« The Dual Agenda: March 23, 2016 Issue

Eldercare Voices

Strategies to Ensure a Safe and Successful Hospitalization for the Older Adult

Jeffrey D. Schlaudecker, MD and Rachel Hart, MD

Adults over the age of 65 account for 48 percent of all hospital admissions. Compared to younger hospitalized adults, they are more likely to be admitted with higher acuity and disease burden, require a longer length of stay, are twice as likely to suffer from adverse events and have higher 30-day readmission rates. For frail older adults, small problems can lead to significant declines in health, physical function and independence. Critically important for a safe and successful hospitalization is a focus on the prevention of iatrogenic complications and further frailty, optimal hospital design, a medication review and effective transitions of care out of the hospital.

Hospital Design

Just as children’s hospitals underwent design changes decades ago to reflect the needs of young patients, today some hospitals are working to meet the unique needs of older adults. The Nurses Improving Care for Health System Elders (NICHE) program and Acute Care for the Elderly (ACE) units are two specific programs that are aimed at improving the care of older adults in the hospital.

In addition to a redesign of care processes and procedures tailored to older hospitalized adults, the physical environments of hospitals are being redesigned to enhance geriatric-oriented care provision. Innovative hospital designs that focus on the needs of older adults and their families have begun to improve the hospital campus, the unit, the room and the amenities available in each of these.

Medication Review

Polypharmacy and inappropriate prescribing are common problems for older adults. Multiple medications for multiple chronic illnesses may be necessary, but can cause increased risk for drug-drug interactions and adverse drug side effects. Medications often inappropriate for older adults include sedating medications, muscle relaxants and drugs causing orthostatic blood pressure problems. These medications can lead to falls and increased confusion.

Problems can also arise when the list of medications isn’t properly reconciled as patients move within areas of the hospital and between the community and the hospital. Medications appropriate in one setting may not be appropriate in all settings. Sedating medications can help stabilize a patient on a mechanical ventilator, but can cause serious consequences for a mobile patient working with physical therapy. Discharge medication reconciliations completed too quickly can lead to duplications, inaccuracies and continued use of medications that are no longer indicated.

When determining medication appropriateness and safety, the medication itself, the dosage, likely effectiveness, drug-drug interactions, drug-disease interactions, unnecessary duplications and the duration of treatment must all be considered.

Unintended Consequences

Iatrogenesis is “any unintended consequence of well-intended healthcare interventions.” While many hospital-based interventions are necessary even appropriate care can carry a risk of harm, such as delirium, falls and infections. Iatrogenesis affects one in three older adults in the hospital, but over 50 percent of cases can be prevented. Implementing prevention strategies can prevent iatrogenic diseases, some of which are highlighted below:

Transition of Care

Care transitions occur any time a patient moves from one level or location of care to another. This can include admission from the emergency department or intensive care unit to a medical floor, discharge to a skilled nursing facility and discharge from the hospital or other facility to home. With each transition, a patient may gain a new set of providers and with the possibility of disrupted continuity. The key to a safe transition is quality communication. Several essential components of safe transitions must be identified and followed. Information should be transferred to the new providers in a timely and accurate way, and patients and families should be educated as partners on the health care team about the illness and the expectations at the next level of care. 

The ideal discharge involves active advanced planning starting on the first day of hospitalization. The plan to be shared at discharge includes a current problem list, an accurate list of medications and scheduled follow-up appointments, completed advance directives, baseline physical and cognitive function notes, and family and health care professionals’ contact information. [Editor's note: an earlier Eldercare Voices column describes one promising model that involves social-worker led interdisciplinary teams in transitional care.]

Conclusion

Hospitalizations can be potentially hazardous for the older adult. With appropriate planning, hospital care can be targeted to limit adverse events from medications, iatrogenic complications and maintain both functional status and independence.

Jeffrey D. Schlaudecker, MD, is a geriatrician-hospitalist and the Kautz Family Foundation Endowed Chair of Geriatric Medical Education at the University of Cincinnati. Rachel Hart,MD, is a geriatric medicine clinical fellow at The Christ Hospital/University of Cincinnati program.

Subscribe to

The Dual Agenda Newsletter

Support Our Work:

Donate