CHAPTER 10 Older people in acute care
FRAMEWORK
It has been said that the modern general hospital may contribute to the incidence of adverse outcomes for frail older people (Parker et al 2006). Unless older people have comprehensive, proactive assessment and are managed in an interdisciplinary and holistic way, they are at risk of delirium, functional decline, falls, medication associated problems, pressure sores, malnutrition and readmissions (Buchanan & Considine 2002).The hospital system should be tailored not only to meet these challenges but, more importantly, to avoid them.
Introduction
Older people are the major consumers of the acute health care services, particularly inpatient services. This is in part due to the ageing of the population but also reflects evolving patterns of disease in older people. Younger patients are increasingly treated in community settings with new models of care or need only short, or even day, stays in hospital. Furthermore, an increasing capacity for community care to manage more severe and complex care is resulting in the average level of acuity and complexity increasing in hospital settings (Gray et al 2002). Older people, especially those with multiple comorbidities and functional consequences as a result of their presenting problems, have longer lengths of stay (Melzer et al 1999). Hospital care expenditures are approximately 30% of the national health care expenditure of 31 billion dollars in Australia (Australian Institute of Health and Welfare [AIHW] 2008a).
Older people are the major consumers of the acute health care services.There were 7.6 million separations from Australian hospitals providing acute care in the year 2006–07, with over 24 million patient days (AIHW 2008b). Of all the admissions, people over the age of 55 accounted for 27% admissions and 60% bed days. Admission rates increased to 45% over the age of 65 years, even though this age group makes up only 13% of the total population. These figures are even more marked for the over 85 year age group (AIHW 2006). Most developed countries have similar figures (Landefeld 2003; Parker et al 2006).
The average length of stay in the 65–74 age groups is around 7.5 days and this increases to 11.6 days for the age group 85 and over (Gray et al 2004). This age-related increase in length of stay is a universal phenomenon. There are often views expressed by many acute care clinicians, politicians and in the media that older people use the health system inappropriately. These ageist views fail to account for the complexity of older people’s medical problems and the complex interplay between the physical, functional, cognitive and psychosocial aspects of health in older people.
The key clinical issues of the 21st century relate to chronic disease and disability.According to the World Health Organization (WHO), cardiovascular diseases, diabetes, obesity and cancer account for 59% of the 57 million deaths annually (WHO online: www.who.int/diet physical activity/publications /facts/chronic/en/). The less well developed countries now have the burden of tackling both acute and chronic conditions. For example, the WHO estimates that the number of people with diabetes will have risen by almost 200% in India during the 1995–2025 period. In absolute numbers, this is around 57 million people! In developed countries, the existing services should cope with the care of older patients with chronic diseases. An estimated 10% of the world’s population experience some form of disability or impairment. The number of people with disabilities is increasing due to population growth, ageing, emergence of chronic diseases and medical advances that preserve and prolong life.
It is well documented that the effect of population ageing on health care expenditure is small and can be managed (Coory 2004). The evidence is that only 10% of the growth in health care expenditure has been attributable to the ageing of the population. We need well organised hospitals with an adequately and appropriately trained workforce (Groves & Wagner 2005).
What happens to older people in hospital
Hospitals are a high risk environment with significant risk of iatrogenic adverse events (Creditor 1993; Jahnigen et al 1982). Older patients are likely to have functional impairment and cognitive decline in addition to the invariable altered physiology making them vulnerable to multiple problems. They are at high risk of experiencing under-nutrition, adverse drug reactions, deconditioning, pressure ulcers, falls and injuries related to falls (Parker et al 2006).
Hospitals are a high risk environment with significant risk of iatrogenic adverse events.Nutrition
It is now well recognised that older people, especially those with comorbidity and cognitive impairment, are at high risk of nutritional decline and that their nutritional state declines rapidly while an inpatient in the acute care sector. Up to 40% of older patients in both acute and subacute care are at high risk of malnutrition (McWhirter & Pennington 1994; Visvanathan et al 2004). The care provided in hospital compounds the nutritional problems with little attention paid to ensuring optimal nutritional intake while a person is in hospital.
Poor nutrition results in delayed recovery from illness, increased length of stay and is also associated with increased morbidity and mortality. Inadequate dietary intake and nutritional deficiencies exacerbate age-related decline in muscle mass. Unfortunately malnutrition is both under-recognised and under-treated in the acute care setting. There is now reasonably good evidence that a proactive approach to nutrition can improve nutritional state including the appropriate use of nutritional supplements and enteral feeding, the utilisation of nutrition assistants, and the establishment of communal dining and protected meal times (Duncan et al 2006; Hickson et al 2004).
Adverse drug events
Adverse drug reactions are more common in older people. This reflects altered physiology, pharmacokinetics, pharmacodynamics and compliance. Most studies have suggested that the number of drugs is a major determinant of adverse effects. It can be argued that the presence of an adverse drug reaction is a marker of frailty (Onder et al 2002).
Older patients are more likely to experience preventable adverse events during hospitalisation than younger patients. Thomas and Brennan (2000) argue that this is most likely due to the complexity of their clinical care. Their US-based study of 15 000 patient records aimed to determine the incidence and types of adverse events experienced by older patients. One relevant finding was that 64% of patients aged over 65 years experienced a preventable adverse drug event.
Deconditioning
Deconditioning of older patients is a common occurrence during hospitalisation. Physiological changes worsened by inactivity, bedrest, medical illness and polypharmacy may end in loss of function in activities of daily living. Muscle mass could diminish in days while muscle power will diminish by 5% per day (Harper & Lyles 1988). This then leads to falls, postural hypotension and osteoporosis, and in some patients results in inappropriate residential care placement.
The attitudes of older people themselves and of caregivers and relatives are also important. For example, an attitude that physical decline is inevitable in old age can lead to a delay in seeking medical attention for treatable problems. There is also the added difficulty for the clinician when an atypical presentation may result in delayed presentation by the patient and delayed diagnosis and treatment by the doctor. For example, myocardial infarction may present as confusion rather than chest pain.
Prevention of deconditioning in hospitals during acute illness requires a multifaceted approach that includes physical therapy, maintenance of nutrition, medical management and psychological support. Pooled analysis of multidisciplinary interventions that included exercise found a higher rate of discharges to home and reduction in length of stay (de Morton et al 2007). Activity and independence should be promoted from the time of admission. Education of health care staff about the dangers of deconditioning is vital, since bed rest continues to be recommended during acute illness despite the lack of evidence showing benefits and the considerable evidence showing potential adverse effects from this advice. Sedative medications and restraints should be used as a last resort, if at all (Kennedy et al 1987).
Prevention of deconditioning in hospitals during acute illness requires a multifaceted approach.VIGNETTE
Miss G was admitted to an acute hospital via the emergency department because of an accident. She fell from her motorised scooter and sustained a large tear on the front of her right shin. This wound extended from below the knee to mid calf and was full thickness exposing muscle tissue. This lady was a diabetic, had mild renal failure and was being treated for hypertension. Her admission time was noted as 11.30 am on Thursday. Miss G was kept in the Emergency Department on a trolley for approximately 6 hours, and was then transferred to a bed in the same department where she remained for 2 more days until a bed was found in the ward on Sunday morning. She had an intravenous drip inserted and was commenced on antibiotics. By this time she had a very sore sacral area, was dehydrated, in pain, had poor urine output and had become confused and upset. Fluids were offered but because she did not like water and was a diabetic there seemed to be a problem getting staff to give her appropriate fluids that she would drink. Her food was brought to her on a tray and she had to feed herself, which was impossible with a drip in one arm and poor movement in the other. She could not eat the food and was not offered much choice of anything she could eat. The medical personnel decided the wound had to be debrided in the operating theatre. Following this procedure the wound extensively enlarged and now completely circumscribed her leg. Dressings were done in the theatre every 3 days and a urinary catheter inserted. Over the following 6 weeks the wound was covered by a skin graft taken from her thigh on the same leg. She developed a deep pressure ulcer on her right heel, was not eating or drinking, was totally immobile, had been accidentally dropped from a lifting machine by staff, sustaining a skin tear on her right arm, was now in severe pain and was drifting in and out of delirium.
Environments
An interdisciplinary approach with gerontological expertise in acute care, starting in the emergency department, can prevent many of the iatrogenic problems. Communication with patients, family, and the team is also vital for effective discharge planning (Hickman et al 2007). In New South Wales the introduction of gerontological nurses in emergency departments has improved the care of older people. In the United States, nurse practitioners were introduced in health care settings over 30 years ago. This has improved the care compared to the care provided by medical practitioners alone (Hooker 2006).
Early markers of prolonged hospital stay have been well studied (Lang et al 2006). So in our view, if a patient’s stay is prolonged, the system should be responsible for taking a proactive approach. If a ‘bed is blocked’ it is the system that should be ‘blamed’ and not the patient.
In a study of patients over the age of 75 who were hospitalised through the emergency departments, predictors of length of stay were studied. Simple assessment of walking difficulties, falls, malnutrition and cognitive impairment were found to be good predictors (Lang et al 2006). However, self-reporting by patients has shown to be unreliable compared to active measurement of function by trained staff. It may be because of the cognitive deficits, either from dementia or delirium, or due to patients’ desire to underplay their disabilities (Dendukuri et al 2005).
Day surgery
As length of Australian hospital stays decreased, concerns were raised about benefits of shorter stays for older people. McCallum et al (2000) investigated personal characteristics, perceived health outcomes (SF-36) and service use of day-only and other patients aged 70+, at 1 and 12 weeks after hospital discharge. Day-only patients were younger, had better self-reported health, were selected for orthopaedic, gastrointestinal and ophthalmic procedures, and used similar levels of formal and informal services after discharge as people with longer stays. There was no evidence of ill effects of day surgery for older people, but improved selection and information-giving procedures can improve outcomes.
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