GENERAL PRINCIPLES: HAZARDS OF HOSPITALIZATION
Almost 20% of people 65 years of age or older are hospitalized each year in the United States, a rate nearly four times that of the general population. Those 65 years of age or older account for approximately 38% of all hospital admissions, 47% of inpatient care days, and 45% of hospital expenditures. Older adults account for 74% of all in-hospital deaths and have more discharges to places other than home. Many are frail and experience disability and comorbid illnesses. Because of their medical complexity, older patients typically require services from multiple health care providers, most of whom have no formal training in geriatric medicine.
Hospitalization is a critical time for older patients, and heralds a period of high risk that extends beyond discharge, especially for the frail and the very old. Because older adults make up almost half of all inpatient care days, they are at a disproportionate risk for hospital adverse events. For example, in the landmark Harvard Medical Practice Study, patients age 65 years or older accounted for only 27% of the hospitalized population but experienced 43% of all adverse events.
Hospitalization-associated disability is a common and feared complication of hospitalization for older adults. New activities of daily living (ADL) deficits occur in as many as 30% of patients 70 years of age or older who are admitted to an acute care hospital from the community, and hospitalization accounts for approximately 50% of new disability that community-dwelling older adults experience. Hospital processes of care and environment developed without the older adult in mind contribute both to failure to recover from functional loss that occurred before admission as well as new decline during the hospitalization (Figure 28–1).
Hospitalization, functional loss, and capacity to recover. ADLs, activities of daily living; IADLs, instrumental activities of daily living.
There are a number of factors that contribute to the hostile environment of hospitals. Bed rest and low mobility are major contributors to functional decline. Even short periods of bed rest can result in significant loss of muscle mass and strength in older adults. There are many reasons that bed rest occurs even when not explicitly ordered. Crowded hospital rooms, beds that are difficult to transfer in and out of either because of height or rails, hallways that are cluttered, slick polished floors, and lack of access to adaptive devices that the patient may use at home such as canes or walkers, eyeglasses, and raised toilet seats or shower chairs are all barriers to mobilization. Patients are frequently attached to peripheral devices such as intravenous line poles, oxygen tubing, urinary catheters, cardiac monitors, or other tethers that further inhibit mobility. Concerns about falls often result in inappropriate confinement to bed. Studies show that most patients will not ambulate on their own unless explicitly told ...