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THE HOSPITAL STAY

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Older hospitalized patients often experience syndromes that are uncommon in younger people, often referred to as “geriatric syndromes,” such as delirium, malnutrition, immobility, falls, and pressure ulcers. Therefore, providers who care for older patients in the hospital must be skilled in recognizing, treating, and preventing these common problems.

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In addition, older patients experience a fivefold increased risk of iatrogenic complications during hospitalization, compared to younger patients. These complications include infections, thrombosis, and ADEs, which can certainly contribute to posthospital institutionalization, functional decline, and hospital readmission. This high rate of complications has made the hospital care of elders a focal point of the patient safety movement over the last two decades, and has garnered the interest of researchers, payers, regulatory bodies, the federal government, patients, and their families.

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Also, older patients commonly experience discomfort and face end-of-life circumstances while in the hospital. Therefore, hospital providers must be proficient in the areas of palliative and end-of-life care as well.

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Common Problems in Hospitalized Older Patients

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Delirium
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Delirium is an acute, fluctuating, alteration in mental status that frequently affects older hospitalized patients (see also Chapter 47). Delirium is important because it is common and is associated with a long list of adverse outcomes. Although delirium occurs in about 25% of medical inpatients, the rates are much higher in surgical and critically ill patients. Delirium has been linked to increases in mortality, institutionalization, and length of stay, in addition to being a marker of future functional and cognitive decline. In the hospital, it is important to prevent delirium, and to recognize it when it occurs.

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The prevention of delirium depends on the identification of high-risk patients, and the avoidance of factors that might precipitate delirium in these patients. The major risk factors for delirium include underlying cognitive dysfunction/dementia, bone fracture on admission, sensory impairment (vision and hearing), high severity of illness, low functional performance, and age. Patients with risk factors for delirium can be treated with proactive preventative strategies, and can be monitored closely for the development of delirium. Prevention of delirium is based on avoiding the precipitants of delirium, which include medications (polypharmacy, or the use of specific medications such as sedatives, analgesics, or psychoactive medications); use of physical restraints; and the presence of an indwelling urinary catheter. Also, avoidance of common complicating disorders is important (eg, electrolyte abnormalities, dehydration, constipation, urinary retention, or infection). In addition to avoiding known precipitants of delirium, proactive strategies such as frequent orientation and use of eye glasses and hearing aids can also help to prevent delirium. The hospital environment also seems to contribute to delirium, possibly via interruptions in normal patterns of sleep and mobility, so efforts to encourage regular ambulation (if possible) and preserve normal sleep patterns may also help prevent delirium. While attention to these issues by individual physicians is important, the case can also be made for a more systematic, interdisciplinary approach. Many institutions have put formal, nurse-driven delirium prevention programs into place. These programs are designed to provide cognitive stimulation and improve sensory inputs, and to avoid environmental factors that might precipitate delirium. The Hospital Elder Life Program (HELP) uses an orientation board and a program of cognitive stimulation to reduce the rate of delirium in at-risk patients.

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Recognition of delirium can be difficult, as most patients with delirium have a “hypoactive” form of the disorder. These patients are not disruptive or aggressive, and their mental status changes can be easily missed. Recognition of delirium can be improved by understanding which patients are at highest risk for it, and by closely monitoring at-risk patients. Once suspected, a diagnostic tool such as the confusion assessment method can be used to help confirm the diagnosis. Additional information about the diagnosis and management of delirium can be found in Chapter 47.

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Immobility and falls
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Older patients fall down frequently (see also Chapter 48). This is evidenced by the fact that there were over 2.1 million emergency department visits for falls in this patient population in 2006. So, it is no surprise to learn that older patients are also at risk of falling when they are hospitalized. Estimates for inpatient falls among all hospitalized patients range from one to nine falls per 1000 patient-days, and the risk varies significantly among different hospital units. Inpatient falls are estimated to result in injury in one-third to almost one-half of cases. Most concerning is that an estimated 8% of falls result in moderate to severe injuries. Patients who suffer falls with injury have longer lengths of stay and higher costs than similar patients who do not fall. In addition to the in-hospital effects, a fall with injury may lead to serious long-term health outcomes as well. Falls among older patients are risk factors for increased use of health care resources in the future, functional decline, loss of independence, higher rates of discharge to extended care facilities, and even death.

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In hospitalized patients, the risk of falls increases with age, and with the history of prior falls. While risk factors are not synonymous with causative factors, some of the known risk factors for falling might be “modifiable,” which is to say that there may be a rational intervention that could mitigate the risk of falling that is related to that factor (Table 16-4). However, for the most part, strong evidence to support these interventions is lacking.

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Table Graphic Jump Location
TABLE 16-4POTENTIALLY MODIFIABLE RISK FACTORS FOR IN-HOSPITAL FALLS
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Given the well-described risk factors for falls among hospitalized older patients, a tool for identifying those patients at highest risk would be useful. Several such tools have been developed and are easy to use, but are known to have significant limitations. First, existing tools do not predict falls with great accuracy. In fact, these tools typically fail to outperform the routine judgement of clinical staff in recognizing fall risk. Also, these tools present fall risk as a dichotomous variable (low-risk or high-risk) when the risk is, in fact, a continuous variable. In addition, global risk tools do not always lead to specific preventative actions (ie, they do not link a specific finding with a specific intervention). The use of these tools has never been proven to directly lead to decrease in falls or injury, and, although they continue to be used in many settings, they are unlikely to lead to dramatic improvements in fall prevention.

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In fact, the majority of inpatient falls may not actually be preventable. Older patients fall down frequently—at home, in nursing homes, and in the hospital. Falls are not a problem that is unique to, or entirely caused by, hospitalization, and the goal of greatly reducing them is likely to be cost-prohibitive. Moreover, there are only limited data supporting the use of any intervention to reduce the risk of falls in the hospital. Most studies on single interventions have not demonstrated reductions, although there is some evidence that patient education about falls and how to avoid them may have a positive effect, as might computer-based interventions to reduce the use of culprit medications. In addition, although the use of multimodal interventions has led to modest effects in long-term care facilities, the study of these interventions in acute care hospitals is limited. A recent meta-analysis could only identify six randomized trials in the hospital setting. That study confirmed a statistically significant reduction in fall rates, but the effect size was small. In fact, the authors calculated a number-needed-to-treat of 1250 patient-days to prevent one fall. Moreover, it is impossible to understand which of the elements of the multimodal intervention might have had led to improvement. The authors also point out that the available studies are of limited quality, the strategies are complex, and compliance with interventions is often poor. A Cochrane meta-analysis of four randomized trials of fall prevention in hospitals only identified two programs that reduced fall rates, and one of those was a subacute facility (with benefit most apparent after 45 days), and the other targeted a very specific population (a geriatric unit with hip fracture patients). These observations make it impossible to generalize to other populations.

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Even more concerning in the race to prevent falls is the possibility that the wrong approach could actually hinder mobility in older patients. In 2008, the Centers for Medicare and Medicaid Services (CMS) announced that it would no longer pay for medical costs related to inpatient falls. The announcement was intended to be a stimulus for prevention of inpatient falls, and it resulted in widespread, intensive efforts to reduce these events. However, critics of this approach have noted the potential for unintended consequences. That is, hospitals might embrace strategies that will decrease inpatient falls by limiting patient mobility. These maladaptive strategies might include the use of restraints or sedative medications, which actually appear to increase rates of falling, and directly oppose the goal of improved mobility. There is a paradoxical relationship between falls and mobility. If a patient is totally immobile, he will have little opportunity to fall. However, immobilized patients will incur the adverse health consequences of immobility. Many patients need to be mobilized while in the hospital, as part of a strategy of increasing strength and well-being, and preserving dignity and autonomy. The best way to enhance mobility and preserve independence in older patients, while simultaneously reducing falls, is simply not known.

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Currently, there is no widely accepted strategy to prevent older adults from falling in the hospital. Some experts suggest that the best approach to fall prevention may be an approach where modifiable risk factors for falling are recognized, and interventions targeting those risk factors are applied (see Table 16-4). Additional studies are needed to identify strategies that will balance the goals of mobility and independence in older patients with the goal of reducing the risk of falls.

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Malnutrition
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Poor nutritional status is common among hospitalized older patients (see also Chapter 35). Studies have estimated that up to 50% of all hospitalized older patients are nutritionally at risk and up to 25% meet criteria for malnutrition. Among hospitalized older patients, poor nutritional status is associated with worse clinical outcomes. During the hospitalization, nutritionally at-risk patients are more likely to suffer from hospital-acquired complications, particularly infection. Compared with patients with good nutritional status, poor nutritional status is associated with longer length of stay, higher readmission rates, increased likelihood of being discharged to an extended care facility, and higher mortality rates.

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Given the prevalence and importance of poor nutritional status in the older hospitalized patient, the Joint Commission mandates nutritional screening in this population. Several screening tools have been developed including the Chandra scale, the Nutrition Screening Initiative, and the Mini Nutritional Assessment. The Mini Nutritional Assessment has been shown to be predictive for in-hospital mortality, longer length of stay, and greater likelihood of being discharged to a long-term care facility.

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The causes of malnutrition are often multiple, and usually they relate to problems with the patient’s appetite, ability to obtain or prepare food, or swallowing function. For example, poor appetite is a consequence of many chronic conditions, or the medications used to treat them. Also, poor functional status, cognitive impairment, or social and financial issues can limit an older patient’s nutritional intake. Of course, some patients have conditions that impair their ability to chew or swallow as well, such as stroke-related deficits or poor-fitting dentures.

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By far, the optimal approach to malnutrition in an older adult is to identify the major causes, and to intervene on those issues. Once that approach has been taken, other interventions are often added. These interventions include dietary counselling, oral supplementation, or enteral feeding in select populations. When possible, oral feeding is the optimal method for nutritional repletion and maintenance. Although most of the existing studies are of low quality, oral protein and energy supplements have been shown to reduce complications and mortality when given to hospitalized elders with malnutrition, and the use of these supplements is widespread.

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At times, more aggressive feeding strategies, involving the use of feeding tubes, are considered in older patients. These strategies do have a role in patients who have reversible deficits in oral feeding ability (eg, postesophageal surgery) and in patients who are cognitively intact but with a long-term need for enteral feedings due to mechanical issues. However, hospital providers should also recognize the limitations of tube feeding strategies in the care of older patients. The preponderance of data suggests that tube feeding does not improve the quantity or quality of life in older patients with dementia who are no longer able to maintain adequate oral nutrition. It is important to recognize that a diminished nutritional intake is a marker of end-stage dementia, and that the placement of a feeding tube in this population carries the risk of complications without any apparent benefit. Families often need significant counselling around this question, and this discussion often leads to broader conversations about the goals of care for these patients.

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Pressure ulcers
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Pressure ulcers are areas of skin damage that occur over bony prominences as a result of pressure, friction, and/or maceration (related to moisture) of the skin (see also Chapter 52). Older patients often suffer from conditions that are risk factors for the development of these ulcers, including immobility, malnutrition, and other comorbid health conditions.

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The vast majority of pressure ulcers form, and are cared for, outside of the hospital. However, pressure ulcers are important in the acute care setting for two major reasons:

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  1. These ulcers can, infrequently, develop while a patient is in the hospital. When they do, they significantly increase the cost of the patient’s care, and the hospital length of stay.

  2. Since 2008, CMS does not reimburse hospitals for care related to a pressure ulcer that develops or worsens while the patient is in the hospital.

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These reasons, taken together, suggest a need for vigilance regarding pressure ulcers in the acute care setting. Hospital providers should document pressure ulcers on admission, and engage the appropriate resources to stage and manage existing ulcers. In addition, the prevention of new ulcers is important, and hospitals should develop nursing protocols that aggressively employ the appropriate prevention measures. Chapter 52 covers the staging, diagnosis, treatment, and prevention of pressure ulcers in detail.

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Preventing Adverse Events in Hospitalized Older Patients

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In 1999, the Institute of Medicine published its landmark report demonstrating that hospitalized patients were often harmed by adverse events that occurred in the hospital. This led to the concept of patient safety—that is, the notion that some of these adverse events are preventable, and that it is the responsibility of the health care institution to minimize the occurrence of these events. Older patients are often disproportionately affected (either in incidence or morbidity) by these adverse effects of hospitalization, which include nosocomial infection, venous thrombosis, and adverse drug reactions (ADRs). Therefore, hospital care for older patients is now focused on the prevention of adverse events in the hospital. Geriatricians and other providers caring for older hospitalized patients should be actively involved with planning and implementing patient safety interventions in the acute hospital setting.

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Preventing nosocomial infections
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A recent multistate survey by the US Centers for Disease Control and Prevention (CDC) estimates that there were over 700,000 health care–associated infections in 2011. These infections result in longer and more expensive hospital stays, and increased morbidity and mortality. The majority of hospital-acquired infections are due to UTIs, pneumonia, surgical site infections, gastrointestinal infections, and bloodstream infections. A full discussion of the management of all these infections is beyond the scope of this chapter, but older patients are disproportionately affected by UTIs, pneumonia, and increasingly, Clostridium difficile infections.

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Hospital-Acquired Urinary Tract Infections
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Despite a rise in prevention efforts, UTIs are still common health care–associated infections. Most of these infections are catheter-associated urinary tract infections (CAUTIs), related to the use of indwelling urinary catheters. Women, older patients, and patients with severe underlying illness are at greatest risk. In 2012, the National Healthcare Safety Network reported an average rate of CAUTI of 1.4/1000 catheter days on an adult medical/surgical ward.

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The prevention of health care–associated UTIs focuses on reducing the unnecessary use of urinary catheters. In addition to contributing to infection risk, catheters are known to increase the risk of delirium and falls and have been referred to as a “one-point restraint.” Urinary catheters remain an important aspect of treatment when used for appropriate indications. Examples of appropriate and inappropriate indications for urinary catheters are listed in Table 16-5. Unfortunately, inappropriate use is common and underappreciated; some reports have suggested that up to 30% of hospital physicians are unaware that their patients have a catheter in place.

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Table Graphic Jump Location
TABLE 16-5EXAMPLES OF APPROPRIATE AND INAPPROPRIATE INDICATIONS FOR INDWELLING URETHRAL CATHETER USE
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There are several alternatives to the use of urinary catheters in hospitalized elders. Urinary retention can sometimes be managed with the use of intermittent straight catheterization (ISC), instead of an indwelling catheter. For men requiring urinary management for indications other than urinary obstruction or retention, condom catheters may be an option. One small study demonstrated a lower occurrence of a composite endpoint of bacteriuria, symptomatic UTI, and death in men treated with a condom catheter, compared to those treated with an indwelling catheter. Condom catheters appear most useful in those men who can comply with the therapy, and who do not experience frequent accidental or purposeful removal of the catheter.

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In institutions with computerized order entry, clinical decision support, electronic reminders, and automatic stop orders have been effective at reducing the overall use and duration of use of urinary catheters. Paper reminders are also effective in institutions lacking computerized order entry.

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Hospital-Acquired Pneumonia
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Pneumonia is one of the most common nosocomial infections. The mortality attributable to nosocomial pneumonia is debated, but maybe as high as 30%. An episode of hospital-acquired pneumonia clearly increases hospital length of stay and costs.

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Hospital-acquired pneumonia, also referred to as nosocomial pneumonia, includes both ventilator-associated pneumonia and nonventilator-associated pneumonia that develops 48 or more hours after hospitalization. Almost all of the data on prevention of hospital-acquired pneumonia comes from intensive care units (ICUs) and the study of ventilator-associated pneumonia. Extrapolation to the non-ICU population may not be appropriate. Prevention strategies for ventilator-associated pneumonia have been well-described elsewhere and are best directed at ICU physicians and staff.

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Understanding the risk factors for developing nosocomial pneumonia (Table 16-6) is critical to implementing effective prevention strategies. Nosocomial pneumonia results from microbial invasion of sterile lung parenchyma as a result of microaspiration of contaminated oropharyngeal or gastric secretions. A defect in host defenses, aspiration of a large inoculum of organisms, or aspiration of a particularly virulent organism may contribute to parenchymal infection.

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Table Graphic Jump Location
TABLE 16-6RISK FACTORS FOR NOSOCOMIAL PNEUMONIA IN OLDER PATIENTS
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There are important strategies to prevent nosocomial pneumonia for hospitalized elders in the non-ICU setting. One of the best strategies is to avoid intubation in patients with respiratory failure. Increasingly, the use of noninvasive ventilation has been effective in reducing the need for intubation. In selected patients with acute chronic obstructive pulmonary disease (COPD) or heart failure exacerbations, noninvasive ventilation can reduce the need for intubation and is associated with less pneumonia, shorter hospital length of stay, and in some studies, lower mortality. Another prevention strategy is to limit the use of medications that raise the gastric pH. Proton pump inhibitors and H2-receptor antagonists are often used to prevent ulcers in hospitalized patients. However, the use of these medications appears to facilitate the colonization of the gastrointestinal tract with pathogenic organisms, and has been associated with increased rates of hospital-acquired pneumonia. In general, the only patients shown to benefit from stress ulcer prophylaxis using these medications are those with shock, respiratory failure, and coagulopathy. As a rule, these medications should be avoided in other hospitalized patients, unless there is a clear indication for their use.

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Although there are limited data to support the use of other pneumonia-prevention strategies in noncritically ill hospitalized patients, extrapolation of data from other populations suggests that simple strategies such as elevating the head of the bed and attention to oral hygiene are also reasonable in most hospitalized elders.

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C difficile Infection
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C difficile has become one of the most common nosocomial infections. In 2009, over 336,000 hospital admissions involved C difficile infections (nearly 1% of all admissions). Patients over 65 years suffer the vast majority of the morbidity and mortality related to these infections.

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The biggest risk factors for infection include antibiotic use and hospitalization. Additional risk factors relevant to the care of a geriatric population include advanced age, severity of illness, use of proton pump inhibitors, and use of tube feeding. While clindamycin and fluoroquinolones are commonly associated with C difficile, any antibiotic (including metronidazole and vancomycin, which are used to treat the disease) can cause infection. Prevention of C difficile requires both infection control measures and antibiotic stewardship. Infection control measures include patient isolation, implementation of contact precautions (gown and gloves), and liberal hand washing with soap and water for all persons entering and leaving the patient’s room (C difficile spores are not effectively killed by alcohol-based hand rubs). There is evidence that formal antibiotic stewardship programs can also lead to decreased rates of C difficile infections in hospitals, by modulating the use of antibiotics. For example, the overuse of fluoroquinolones appears to have led to the development of fluoroquinolone resistance among highly virulent strains of C difficile, and the reduction in the use of fluoroquinolones specifically, and antibiotics more generally, is an important intervention in the prevention of C difficile infections. The use of probiotics for prevention of C difficile infection is somewhat more controversial. A large meta-analysis found that agents such as Saccharomyces boulardii or Lactobacillus rhamnosus, used as probiotics, prevent diarrhea associated with C difficile. However, it is less clear if these agents reduce the overall incidence of C difficile infections, and the most recent guidelines from the American College of Gastroenterology still recommend against the prophylactic use of probiotics to prevent this infection.

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Preventing venous thromboembolism
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Prevention of venous thromboembolism (VTE), which includes deep venous thrombosis (DVT) and pulmonary embolism (PE), is an important consideration in hospitalized patients. VTE is associated with increased morbidity and mortality in this population.

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While there is no consensus on quantifying patient-specific risk factors, patients admitted with certain conditions (eg, heart failure, severe respiratory disease, or malignancy), patients confined to bed, and older patients are considered to be at increased risk for VTE. Multiple studies, including several meta-analyses, have demonstrated the efficacy of pharmacologic prophylaxis against VTE in high-risk hospitalized patients. Studies have shown that low-molecular-weight heparin (LMWH), unfractionated heparin, and fondaparinux all reduce the risk of both DVT and PE without a significant increased risk of major bleeding (minor bleeding episodes, including development of hematomas, may be more common in patients receiving pharmacologic prophylaxis). Prophylaxis has not been associated with a mortality benefit, and its cost-effectiveness has not been well-studied. For patients at high risk of bleeding, the use of intermittent pneumatic leg compression is a reasonable substitute for heparin products.

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The use of standard order sets and reminders built into computerized order entry systems can facilitate routine use of VTE prophylaxis in high-risk patients.

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Preventing adverse drug reactions
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Older patients experience a greater number of ADEs than younger patients (see also Chapter 64 on drug therapy). This is in part due to the large number of medications prescribed to this population.

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Assuring the appropriate use of medications in older patients is challenging for a number of reasons. First, it is worth noting that older patients are often excluded from clinical trials involving medications. This means that the conclusions of many medication studies might not apply to this population of patients. Also, pharmacokinetics and pharmacodynamics are different in older patients, with implications for dosing and response to medications in this population. In addition, older patients are prescribed more medications than their younger counterparts. This leads to more opportunity for side effects, and more drug-drug interactions. It can be very difficult for a provider to have a complete grasp of all of the concerning side effects and interactions for a patient taking 10 or 20 different medications. This difficulty is illustrated by the concept of prescribing cascades. A prescribing cascade occurs when one medication causes a side effect, and another medication is used to treat that side effect, without recognizing that the original symptom was a medication side effect itself. This cascade can lead to unnecessary polypharmacy, and very complicated medication regimens.

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Unfortunately, there is no easy way to eliminate these prescribing problems in complex, older patients. However, attending to a few basic tenets can reduce the number of these adverse events:

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  • Drug side effects and interactions should always be considered in the differential diagnosis of problems in patients taking multiple medications. A trial of discontinuing suspect medication is often appropriate.

  • High-risk medications should be avoided in older patients. Careful attention should be paid to medications most likely to lead to ADEs including analgesics, sedatives, cardiovascular medications, and psychoactive drugs. Although the use of any medication is dependent on an assessment of the risks and benefits of that medication, there are some medications for which the risk most often exceeds the benefit. The Beers list and the STOPP criteria have been created to increase the awareness of these high-risk medications, and help clinicians avoid their use in this population.

  • Any new medication should be prescribed with great thoughtfulness, considering the likelihood of an adverse effect and the goals of care. Especially in older patients, newly prescribed medications should be considered therapeutic trials, and if the beneficial effects of the medication are not apparent, or adverse effects are seen, the patient may be better off without that medication, regardless of any theoretical benefit.

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In addition, the use of clinical pharmacists and computerized systems can assist providers in appropriate medication prescribing in this population.

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Palliative and End-of-Life Care

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There is a tremendous need for high-quality palliative and end-of-life care for older inpatients (See Also Chapter 55). In 2007, 32% of all deaths occurred in the hospital. Hospitalizations that end in death can be chaotic for patients and family members, and these hospitalizations cost 2.7 times as much as hospitalizations resulting in live discharges. Despite the fact that many people die in hospitals, there is evidence that end-of-life care in hospitals is often inadequate. Surveys of patients and families have shown that patients dying in hospitals believe they do not have enough contact with physicians, emotional support, or information about what to expect of the dying process. In addition, a substantial percentage report moderate or severe pain in the last 3 days of life.

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Although the terms “palliative care” and “end-of-life care” are sometimes used synonymously, they are better viewed as separate, but overlapping domains. Palliative care refers to care that aims to improve the quality of life through the relief of suffering. Palliative care focuses, primarily, on pain relief and symptom management. End-of-life care is the care provided to a patient who is nearing death. End-of-life care often includes palliative elements, but also incorporates specific interventions that are related to the impending death. Specifically, end-of-life care typically includes discussions about prognosis and patient wishes, and detailed planning of the patient’s care as he approaches death.

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Delivering high-quality palliative and end-of-life care requires experience, a special set of skills, and a substantial investment in time. Central to the process is the need for extensive communication between the hospital providers, and the patient and family. End-of-life care in the hospital is based on the successful achievement of several goals:

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  • Assessing the patient’s understanding of the disease process and prognosis, current symptoms, and wishes, including goals of care.

  • Determining the patient’s prognosis.

  • Educating the patient and family about the disease process, the prognosis, and the types of care available.

  • Negotiating realistic goals of care.

  • Providing appropriate palliative care, including pain control, and control of other symptoms such as nausea, dyspnea, and others.

  • Addressing spiritual and psychosocial needs of the patient and family.

  • Planning for discharge and postdischarge care.

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Accomplishing these goals can be very challenging, often requiring the work of a multidisciplinary team. As a result, many hospitals have developed formal palliative care programs to adequately address the needs of dying patients. As of 2011, 67% of all hospitals with more than 50 beds report having a palliative care program. While hospitals employ a variety of practitioners to staff their programs, geriatricians, hospitalists, and oncologists are well-represented in most programs. Board certification is now available in the area of hospice and palliative medicine. A full discussion of palliative and end-of-life care can be found in Chapter 55.

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