As a geriatrician Dr. Joel Sender, Division Director, Geriatrics at SBH, knows that a hospital’s primary burden in treating older inpatients is to make sure the patient’s functional status remains high and the likelihood of delirium remains low.
“We are aware that what happens during the hospital experience can be harmful to an elderly patient,” he says. “Even a three-day hospital stay for a weakened elderly person can result in an inability to get back to their previous state for three to six months after they leave the hospital. That’s a lot in terms of lost time and plenty of time for bad things to happen.”
To better accommodate its elderly inpatients – which while comprising only 15 percent of the residents of most communities, may account for as high as 50 percent of all hospitalized patients – SBH recently opened an ACE (Acute Care Elderly) unit. The unit, located on the third floor of St. Barnabas Hospital, includes 12 beds dedicated to this clientele.
In addition, the hospital recently received NICHE designation – which stands for Nurses Improving Care for Healthsystem Elders. This demonstrates a hospital’s commitment and continued progress in improving quality, enhancing the patient and family experience, and supporting the hospital’s efforts to serve its communities. NICHE’s vision is for all patients ages 65 and over to be given sensitive and exemplary care.
As part of SBH’s overall push to support the needs of the elderly, plans also call for the opening of a separate, four-bed geriatric emergency department. Construction on this unit is scheduled to be completed during first quarter 2020.
THE COST OF HOSPITALIZATION
Delirium is a common clinical syndrome characterized by acute cognitive dysfunction and inattention. In elderly adults it can lead to a downward spiral of functional decline, loss of independence, institutionalization, and, ultimately, death. It’s been estimated that as high as a third of the 12.5 million patients over 65 years of age hospitalized each year in the U.S. experience complications during hospitalization because of delirium.
“We try to prevent delirium and loss of function by making sure we orient these patients, maximize their mobility, pay close attention to their needs, and feed and medicate them properly,” says Dr. Sender. “This means, as an example, making sure our elderly patients have their eyeglasses and hearing aids with them in the hospital so they don’t become confused. We know that the time an elderly patient spends in a hospital can result in terrible end points.”
Reasons for delirium can include prior history of dementia, a new serious illness, dehydration, exposure to new medications, and disruption of normal routines and sleep disturbance, among others.
For many older persons, hospitalization results in functional decline despite the cure or improvement of the condition for which they were admitted. According to a 25-year-old study reported in the Annuals of Internal Medicine, which still holds true, “Hospitalization can result in complications unrelated to the problem that caused admission or to its specific treatment for reasons that are explainable and avoidable.”
Normal aging is often associated with functional changes, such as a decline in muscle strength and endurance; slower response times, poorer vision and hearing, reduced ability to physically and mentally respond to an illness or health challenge, lack of perception of hunger and thirst, and impaired balance. A trip to the hospital might include bed rest causing unintended immobilization, unfamiliar surroundings, new medications with unpleasant and disorienting side effects, and even restraints should the patient seem to struggle. These factors among others, may place a vulnerable older person into physical decline and possibly into delirium which can radically alter the outcome of that hospital stay and lead them to dependency which might even require or promote admission to a nursing home.
KEEPING PATIENTS MOBILE
Elderly patients in St. Barnabas Hospital’s ACE unit stay as mobile as possible, with assistive devices like canes or walkers provided when necessary. Social workers and physical therapists routinely come to the floor to encourage patients to stay active and use their muscles to maintain strength. Staff continually explores activities that will keep patients stimulated, such as musical therapy at bedside, and encourage family members to visit and participate in their loved one’s overall care.
According to Princess Ukachukwu-Lyttle, a geriatric nurse practitioner on the unit, “We assess the patient’s total care using the ‘head to toe approach.’ We work closely with their families and we follow the patients once they leave. Transition back to home is enhanced by personal communication with the patients’ doctors, the pharmacy, and the family. It is so important to make sure the information about what just took place in the hospital is clearly presented to other caregivers, whether it be family, pharmacy, visiting nurse, or even referring rehabilitation facility. We keep our communication lines open even after they’ve left and encourage the patient and family to ask questions.”
This can also make a huge difference when it comes to length of stay, says Dr. Sender. “For hip fractures, normally after surgery older patients can return home in 3 ½ days, but the national average is closer to nine days because of delirium. If delirium is present it becomes more difficult to send a patient home. As a result, there is strong pressure to send such a patient to a nursing facility, which is certainly not our goal. We much prefer to discharge patients back to their own homes.”
He says that creating a special area in the hospital with a trained team of health professionals who dedicate themselves to the care of seniors truly makes a difference. Special units for the elderly can reduce the incidence of delirium and deconditioning. The staff is more aware of age-related problems with skin care, urinary incontinence, constipation, pain control, the need to have assistance with meals, and helping get them in and out of bed.
Furthermore, they are accustomed to taking into account the following facts:
• Older adults who cannot reposition themselves are at increased risk
for pressure ulcers, which affect an estimated million adults annually.
• Older patients may have multiple medical issues and multiple medications.
• New medications may be introduced, which can lead to side effects.
• Older adults are at risk for falls, especially if they are sedated or disoriented. This is the leading cause of injury and deaths among this population.
• Older adults can be at risk for malnutrition, as studies show that nearly six in 10 patients 65 and older have problems eating. This can severely hamper recovery.
• Older adults are more at risk of the spread of infectious diseases in hospitals such as MRSA and pneumonia.
GERIATRIC ED
Dr. Sender believes the new geriatric emergency department will play a key role in supporting the needs of elderly patients. The new special area will feature less harsh lighting, non-slip floors and a dedicated bathroom that will “allow the patient to leave behind Times Square and the mayhem of a busy ER.” This is especially important in most urban hospitals, where a large majority of inpatients come in through the ER. Medical and nursing staff, he says, will improve recognition of geriatric problems before they can get out of hand. Coordination with inpatient care services will start more quickly and reduce opportunities for complications in the patient’s health.
“It’s all about creating a safe physical space that can adjust to the needs of these patients,” he says. “It’s about teaching everyone to pay attention to several simple rules that respect the health and well-being of older patients. We know that for senior patients a hospital stay can be a great challenge – and, if not handled correctly, it may lead to serious and unnecessary declines in health.”
