PREVENTING SPECIFIC ADVERSE OUTCOMES — Living facilities and hospitalization for the older adult patient can result in unintended adverse consequences from interventions meant to be therapeutic. Bed rest, polypharmacy, tethering devices (eg, intravenous lines, urinary catheters, telemetry, restraints), sensory deprivation, disruption of usual sleep patterns, and lack of proper nutrition all contribute to functional, physical, and cognitive decline. Since many older adults live on the brink between independence and functional dependence, even a small decline in function during hospitalization can place them in a position of newly acquired dependence.
Some decline may be unavoidable due to the effects of the acute illness. However, many of the harmful effects of hospitalization can be avoided or minimized by addressing specific risks that predispose to a poor clinical outcome.
Functional decline — Bed rest and lack of mobility combine to hasten physical deconditioning and muscle weakness . Immobility is associated with increased risk for falls, delirium, skin breakdown, and venous thromboembolic disease. Improved mobility during hospitalization has been linked to decreased risk of death at two years.
Although a few conditions require absolute bedrest (eg, unstable fractures and certain critical illnesses), most medical conditions do not necessitate immobility. Activity orders for bed rest should be avoided unless absolutely medically required. Staff should attempt to get patients out of bed to a chair with meals, which also decreases risk of aspiration and, when possible, encourage patients to walk several times daily.
Patients who have difficulty ambulating on their own or who pose a significant fall risk may need supervision by trained staff (eg, physical therapy) or referral to a specialized mobility program. Increased activity during hospitalization can mitigate functional decline so that patients can transition optimally outside the hospital setting.
Falls — Older hospitalized adults are at great risk of falling due to the effects of the acute illness compounded by an unfamiliar environment and side effects of treatments. The etiology of a fall is often multifactorial. Many of the interventions needed to address the acute illness can increase the risk of falling. As an example, interventions to treat an older adult in heart failure (eg, antihypertensive medications, diuretics, telemetry, and an indwelling urinary catheter) all combine to increase the patient’s propensity to fall.
Several strategies can help prevent falls in the hospital setting.
●The risks and benefits of medications with significant psychotropic and anticholinergic effects (eg, opioid analgesics, benadryl) should be carefully weighed.
●Patients should be monitored when prescribed drugs that might increase the risk of falls (eg, when diuretics are prescribed, blood pressure and volume status should be monitored closely to avoid orthostatic hypotension).
●Patients at higher fall risk may need supervision with ambulation.
●Time out of bed throughout the day should be encouraged, whether walking or sitting in a chair, to prevent orthostatic hypotension associated with prolonged immobility.
●Intravenous lines and urinary catheters should be discontinued as early as possible.
●Restraints should be avoided since restraints, either physical or pharmacologic (eg, antipsychotics, benzodiazepines), may increase the risk of falling.
Nonetheless, it is likely that the majority of falls that occur in the hospital setting may not actually be preventable. Bed alarms have not been demonstrated to be effective at reducing falls and may increase the risk of alarm fatigue, be distressing to patients, and lead to a false sense of security. In the United States, Medicare does not reimburse hospitals for complications or extended length of stay related to falls that occur during the course of hospitalization. It is important that institutions not adopt potentially deleterious practices, such as increased use of strict bed rest orders, restraints or restraint-like chairs or other devices, in an effort to decrease their revenue losses.
Delirium — Delirium is acute brain failure characterized by inattention and a fluctuating course. The Confusion Assessment Method is frequently used to diagnose delirium. An altered level of consciousness and/or disorganized thinking are usual components of delirium. Early recognition of delirium is important in ensuring prompt delivery of appropriate care.
Many aspects of hospitalization inherently promote delirium for the older patient. The change in environment from the comfort of home to a hospital room is disruptive to the patient’s daily routine. An older patient, particularly someone with preexisting cognitive impairment, is prone to developing delirium. Pain, interruption in sleep patterns, and several classes of medications are also important risk factors for delirium. Confusional states can be worsened when sensory input is affected, such as occurs when a patient lacks access to eyeglasses or hearing aids.
Effective measures to prevent delirium include orientation protocols, environmental modification, nonpharmacologic sleep aids (eg, warm milk or herbal tea offered at bedtime, relaxing music, soft lighting, massage), early and frequent mobilization, minimizing use of physical restraints, use of visual and hearing aids, adequate pain treatment, and reduction in polypharmacy (particularly psychoactive drugs).
Some hospitals have found that patients with delirium benefit from specialized care delivered in a dedicated room for disoriented patients. This room supports multidisciplinary care that avoids the use of restraints and reduces use of psychoactive drugs. These “delirium rooms” can offer a useful option for caring for delirious patients, using the T-A-DA method (Tolerate, Anticipate, and Don’t Agitate) to guide the approach to caring for delirious patients.
Sleeplessness/sleep deprivation — Multiple factors contribute to sleep deprivation during hospitalization, including an unfamiliar sleep setting, conditions related to illness (eg, shortness of breath, pain), environmental factors (eg, noise, light), and the logistics of providing care (eg, phlebotomy, medication schedules). Inadequate sleep, whether it is too short in duration, of poor quality, or interrupted, may contribute to a host of complications.
The link between poor sleep and delirium remains elusive. However, older hospitalized adults who received a multicomponent intervention, including protocols to address sleep deprivation, had a decreased risk for developing delirium. Strategies such as bundling care at night (eg, vital sign monitoring, dispensing medications, toileting) and creating a conducive environment for sleep with low light and quiet surroundings may help achieve improved sleep for patients receiving care in the hospital and decrease the risk for delirium and other adverse events.
Tethers — Some tethering medical devices, such as urinary catheters, intravascular lines, cardiac telemetry leads, and restraints, may be necessary to provide optimal care. However, tethering devices make it more difficult to mobilize patients safely and are associated with increased rates of delirium, infection, and falls, and the devices can contribute to sleepless nights and distress from ringing alarms. Tethers are commonly ordered when not absolutely indicated and, even when initially appropriate, may remain in place when no longer needed. As an example, despite the well-publicized risks of indwelling urinary catheters, their use and associated complications have not declined over several decades.
Clinicians should weigh the risks and benefits of each tethering device and initiate use only when the likelihood of benefit is significant and in keeping with the patient’s preferred intensity of care, and there is no effective alternative. As an example, if a patient prefers not to be resuscitated in the event of a cardiac arrest, the benefit of continuous cardiac telemetry should be questioned.
There may be options to reduce the total tether burden, such as the use of fluid boluses rather than continuous intravenous fluids. In most cases, urinary catheters should not be used as a treatment for incontinence or as a substitute for getting the patient up to the bathroom.
Infections — Underlying health conditions, poor nutritional status, and greater severity of illness contribute to increased rates of hospital-acquired (or nosocomial) infections in older patients. Heightened clinical suspicion is necessary to identify infection in older patients as they may demonstrate only atypical symptoms, including delirium. Fever may not be present in older patients with an active infection.
Infections commonly seen in older hospitalized patients include:
●Clostridioides (formerly Clostridium) difficile-associated diarrhea – C. difficile is the most frequent cause of nosocomial diarrhea and a significant cause of morbidity and mortality among hospitalized older patients. The incidence of C. difficile infection continues to rise.
Contact precautions help to prevent spread of C. difficile spores and should be used in patients who have suspected or proven C. difficile infection.
●Pneumonia – Hospital-acquired pneumonia (HAP) is pneumonia that is not associated with mechanical ventilation and that develops 48 hours or more after admission.
Patients with advanced dementia, severe Parkinson disease, or other neurologic conditions are at high risk for aspiration pneumonia. Older patients treated with antipsychotics are also at increased risk for developing aspiration pneumonia.
HAP prevention measures include avoiding acid-blocking medications, attending to oral hygiene, and feeding only at times when the patient is alert and able to sit upright. Patients who cough when swallowing may be showing signs of swallowing dysfunction and aspiration. Offering increased assistance with feeding, modified consistency of foods, and a formal swallowing assessment may be warranted.
●Urinary tract infections – Urinary tract infections associated with urinary catheters are the leading cause of secondary nosocomial bacteremia, which is associated with high mortality. Patients with indwelling catheters often do not experience typical signs of urinary tract infection. Blood and urine cultures should be obtained when patients develop fever or otherwise unexplained systemic manifestations compatible with infection (eg, altered mental status, fall in blood pressure, metabolic acidosis, and respiratory alkalosis).
The most effective strategies to reduce urinary infections are avoidance of unnecessary catheterization and catheter removal when the catheter is no longer indicated.
●Intravascular catheter-related infections – Intravascular catheter infections are an important cause of morbidity and mortality.
Several preventive measures, such as wiping access sites with antiseptic and connecting only to sterile devices, can markedly reduce the rate of intravascular catheter infections.
Infection control programs aim to prevent and reduce rates of nosocomial infections. Major components of infection control are :
●Standard (universal) precautions
●Isolation precautions when appropriate, with recognition that isolation may increase the risk of delirium in older adults
●Environmental cleaning
●Surveillance
Standard precautions are recommended in the care of all hospitalized patients to reduce the risk of infection transmission between patients and health care workers, even when the presence of an infectious agent is not apparent. Precautions include hand hygiene before and after every patient contact; use of gloves, gowns, and eye protection for situations in which exposure to body fluids is possible; and safe disposal of sharp instruments in impervious containers.
Malnutrition — Poor nutrition for older hospitalized patients may result from several factors:
●Impaired cognition or delirium
●Poor appetite, nausea, or constipation (due to underlying illness or as side effects of medications)
●Restriction of movement
●No access to dentures
●Difficulty in self-feeding
●Severely restricted diet orders (eg, “nothing by mouth”)
Evaluation for malnutrition includes a history of changes in weight, dietary intake, and physical examination, as well as select laboratory and radiologic studies.
Simple interventions such as getting an older patient out of bed at mealtime and providing assistance with feeding can improve nutritional intake during hospitalization. Inpatient assessment by a nutritionist can identify nutritional deficiencies in older patients and, combined with subsequent nutritional follow-up in the community after discharge, may decrease mortality. Patients should be allowed to eat unless medically required to be maintained “nothing by mouth.” Generally, restricted diets are not required for older patients and when ordered may further limit the nutritional intake of older patients. Even patients with heart failure may be allowed access to an unrestricted diet without adverse impact during hospitalization.
Nutritional repletion may be provided to restore the patient to a target weight, with recognition that weight correction in the older population is less readily accomplished than in younger people.
Pressure ulcers — Several host and environmental factors increase the risk of developing pressure ulcers during hospitalization in older patients, including :
●Poor nutritional status
●Incontinence, causing a moist environment
●Immobility
●Neurologic impairment
Optimizing nutritional status and limiting time spent in one position can help prevent pressure ulcers. Patients who are bed-bound should be repositioned at least every two hours, with proper repositioning techniques to minimize shear forces. Pressure-reducing products for patients at increased risk of ulcers should also be used. Clinical risk assessment and preventive interventions are discussed in detail separately.
Venous thromboembolism — Hospitalization is a significant risk factor for developing venous thromboembolism. The use of prophylaxis for venous thromboembolic disease, including pharmacologic or mechanical methods, depends on the individual risk of thrombosis and bleeding. Prophylactic anticoagulation is generally recommended for most patients >75 years of age who are hospitalized for an acute illness and who do not have risk factors for increased bleeding.
Adverse drug events — Serious adverse drug events include delirium, urinary retention, orthostasis, metabolic derangements, bleeding from anticoagulation, and hypoglycemia related to medications for diabetes. Gastrointestinal side effects, including nausea, anorexia, dysphagia, and constipation, are common. Adverse drug events increase the length of stay and costs of care.
Several high-risk drugs are commonly associated with adverse drug events in hospitalized patients. Multiple medications, often new to the patient during hospitalization, potentiate the risk of nutritional, functional, and cognitive decline in older adults during hospitalization, as well as increase the risk of overall mortality. With physiologic decreases in liver and kidney function, older patients have a higher incidence of adverse drug events than younger patients.
Minimizing the use of nonessential medications can reduce the risk that an older patient will suffer from an adverse drug event. Avoiding potentially inappropriate medication and starting with the smallest possible therapeutic dose can similarly help avoid adverse drug events. Older patients who have impaired renal or hepatic function should have dosage of medications (eg, antibiotics) adjusted appropriately.
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