Current Geriatric Diagnosis & Treatment, 1st Edition
Section II - Environments of Care
7. Hospital Care
- Seth Landefeld MD
Hospital care is a critical issue for older patients, and hospitalization heralds a period of high risk that extends beyond discharge, especially for the frail and the very old. In addition, older patients are the lifeblood of every hospital, except those limited to obstetrics and pediatrics. These points are illustrated by the following observations:
- Persons age 65 years or older account for 36% of hospitalizations and nearly 50% of hospital revenues, even though they comprise only 13% of the population.
- Nearly 66% of Americans die in a hospital, and >80% of deaths occur in persons 65 years of age or older. In the year before death, nearly all older Americans are hospitalized, accounting for -20% of all Medicare expenditures.
- Adverse outcomes of hospitalization are directly related to age: Loss of ability to care for oneself increases with age (occurring in 15%, 30%, and 45% of medical patients in their 70s, 80s, and 90s, respectively), as do hospital mortality rates.
Hospital care can be improved in older patients, and it is likely that such improvements would lessen suffering and save lives and money. Preventable adverse events occur in 5% of persons age 65 years and older compared with 2% of younger patients. Opportunities to administer preventive maneuvers, such as pneumococcal and influenza vaccination, are frequently missed. Focused efforts have improved treatment of specific conditions such as myocardial infarction, congestive heart failure, and pneumonia. Moreover, reengineering the microsystem of care (eg, how care is delivered on a hospital ward or how hospital care is linked to posthospital care) can improve the outcomes of older patients.
Efforts to improve hospital care for older persons may prove especially high yield because of their high risk for adverse outcomes. An intervention that reduces hospital mortality 20% in terms of relative risk might reduce hospital mortality from 10% to 8% in 80-year-olds but only from 2% to 1.6% in 50-year-olds. Thus, such an intervention would prevent the deaths of 20 of every 1000 hospitalized 80-year-olds compared with 4 of every 1000 hospitalized 50-year-olds.
Bird CE et al: Age and gender differences in health care utilization and spending for Medicare beneficiaries in their last years of life. J Palliat Med 2002;5:705. [PMID: not available] (During the last year of life, most older Americans are hospitalized, accounting for >66% of Medicare expenditures for these persons.)
Brennan TA et al: Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370. [PMID: 1987460] (Adverse events occurred in 4% of hospitalizations, and 25% were due to negligence. Adverse events were twice as common in patients age 65 years and older.)
Fried TR et al: Older persons' preferences for site of terminal care. Ann Intern Med 1999;131:109. [PMID: 10419426] (Far more people prefer terminal care at home than receive it.)
Two general issues should be considered in caring for older persons in the hospital: determining the goals of care and designing and implementing strategies to achieve those goals. Failure to consider both these issues explicitly is common, often leading to a disconnect between hospital care and the hopes and expectations of those involved. Such disconnects lead to frustration and dissatisfaction on the parts of patients, family members, and caregivers.
The goals of hospital care for older persons vary widely. For patients, for example, the goals may include prolonging survival, relieving specific symptoms, maintaining or regaining ability to walk or care for oneself, getting help taking care of oneself, being reassured during a frightful experience, and providing comfort and peace while dying. Family members may share these goals but may also have additional goals, such as getting help caring for the patient, facilitating a transition in care from home to long-term care, or being protected from a frightening situation. Physicians and other professionals involved in the care of the patient may share some of these goals and also aim to reduce the pathophysiological manifestations of disease (such as hypoxia) or to get the patient out of the hospital in a certain amount of time to reduce work and hospital costs.
At the time of admission, the physician should attempt to define the major goals of care of each patient and of other involved parties, including key family members and professionals. Assumptions that a patient
wants “everything” or wants “comfort care” will often be incorrect. The discussion of goals of care should be tailored to the situation; it may be brief or postponed in a life-threatening situation, and it may be a major focus of the admission evaluation in other patients with worsening of a chronic condition. Such discussions may be initiated with open-ended requests, such as “Different patients have different goals when they are admitted to the hospital. Can you tell me about what you would like us to accomplish while you are in the hospital?” Discussions of goals of care will be more broad ranging than simply cataloging do-not-resuscitate (DNR) decisions or reviewing options for specific therapeutic interventions. In fact, DNR and other decisions may be ill-informed without discussion of the goals of care.
Explicit articulation of goals of care will sometimes identify disagreements or unreasonable expectations, which should be recognized and usually addressed. Also, some goals may conflict with specific duties (eg, the physician's primary duty to act in the patient's interest) and should not be pursued. In general, a physician responsible for a patient should not act on goals of reducing lengths of stay or limiting therapy when those actions are not in the patient's interest.
Designing and implementing strategies to achieve the goals of care will require the physician's expertise and will often involve teamwork with other experts. For example, consider the situation of an 83-year-old widow with chronic obstructive pulmonary disease (COPD) and mild cognitive impairment who lives alone, has declined over the past month in her ability to take care of her home and her affairs, is admitted with hypoxia and hypercarbia attributed to a COPD exacerbation, and wishes to live in her home until she dies. Although the physician may have the expertise to treat the COPD exacerbation, he or she may want to involve nursing, social work, and occupational therapy in rehabilitative and adaptive efforts to promote the patient's independent function at home after discharge. To achieve the patient's goals of care, the physician's time may be spent better on involving and coordinating these other expert professionals than in “fine-tuning the numbers” beyond that necessary for the patient's function.
Fried TR et al: Understanding the treatment preferences of seriously ill patients. N Engl J Med 2002;346:1061. [PMID: 11932474] (Seriously ill patients differed in their choices and attitudes about the burdens of treatment, possible outcomes, and their likelihood.)
Tsevat J et al: Health values of hospitalized patients 80 years or older. HELP Investigators. Hospitalized Elderly Longitudinal Project. JAMA 1998;279:371. [PMID: 9459470] (Most patients were unwilling to trade survival for quality of life, but preferences varied greatly. Proxies and multivariable analyses could not gauge health values of patients accurately, indicating that health values should be elicited directly from the patient.)
Assessment of complementary clinical domains should be performed on admission in each older patient. Problem-focused assessment will identify and address the reason for admission. In addition, a geriatric assessment tailored to the hospitalized patient will improve the care of most older patients.
Geriatric assessment of the hospitalized patient focuses on assessment of the patient's neuropsychiatric and functional status and of the social context of the patient's life and illness.
Neuropsychiatric assessment should include assessment of mental status, affect, and mobility. Among hospitalized older medical patients, ≥20% have dementia, ≥10% are delirious on admission, and another 15% experience delirium during hospitalization. Symptoms of depression are common, and 33% of hospitalized older medical patients have major or minor depression.
Neuropsychiatric assessment begins on meeting the patient. Stop to consider the possibility of dementia, delirium, depression, and impaired mobility: They are frequently present but infrequently reported. To whom are you speaking? If you are obtaining the history from a surrogate rather than the patient, cognitive impairment from dementia or delirium or both is likely. Look for impaired consciousness or attention. Listen for evidence of any change in mental status or behavior, and watch for signs of impaired thinking, speech, judgment, or function in performing activities of daily living (ADLs). Mental status can be further assessed by the Mini-Mental Status Examination or by shorter tests. Serious cognitive impairment is indicated by failure to know the year or by inability to recall any of 3 items; it is largely ruled out by orientation to date or by recall of 3 items and ability to draw the face of a clock (see Chapter 4). Ask the patient whether he or she has felt sad, depressed, or hopeless over the last month.
Functional assessment determines the patient's ability to walk and to perform basic ADLs (eg, bathing, dressing, transferring from a bed to a chair, using the toilet) both on admission and at baseline before onset of the acute illness. Patients who are dependent on admission (ie, they require the help of another person in performing 1 or more ADLs) have longer hospitalizations on average than otherwise similar patients who are not dependent. They are at higher risk for death in the hospital. If they survive, they are at high risk for remaining dependent on discharge. Patients dependent in ADLs at discharge are at increased risk for nursing home placement and for death during the next year.
The patient's social context is critical to care and recovery, especially after hospitalization, and this domain falls within the responsibilities of the physician as well as the social worker. Ask where the patient lives and with whom, whether he or she feels safe there, and whether he or she wishes to return to that place when leaving the hospital. Determine who assists, or would be available to assist, the patient with ADLs and instrumental ADLs, such as shopping, performing household chores, using transportation, and handling medicines and money. Will these persons be able to provide the care needed after hospitalization? These persons will be important factors in continuing medical care outside the hospital as well as in other aspects of the patient's well-being.
Neuropsychiatric and functional assessment and a geriatrically focused review of systems may identify conditions that are commonly considered geriatric syndromes, including dementia, delirium, functional decline, incontinence, falls, sensory impairment, and social isolation. Each of these conditions can and should be addressed specifically. In addition, however, it is important to recognize that frequently 2 or more geriatric syndromes occur synchronously in frail patients, and that the burden of this frailty on patients, families, and professionals is substantial.
Bierman AS: Functional status. The sixth vital sign. J Gen Intern Med 2001;16:785. [PMID: 11722694] (An appeal for systematic assessment of functional status in hospitalized elders.)
Covinsky KE et al: Measuring prognosis and case-mix in hospitalized elders: The importance of functional status. J Gen Intern Med 1997;12:203. [PMID: 9127223] (Ability to perform ADLs on admission is a strong predictor of survival and lower hospital costs.)
Lachs MS et al: A simple procedure for general screening for functional disability in elderly patients. Ann Intern Med 1990;112:699. [PMID: 2334082] (A reasonable approach that can be adapted to hospitalized older patients.)
In general, the treatment of disease should not differ according to age. Treatment should be selected on the basis of the goals of care for a particular patient and on the basis of evidence that a particular treatment regimen will achieve the specified goal.
Older patients may differ from younger patients according to their goals. For example, treatment directed primarily at amelioration of symptoms and dysfunction rather than prolongation of survival may be desired more often by patients in their 90s than by those in their 60s. Also, insofar as these choices are influenced by prognosis, which is determined in part by age, patients should be informed accurately when they desire this information. Nonetheless, the goals of care differ between patients of the same age and should be determined individually.
Evidence of the efficacy of a treatment regimen in achieving a specific goal should be sought. In some situations, treatment efficacy may differ by age. For example, thrombolytic therapy of acute myocardial infarction is less efficacious in prolonging survival in persons age 75 years and older than in younger persons, and acute coronary revascularization may be more efficacious in these patients. Doses of therapies often need to be titrated to reflect renal or hepatic function, which often decline with age. The risk of side effects from many drugs and procedures also increases with age, and these risks should be considered in estimating the net benefit of a specific treatment strategy.
Unfortunately, most evidence about the efficacy of many therapies is based on studies of younger persons, and specific evidence about the efficacy of those therapies in persons age 75 years or older is inadequate. In these situations, it is reasonable to extrapolate from evidence in younger patients, taking into account age-related differences in hepatic and renal function and risks of side effects when deciding on and implementing a specific treatment regimen.
Thiemann DR et al: Lack of benefit for intravenous thrombolysis in patients with myocardial infarction who are older than 75 years. Circulation 2000;101:2239. [PMID: 10811589] (Thrombolytic therapy for patients >75 years old is unlikely to confer survival benefit and may have a significant survival disadvantage in contrast to the benefit of therapy in younger patients.)
Hutchins LF et al: Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med 1999; 341:2061. [PMID: 10615079] (A total of 63% of cancer patients are 65 years of age and older, but only 25% of patients enrolled in cancer-treatment trials are 65 years or older.)
Hospitalization provides an opportunity for the assessment and implementation of routine preventive maneuvers in older patients: In the hospital, patients receive far more medical care and attention than they do outside the hospital, and they are more available for and adherent to preventive maneuvers. Maneuvers that should be considered in every older hospitalized patient include
- Influenza vaccination.
- Pneumococcal vaccination.
- Testing and treatment for systolic hypertension, atrial fibrillation, and hypercholesterolemia.
- Determination of smoking status and counseling about smoking cessation.
- Screening for alcoholism and seeking counseling when indicated.
- Screening for dementia and depression and providing referral when indicated.
Screening for treatable cancer is usually not considered during hospitalization. Nonetheless, it is reasonable to implement otherwise indicated screening for breast or colorectal cancer during hospitalization.
For most patients, optimization of their daily function, including prevention of functional decline or return to baseline function, is an important goal during hospitalization. Functional decline may be prevented, and functional recovery promoted, by multicomponent strategies incorporating comprehensive geriatric assessment and management and principles of health care improvement. These strategies are exemplified by Geriatric Evaluation and Management (GEM), Acute Care for Elders (ACE), and the Hospital Elder Life Program (HELP). ACE has 4 key elements:
- A physical environment designed to facilitate independent function comfortably. Illustrative features include carpeting, uncluttered halls, and handrails to help walking.
- Patient-centered care tailored to each patient to maintain and promote independent function. Protocols are implemented by the primary nurse and based on a daily assessment to improve self-care, continence, nutrition, mobility, sleep, skin care, mood, and cognition.
- Planning to ease the return to home and to focus patient, family, and clinicians on this goal. The primary nurse assesses plans and needs on admission, and family members and a social worker are involved in planning early on.
- Medical care review avoids unnecessary procedures and medicines.
ACE is implemented on a hospital ward, the ACE Unit, to promote team function of the full array of clinicians caring for each patient and to enhance the potency of the intervention. ACE differs from GEM in that it is designed to be feasible for all hospitalized older patients from the time of hospital admission. Thus, ACE provides the opportunity to prevent further functional decline and rapidly ameliorate decline that occurred before admission.
HELP focuses on prevention of delirium. This intervention targets specific risk factors for delirium: cognitive impairment, hearing or visual impairment, sleep deprivation, immobility, and dehydration. HELP is implemented by an interdisciplinary team incorporating extensively trained volunteers.
Cohen HJ et al: A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med 2002; 346:905. [PMID: 11907291] (Inpatient geriatric evaluation and management reduced functional decline with affecting survival or costs.)
Counsell SR et al: Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of Acute Care for Elders (ACE) in a community hospital. J Am Geriatr Soc 2000;48:1572. [PMID: 11129745] (ACE improved process of care measures and satisfaction of patients, families, and providers.)
Inouye SK et al: A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340:669. [PMID: 100533175] (The Hospital Elder Life Program [HELP] reduced the incidence of delirium from 15% to 10%.)
Jencks SF et al: Change in the quality of care delivered to Medicare beneficiaries, 1998—1999 to 2000—2001. JAMA 2003;289: 305. [PMID: 12525231] (Measures of the process of hospital and outpatient care have improved for older Americans, and there is much room for further improvement.)
Landefeld CS: Improving care for older persons across the continuum of care: beyond ACE and GEM. Ann Intern Med 2003; 139:421. [PMID: not available] (Overview of comprehensive approaches to improving care of hospitalized older persons.)
Landefeld CS et al: A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. N Engl J Med 1995;332:1338. [PMID: 7715644] (Acute Care for Elders [ACE] improved functional outcomes at discharge and reduced nursing home admissions.)
Nichol KL et al: Influenza vaccination and reduction in hospitalizations for cardiac disease and stroke among the elderly. N Engl J Med 2003;348:1322. [PMID: 12672859] (In patients aged 65 years or older, vaccination against influenza was associated with reductions in the risk of hospitalization for heart disease, cerebrovascular disease, and pneumonia or influenza as well as the risk of death from all causes during influenza seasons.)
Stuck AE et al: Comprehensive geriatric assessment: A meta-analysis of controlled trials. Lancet 1993;342:1032. [PMID: 8105269] (Comprehensive geriatric assessment and management was associated with improved survival and health outcomes.)
In addition to monitoring the response to therapy of the primary manifestations of the reason for admission, neuropsychiatric and functional status should be monitored during hospitalization. Delirium develops in -15% of hospitalized older medical patients and decline in ADL function occurs in 17%. Each of these events is associated with worse patient outcomes, longer hospital length of stay, and increased costs. There is little evidence about the efficacy of acute rehabilitation on delirium or functional decline once they have developed during hospitalization. Nonetheless, delirium and functional decline should be recognized as signs of the failure or side effects of the treatment regimen and of inadequate efforts to maintain function, and both
should be reconsidered. For example, is delirium related to sleep deprivation or to a sedative—hypnotic? Is functional decline related to delirium, to poor nutrition, or to bed rest and insufficient exercise and physical therapy?
PLANNING TO GO HOME
Planning to go home, or to another setting, from the hospital should begin on admission. Moreover, this planning process should focus on defining and achieving the patient's goal of living in a particular setting. By defining this goal and beginning to work toward it early in hospitalization, planning to go home will facilitate the patient's leaving the hospital at the appropriate time. Planning to go home may differ in its focus from conventional “discharge planning,” which sometimes seems aimed at getting patients out of the hospital with the connotation that they have worn their welcome thin and passed their expected length of stay. Also, by focusing on a desired goal of hospitalization, planning to go home provides a positive focus that may counter the negative expectations many older patients and their families have about the outcome of hospitalization.
Planning to go home is a joint responsibility of the patient and family, the patient's physicians and nurses, and the hospital social worker. The physician should inquire on admission or shortly thereafter about the patient's goal and the resources that may be necessary to achieve that goal. This information should be discussed with the social worker, who can collect further information and coordinate the needed resources.