To prevent the onset of disability in their elderly patients, hospitals should focus on maintaining and restoring patients’ abilities to carry out activities of daily living while they are still inpatients, according to physicians from the San Francisco VA Medical Centre (SFVAMC) and the University of California, San Francisco (UCSF).
Writing in the Journal of the American Medical Association, a team led by SFVAMC geriatrician Dr Kenneth E Covinsky reviews the case history of a 70-year-old patient who lived independently before hospitalization but became permanently disabled afterwards, despite successful treatment of her medical illnesses.
“If you are over the age of 70, chances are one in three that if you go into the hospital, you will come out with a major new disability, such as lack of mobility or impairment of cognitive function, resulting from any of a constellation of factors that threatens your ability to live without assistance,” says Dr Kenneth E Covinsky, who is also a professor of medicine at UCSF. “Fortunately, we can prevent a lot of hospital-related disability by looking at how our older patients actually function, not at what diseases they may have.”
The authors used the patient’s story as a point of departure to review recent research and discuss why hospital-associated disability occurs and some possible ways to prevent it.
“For older people, hospitalization can become an episode of forced dependence,” says Dr Kenneth E Covinsky. “They are put in bed, their clothes are taken from them, their meals are brought to them, and very often, they will not get out of bed for days at a time. This has long-term effects on their ability to function for themselves.”
Many elderly patients are given urinary catheters as standard procedure upon admission, Dr Kenneth E Covinsky says, “which pretty much guarantees that they will stay in bed.” Catheters also present a sizable risk of infection and other side effects. “The idea behind placing a catheter is that we can monitor very accurately how much fluid the patient is producing, which is useful for treating heart failure and other conditions,” Dr Covinsky says. “However, we need to ask whether that accuracy is worth the cost to the patient – and it almost never is.”
Another common way in which patients are kept immobile in the hospital, says Dr Kenneth E Covinsky, is by the insertion of an intravenous (IV) line, which in turn is attached to an IV pole. “With this big pole stuck to them, they basically can’t move,” he says. “Hospital staff are not commonly trained to think whether the patient really needs an IV, or if they can be disconnected from the pole so that they can get up.”
The authors recommend that hospitals adopt treatment models for their elderly patients that focus on maintaining function. As an example, Dr Kenneth E Covinsky points to Acute Care for Elders (ACE) units that have been established in some hospitals, based on a model developed by Dr Seth Landefeld, SFVAMC chief of geriatrics and UCSF professor of medicine.
“On ACE units, there is much more emphasis on maintaining and restoring mobility and the ability to carry out activities of daily living,” says Dr Kenneth E Covinsky. “If patients can get themselves dressed, they are encouraged to dress in their street clothes. Instead of having food brought to them, they eat in a common dining room. Instead of the usual discharge planning process, which is often focused on simply clearing out the bed for the next patient, on ACE units it’s called ‘planning to go home,’ and the emphasis is on what the patient actually needs to continue independent life at home.”
The authors acknowledge that, in spite of these efforts, some elderly patients will still leave the hospital more disabled than when they arrived, often because of pre-existing vulnerabilities such as depression, cognitive disabilities, or advancing age. They say that hospitals need to recognize the risk of post-discharge disability and plan for it.
“When we send patients home with functional disabilities, we need to look at their situations realistically,” says Dr Kenneth E Covinsky. “Do they need to go up a flight of stairs to get in the door? Is there a caregiver to help them? Does the caregiver work? Do they need help getting groceries home? Is there equipment we should send them home with that will help them? Our job is to help them maintain independence to whatever extent we can.”
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