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Hospital Units Tailored To Older Patients Can Help Prevent Decline
By Anna Gorman
Published: August 9, 2016
Nurse specialist Annelie Nilsson checks on patient Janet Prochazka during her stay at the Zuckerberg San Francisco General Hospital, after Prochazka took a bad fall in March.
Heidi de Marco/Kaiser Health News
Until March of this year, Janet Prochazka was active and outspoken, living by herself and working as a special education tutor. Then a bad fall landed her in the Zuckerberg San Francisco General Hospital.
Doctors cared for her wounds and treated her pneumonia, but Prochazka, who is 75, didn't sleep or eat well in the hospital, and she became confused and agitated. Then she contracted a serious stomach infection.
Patients over 65 tend to be less resilient during a hospital stint than younger patients, research finds, and more vulnerable to mental or physical deterioration, even if they recover from the illness or injury that sent them there. One study published in 2011 found that about a third of patients older than 70 and more than half of patients over 85 left the hospital more disabled than when they arrived.
As a result, many previously independent seniors are unable to care for themselves after discharge and need assistance with daily activities such as bathing, dressing or even walking.
"The older you are, the worse the hospital is for you," says Dr. Ken Covinsky, a physician and researcher at the University of California, San Francisco's division of geriatrics. "A lot of the stuff we do in medicine does more harm than good. And sometimes with the care of older people, less is more."
As hospital staffs focus on treating the acute injury or illness, they may fail to ensure that older patients get adequate nutrition, he says, or fail to get them out of bed enough or control their pain adequately.
Hospital patients are often inadvertently restricted in their movements because of tethers to oxygen tanks and IV poles. They are subjected to various procedures and medications, and are often in noisy rooms, where careful monitoring means checking their vital signs at all hours of the night.
Ron Schwarz, 79, was hospitalized after falling in the shower. He spent time healing at the Acute Care for Elders unit at San Francisco General, one of about 200 such units nationwide.
Heidi de Marco/Kaiser Health News
And if the drug side-effects, interrupted sleep, unappetizing food and long days in bed are annoying when we're young, they can cause lasting damage as we get older, Covinsky says. Studies find that elderly patients often process medications differently than younger people, for example, and frequently have multiple medical problems, not just one.
Their needs are particular enough that some hospitals have established separate medical units to treat elderly patients.
San Francisco General is one such hospital. Its Acute Care for Elders ward, which opened in 2007, is staffed by a health team trained in geriatrics. They focus less on the original diagnosis and more on how to get patients back home, living as independently as possible.
Early on, for example, the staff tests patients' memory and assesses how well they can walk and care for themselves at home. Patients are also encouraged from the start to do things for themselves as much as they are able throughout their stay. The health team removes catheters and IV tethers as soon as medically advisable, and supports patients in getting out of bed and eating in a communal dining area.
"Bed rest is really, really bad," says the unit's medical director, Dr. Edgar Pierluissi. "It sets off an explosive chain of events that are very detrimental to people's health."
Such units are still rare—there are only about 200 around the country. And even where they exist, not every elderly patient is admitted, in part because space is limited.
Prochazka initially went to the emergency room and was admitted to the intensive care unit from there. She was transferred to ACE about a week later.
Though the move to the specialized unit helped Prochazka, her doctor says, it couldn't completely restore her former health.
"She will not leave here where she started," Pierluissi said several days before Prochazka was discharged. "She is going to be weaker and unable to do the things you really need to do to live independently."
Still, the unit's staff—a team that includes a doctor, a nurse, a pharmacist and a social worker—came up with a plan specifically for Prochazka's needs that helped her heal. They weaned her off some of her medications. They got her up and walking. They also limited the disorienting nighttime checks.
Prochazka says that, once on the unit, she got "the first good night of sleep I have had." Ultimately, she was able to return home, and her health has continued to improve as she slowly regains strength.
How hospitals handle the old and very old is a pressing problem, geriatricians say. Nearly 13 million seniors are hospitalized each year—a trend that will only accelerate as baby boomers age.
Yet hospitals face few consequences if elderly patients become more impaired or less functional during their stay, Covinsky points out. The federal government penalizes hospitals when patients fall, get preventable infections, or return to the hospital within 30 days of their discharge, but the institutions aren't held accountable if patients lose their memory while there or become so weak they can't walk. As a result, most hospitals don't measure those things.
"If you don't measure it, you can't fix it," Covinsky says. The extra investment needed to create specialized units would pay off in the long run, he believes — for patients, hospitals and for the U.S., as it works to bring down health care spending.
ACE units have been shown to reduce hospital-inflicted disabilities in older patients, decrease lengths of stay and reduce the number of patients discharged to nursing homes. In one 2012 study published in the journal Health Affairs, researchers found that hospital units for the elderly saved about $1,000 per patient visit.