Hospitalization of Older Adults: Are We Doing a Good Job?
Article Outline
Barbara Resnick, PhD, CRNP, FAAN, FAANP
This may seem like a rhetorical question given the many concerns identified in the care of older adults. Programs such as Acute Care for the Elderly (ACE units) and Nurses Improving Care for Health System Elders (NICHE) programs suggest we are trying to address this level of care. The NICHE program, for example, which was funded by the Hartford Institute in 1992 to disseminate best practices related to geriatric nursing, communicate innovations, and increase public awareness of issues in gerontology, includes more than 100 acute care facilities. We have, I believe, much work yet to do. Thus our goal in this journal issue, which is focused totally on work done in the acute care area, is to highlight some terrific projects focused on older adults in acute care settings.
Doing a brief review of the literature looking at outcomes for older adults in acute care, I was reminded of some of the more prevalent problems identified: consent issues—consent to go to the hospital and then consent to have procedures or treatments performed, medication management, cognitive issues, falls, optimizing and maintaining function, urinary function, nutritional issues, care of the caregivers/families, pressure ulcers, and infections. What do we know about the current practices in acute care, and where should we go? On the good news side, nurses were responsible for high rates of adherence to certain screening indicators (pain, nutrition, functional status, pressure ulcer risk; P < .001 when compared with physicians). Unfortunately, however, in patients with functional limitations, nursing admission assessments of functional limitations often did not agree with reports of actual limitations by patients on admission. Moreover, one must ask, what happens after these baseline nursing assessments are performed? How is the information used? Assessing is easy compared with the follow-up work of preventing clinical problems and optimizing function, nutrition, skin integrity, and the like.
Looking Specifically at Consent
Respect for patient autonomy is critical, and informed consent is required for clinical procedures such as surgical interventions, blood transfusions, and certainly the use of experimental drugs. Survey findings of older patients noted that 85% of these individuals wished to participate in even trivial medical decision making such as medication management with vitamins or replacements, and 92% wished to participate in treatments with moderate risk such as drugs with side effects.1 When a risk was initially posed as less than a 5% to 20% risk and the benefits of therapy were substantially higher, such as prevention of death from a pulmonary embolus, 93% wanted to make the decision. If the risk of brain hemorrhage was 20% or greater, 95% wanted to make the decision. Younger patients (<65 years) were more likely to prefer requiring that health care providers obtain their “permission no matter what” than were older patients (≥65 years), and older patients were more likely to waive consent across levels of risk.1
OK, so you are thinking—great idea, consent, but how about those individuals with cognitive impairment (CI) or those with delirium during the hospital admission? Although prevalence varies depending on the study, we generally estimate that approximately 50% of hospitalized elders have CI. CI is not, however, a measure of ability to give consent. Rather, there are measures that can be used, such as the Evaluation to Sign Consent,2 which more comprehensively address the individual's ability to understand what is being recommended and weigh the benefit and risks. We all need to be careful to avoid being too paternalistic or maternalistic and provide older individuals with at least an opportunity to consent.
Hospital-based infections, particularly methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resilient Enterococcus (VRE) and Clostridium difficile are prevalent and known to increase morbidity as well as length of stay for the highly vulnerable older individuals who are exposed to them. It is not clear that staff working in acute care settings really know the best ways to prevent the passage of these infections. Interventions such as removing catheters as soon as possible, treating infections only and not contamination or colonization, stopping treatment when the individual is cured, and isolating and containing the contagion are all important steps to prevent antimicrobial resistance. Preventing spread from health care workers' hands and clothing, from environmental surfaces, and from equipment used in the settings is also critical. Hand washing with what? Soap and water are optimal for prevention of C. difficile, but alcohol-based preparations are equally or more effective for MRSA or VRE. More intensive cleaning of the environment is needed with hydrogen peroxide vapors and quarternary amines. Currently there is not 100% compliance with these recommendations.
Medication management is certainly a whole additional area of patient safety (see the Pharmacy Column in this issue). The transfers of one list of medications for an older adult from the home, nursing home, or assisted living setting to the inpatient acute care setting is critical so that old problems (such as cardiac arrhythmias) are not exacerbated. Likewise, a careful review of discharge medications with the patient, family, or facility the older individual will go to upon discharge is also important. We look toward electronic medical records to help solve medication problems, although we must remember that electronic data will only be as good as the information that is entered.
And last, but not at all least, is the whole area of function and optimizing function in older adults during acute care stays. Having just lived through a 2-month period of being non–weight bearing because of orthopedic surgery, I learned firsthand how quickly muscle wasting and atrophy occur. We owe it to our older patients to prevent this decline and to consider this aspect of care as critical, even in the face of potentially life-threatening illness. As with restorative care philosophies implemented in the nursing home or assisted living setting, this philosophy of care must be supported by all members of the health care team and include the family, administration; it must also be supported by the hospital environment and policies.
So, I do not believe we are there yet in terms of providing the best possible care to older adults in the acute care setting. I urge you to review the articles provided in this issue of Geriatric Nursing and consider trying some of the interventions recommended to improve care to those you nurse in acute care. If you are not one of those nurses providing direct care to older individuals in acute care, please share your journal with others or refer them to these articles so we can spread the word. In so doing, we can stop the finger pointing and start working together through the common transitions patients endure in our health care system. This will be a win-win for patients and providers alike.
References
PII: S0197-4572(08)00134-1
doi:10.1016/j.gerinurse.2008.04.001
© 2008 Mosby, Inc. All rights reserved.
