The risk of an older adult developing a new activity of daily living (ADL) disability during a hospitalization is estimated to be at least 30%, and about half of all older adults’ disabilities develop during a hospitalization.¹ Frail elders with limited functional reserves fare even worse. Unfortunately, one year after hospital discharge, less than half of older adults have returned to their prehospitalization level of functioning.² Certainly, hospitalization may be necessary to provide treatment to older adults. Knowledge of the many causes of functional decline in the hospital and actions aimed at functional status preservation are paramount for any practitioner caring for hospitalized older patients. It has been estimated that 7% to 15% of the 1 million older adults with Medicare who are hospitalized each year experience a preventable adverse event.

Because of severe physiologic stressors and nosocomial exposures, hospitalization is best thought of as a resource to use carefully in the care of older adults.

CASE 1 Robert Johnson (Part 1)

You are called by a local emergency department about your 81-year-old patient, Mr. Johnson, who has suffered a mild stroke and fractured his hip during a related fall. Mr. Johnson has been your patient for about 7 years, since relocating to be near his adult children. Since losing his wife 3 years ago, Mr. Johnson’s visits to your office have been sporadic, and he is under the care of several subspecialists for his macular degeneration, presbycusis, hypertension, and mild diastolic congestive heart failure. Cognitive testing was borderline during a visit 1 year ago, and a geriatric depression screen was positive, but he declined pharmacologic interventions and counseling at that time. The decision is made to admit Mr. Johnson to the hospitalists and obtain a consultation from the orthopedic service.

What factors in his history need to be relayed to the team that will be caring for him in the hospital?

Communication is essential in the hospital

Caring for older adults in the hospital should involve an interprofessional group of care providers. Optimal geriatric hospital care is provided by nursing case managers and geriatric social workers to assist in coordinating discharge needs, dieticians working to find food that is the correct caloric density and texture, nurses and nursing assistants providing direct patient care who are often the first to notice a patient change, consulting physicians, hospitalists, pharmacists, physical therapists, occupational therapists, and speech and language pathologists all working together to bring optimal care to older adults and their families. This large number of team members all must communicate with each other and with the patient and family during the hospitalization. This gathered information must additionally be communicated in an efficient and accurate way to the receiving facility that will take over care once the patient has left the hospital. This can include a rehabilitation facility, a skilled nursing facility, a long-term acute care hospital, a family member’s home, or the patient’s own residence (see Chapter 2.

Since the term hospitalist was first used in 1996 to describe the growing number of physicians whose primary site of practice was within the hospital, the field has expanded rapidly.³ In urban areas today, hospitalists provide the majority of nonsurgical care to hospitalized adults in the United States.³ The hospitalist often is the primary care coordinator and communicator among the many team members involved in the care of an older adult in the hospital.

Outcomes for hospitalists are generally at least as efficient and effective as nonhospitalist providers, but the field has highlighted the critical need for excellent communication within all members of the health care team, including the family. With the increased percentage of patients being cared for by hospitalists, the importance of communication across locations of care has increased. It is critically important for the hospitalist to communicate at the time of admission and discharge with both primary care providers and with accepting physicians at skilled nursing facilities or rehabilitation units.

Primary care physicians, hospitalists, caregivers, and all members of the health care team caring for a hospitalized geriatric patient need to ensure maximal communication.

Hospital design and systems change to benefit older adults

Much as pediatric hospitals underwent changes in design to better reflect the unique needs of their young patients, specific areas in many hospitals today are designed to optimally meet the needs of older adults. NICHE and ACE units are two specific programs that are aimed to improve the care of older adults in the hospital.

In 1992, with funds from the John A. Hartford Foundation, New York University began broadly field-testing nursing care models including the geriatric resource nurse (GRN) program. This project became known as Nurses Improving Care for Health System Elders (NICHE) and aimed to create a better care environment for the hospitalized elderly patient by improving nursing practice.⁴ Nursing leadership is integral to good care of older adults, and the NICHE program provides resources, project management support/mentoring for NICHE-based hospital initiatives, evidence-based clinical protocols that address “never events,” and shared information, knowledge, and expertise to more than 300 participating hospitals.⁵

Acute care for the elderly (ACE) units have demonstrated improved functional outcomes without increased costs or length of stay.⁶ This model of comprehensive inpatient geriatric care incorporates (1) hospital environment modifications, (2) minimization of adverse effects of hospitalization, (3) early discharge planning, and (4) patient-centered care protocols.⁷

The benefit of ACE units is also being expanded hospitalwide. The concept of a mobile acute care for the elderly (MACE) unit has also been described. The main goals of the MACE unit are to bring the interdisciplinary, patient-centered team approach to hospitalized older adult patients throughout a hospital, rather than having the team located solely on one geographically based unit. A 2010 study found that among more than 8000 older adults, those being treated via MACE service (compared to those admitted to an ACE or a traditional unit) had lower length of stay and lower costs with no change in in-hospital mortality or 7- or 30-day readmission rates.⁶

Stressors in the hospital are summative and include the inciting medical or surgical event, and also sleep deprivation, medication side effects, sensory deprivation, and caloric deficiencies resulting from restrictive diets, nothing-by-mouth status, or general illness.

Hospital physical design

In addition to a redesign of care processes and procedures for caring for older hospitalized adults, the physical environments of hospitals are additionally being designed to allow for improved care.⁸ Hospital design that focuses on the needs of older adults and their families has improved the hospital campus, the unit, the room, and the amenities available. Design features can include reserved or valet parking and benches along long walkways; handrails; matte floor finishing or low-pile carpeting; low-color-contrast floors with clear contrast with walls; sound-absorbing materials in rooms with available assistive listening devices; choice of chairs with armrests; automatic faucets and doors; and easy-to-see and easy-to-activate call systems.⁸

Patient- and family-centered geriatric hospital care

Because many older adults rely on additional support for successful aging, geriatric hospital care must embrace the principles of patient- and family-centered care. As defined by the Institute for Patient- and Family-Centered Care, the core principles include respect and dignity, collaboration, participation, and meaningful information sharing.⁹ Family is defined as broadly as possible to include any person that an older adult may rely on for support, whether emotional, physical, or financial.⁹ Partnership with family during the hospitalization of older adults is paramount to a successful admission, and every attempt to involve family at the highest level desired by the patient should be sought. Minimizing barriers to family participation in health care should always be a paramount goal of excellent care.

The use of specialized acute care for the elderly (ACE) units can improve outcomes by modifying the hospital environment to be less disruptive to older adults.

The admission process: Opportunities for health status updates

When an older adult requires admission to the hospital, communication among providers inside and outside the hospital is critically important. The primary care physician and/or the nursing home physician and the family must all be involved to ensure a meaningful admission. For patients living in long-term care settings, often the nurses and/or patient care attendants/nursing assistants have valuable information about symptom development, and attempts to contact these care providers should be undertaken. Because older adults vary widely in their functional and health status, critical decisions about treatment should never be based solely on the patient’s age. The in-hospital medical team will need guidance from community-based providers to accurately assess the older patient’s baseline functional status.

At the time of admission, the hospital provider should perform a review of systems that focuses on geriatric syndromes and other issues common to older adults, including cognition and functional independence in ADLs and instrumental activities of daily living (IADLs). Vaccine status, especially about pneumococcal, seasonal influenza, and herpes zoster should also be ascertained. The time of admission to the hospital is also an excellent time for a medication review for both accuracy and necessity of all medications, both prescribed and over-the-counter. The presence of advance directives and documentation of a surrogate decision maker is also among information that should be incorporated into the admission record. Advance directives should also be discussed and documented.

The admission process provides an opportunity to review medications and ensure appropriate indications for all prescriptions, as well as ascertain vaccine status, code status, alcohol use, and elder abuse risk factors.

Elder abuse

Screening for elder mistreatment among asymptomatic populations has not been evaluated, but the presence of elder abuse has been estimated to be between 2% and 10%.¹⁰ Elder abuse can broadly be defined as physical, psychological, or sexual abuse, material exploitation of money or property, or neglect and failure to meet a dependent older person’s needs. The possibility of nonaccidental trauma or neglect of an older adult admitted to the hospital should be entertained by the clinician based on a high index of suspicion.¹⁰ Identification of social support and appropriate referral to area Adult Protective Services agencies should be made whenever elder abuse is suspected (see Chapter 33).

Alcohol abuse

During the admission to the hospital, a discussion on alcohol use should be completed. The prevalence of older adults with alcohol-related problems has been reported to be between 2% and 22%, depending on the definition used.¹¹ With the aging population, even with a constant prevalence, the number of older adults with alcohol use problems will increase dramatically. Screening tools for younger adults usually focus on work or legal difficulties that arise from drinking, and these consequences are rarer in older adults with harmful drinking patterns.¹¹ Unfortunately there are currently no appropriate screening questionnaires validated for older adults to detect harmful or hazardous drinking patterns (see Chapter 34).

Frailty as a risk for poor hospital outcomes

Frailty is a geriatric syndrome defined as a state of increased vulnerability to both acute and chronic stressors as a consequence of reduced physiologic reserve.¹² Frailty is associated with functional decline, loss of independence, and mortality. The identification of this syndrome should be readily considered for any older adult being admitted to the hospital (see Chapter 29). The concept of frailty is relevant for providers of geriatric hospital care, because it provides a ready explanation for the different stress tolerances of older adults. Stressors in the hospital are summative and can include not only the inciting medical or surgical event, but also sleep deprivation, medication side effects, sensory deprivation, and caloric deficiencies resulting from restrictive diets, nothing-by-mouth status, or general illness.^12–14 For men and women older than age 60, ten days of bed rest results in a similar loss of muscle mass as a decade of normal aging.¹³ To help lessen the impact of hospitalization on older adults, physical activity (especially resistance training), nutritional consultations and supplementation, and vitamin D supplementation when appropriate should be strongly considered.¹³

Perioperative care of the elderly patient in the hospital

Nearly half of all patients undergoing a surgical procedure are now older than age 65, with the percentage expected to increase further over the next 15 years as the population continues to age.¹⁵ Studies have shown 21% of elderly patients will suffer from at least one perioperative complication following a nonthoracic surgery, potentially leading to prolonged hospitalization, increased mortality, and long-term morbidity.¹⁶^,¹⁷ Because of the heterogeneity of elderly patients, a patient-centered approach in close conjunction with the surgical team is required to reduce the risk of complications and adverse outcomes.

CASE 1 Robert Johnson (Part 2)

Mr. Johnson was admitted to the hospital yesterday for his focal weakness and hip fracture. He was seen by a neurologist, who expects continued recovery of left leg weakness that is the result of a small ischemic stroke. He was put on nothing-by-mouth status at the time of admission and the orthopedic surgeon is planning on taking him for operative repair later this afternoon.

In what ways can his care be optimized at this point in the hospitalization?

Establishing goals of care

The preoperative evaluation of elderly patients begins with a frank discussion on goals of care (Figure 10-1). Survival and longevity may be the most important outcomes for a younger population but it may not be the primary goals for every elderly patient. A more important outcome may be related to the patient’s functional status following the surgery. A full discussion of all the potential outcomes is necessary, with an honest discussion of prognosis of recovery related to functional status and the potential loss of independence. Elderly patients may elect to forgo emergent interventions if the outcome would likely lead to loss of independence and functional status, and instead may elect for only comfort care measures. The role of the medical clinician in the preoperative evaluation is to help review all of the options for the patient including the option for palliative care. The preoperative evaluation provides an excellent opportunity to better define end-of-life decision making for the patient, especially for those surgical interventions that carry significant risks for the elderly patient. Patients should be encouraged to discuss their decisions with family members and their health care power of attorney to prevent undesired interventions in the future.

Figure 10-1 Preoperative evaluation. (Adapted from Fleisher LA, Beckman JA, Brown KA, et al. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009;120(21):e169-e276.)

Emergent surgery

Generally, patients who have acute surgical emergencies may proceed to the operating room with the assumption that any potential risk would be less than the potential benefit of the surgery. This may not be as true for elderly patients, and goals of care still must be addressed even in the emergent situation. A lifesaving surgical intervention that leads to loss of independence may not match the goals of care for an elderly patient, and palliative care is an important option to provide the patient. The emergent evaluation includes a brief discussion on preoperative functional status to help assess functional reserve along with the goals of care for the individual patient. Elderly patients who undergo emergent surgeries have a higher risk of adverse outcomes and long-term morbidity that may lead to loss of independence especially in those with low preoperative functional status.

Perioperative care in the hospital must be based on goals of care and should strive to ensure evidence-based use of risk stratification, medications, and early mobilization to prevent prolonged hospitalizations and nosocomial infections.

Cardiac evaluation

Cardiac risk factors

For patients who are unable to achieve 4 METs or if functional capacity is unknown, an evaluation of risk factors for perioperative events (e.g., ischemic heart disease, renal insufficiency, cerebrovascular disease, diabetes, or history of congestive heart failure) should be pursued.²⁴ Patients who have no risk factors may proceed to the OR without any further cardiac evaluation. Patients with one to two risk factors may proceed to OR with beta-blockade, or noninvasive coronary evaluation can be considered. Patients with three or more risk factors undergoing an intermediate-risk surgery may also proceed to OR with beta-blockade or may undergo noninvasive coronary evaluation. Those patients with three or more risk factors undergoing high-risk surgery may proceed to the OR with beta-blockade and a statin, or noninvasive coronary evaluation should be considered if those results have the potential to alter decision making and change management.

Cardiac risk reduction through medical interventions

Beta-blockade

There have been multiple studies looking at beta-blockade in the perioperative period, with conflicting results.25–28 Early studies showed significant promise for the prevention of acute myocardial infarction; unfortunately, follow-up studies have not consistently demonstrated this benefit. Two studies in 2007 and 2009 led to an update of the American College of Cardiology Foundation/American Heart Association (ACCF/AHA) Perioperative Guidelines in 2009, and provide guidance for applying the conflicting data in practice.²⁵

More recent studies confirmed the cardioprotective benefit of perioperative beta-blockade but demonstrated the increased risk of stroke and death. The differences between the studies provide insight into the mechanism of risk for perioperative beta-blockade and provide guidance for initiating beta-blockade. The avoidance of hypotension and bradycardia appears vital to reduce the risk of ischemic stroke. Beta-blockade should be initiated at a low dose and titrated slowly up to goal prior to surgery. The exact timing for initiating beta-blockade has not been established, but based on the results of available data, same-day initiation with rapid titration should be avoided.²⁷

HMG-COA reductase inhibitors (statin therapy)

The only prospective randomized trial on perioperative statin use was a small study of 100 patients investigating the perioperative use of atorvastatin for vascular surgery.²⁹ Patients were placed on 20 mg atorvastatin for a total of 45 days and a minimum of 2 weeks prior to the surgery with a composite outcome of death from stroke and acute coronary syndrome. A statistically significant difference in composite outcome was reached in the atorvastatin arm versus placebo at 6 months (8% vs. 26%). Multiple retrospective studies have also shown reduced perioperative cardiac events with the use of statins in both vascular and nonvascular studies. Based on the limited evidence available, the 2009 ACCF/AHA Guidelines find the use of statins “reasonable” for patients undergoing vascular surgery and “may be considered” for patients with one or more risk factors undergoing intermediate-risk surgery.²⁵

Perioperative pulmonary complications

Perioperative pulmonary complications (PPCs) are encountered frequently following noncardiothoracic surgeries and contribute significantly to perioperative and long-term morbidity and mortality. The American College of Chest Physicians includes atelectasis, pneumonia, respiratory failure, and exacerbation of underlying chronic lung disease as PPCs. An incidence of 5.5% to 6.8% is found when using rigorous methods to define PPC.¹⁷^,³¹ PPCs are an even stronger predictor than perioperative cardiac complications for longer term perioperative mortality in the elderly, with a hazard ratio of 2.41.³⁰ Despite being a stronger predictor for adverse outcomes and having a similar frequency as perioperative cardiac events, perioperative pulmonary evaluation and PPCs prevention are often placed at a lower priority by clinicians and patients. Because advanced age is a risk factor for PPCs, clinicians who care for the elderly need to have increased awareness and diligence in evaluating and preventing PPCs.

Preoperative pulmonary evaluation

The preoperative pulmonary evaluation starts with identification of risk factors for developing PPCs (Box 10-1). Of the risk factors listed, a history of chronic obstructive pulmonary disease (COPD) and age older than 60 are the two highest predictors of the development of PPCs. The risk for PPCs increases with each decade, with odds ratios of 2.09 for patients 60 to 69 and 3.04 for patients 70 to 79.³² Another important risk factor is functional status, which predicts both overall mortality and risk for PPCs with an odds ratio of 2.51 for developing PPCs if patients are unable to perform any ADLs and 1.65 if they require assistance for some of their ADLs. Those patients who are identified as having any risk factors for PPCs should proceed to additional evaluation and undergo preoperative and postoperative interventions to reduce risk.

BOX 10-1

PULMONARY RISK FACTORS