. G. Welch
A Trial of Increased Access to Primary
\n Care<\/strong>
N. Engl. J. Med., September 19, 1996; 335(12):
\n 895 – 898.
[Full Text]<\/a>
\n

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I.
\n Bourdel-Marchasson, P.-A. Joseph, P. Dehail, M. Biran, P. Faux, M.
\n Rainfray, J.-P. Emeriau, P. Canioni, and E.
\n Thiaudiere
Functional and metabolic early changes in calf
\n muscle occurring during nutritional repletion in malnourished elderly
\n patients<\/strong>
Am. J. Clinical Nutrition, April 1, 2001;
\n 73(4): 832 – 838.
[Abstract]<\/a> [Full Text]<\/a> [PDF]<\/a>
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<\/td>\n<\/td>\n\"Home<\/a><\/td>\n<\/td>\n\"Postgrad\"Home<\/a>
C E Bowman, J
\n Elford, J Dovey, S Campbell, and H Barrowclough
Acute hospital
\n admissions from nursing homes: some may be avoidable<\/strong>
Postgrad.
\n Med. J., January 1, 2001; 77(903): 40 – 42.
[Abstract]<\/a>
\n [Full
\n Text]<\/a>

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\nAmerican College of Physicians.<\/a><\/span><\/div>\n","protected":false},"excerpt":{"rendered":"

Search Annals: Advanced search  Home | Current Issue | Past Issues | Search | Collections | Subscribe | Contact Us | Help | ACP Online             Article    Table of Contents                    Abstract of this article    Figures\/Tables List    Articles citing this article  Services    Notify a friend about this article    Alert….<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1596,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"class_list":["post-1601","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1601","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/comments?post=1601"}],"version-history":[{"count":1,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1601\/revisions"}],"predecessor-version":[{"id":1603,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1601\/revisions\/1603"}],"up":[{"embeddable":true,"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/pages\/1596"}],"wp:attachment":[{"href":"https:\/\/jacobimed.org\/old\/wp-json\/wp\/v2\/media?parent=1601"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}