Elderly Patients in Hospital

It is generally accepted that elderly people fare best when care is provided in their own homes. However, some conditions require more intensive management than can be provided in the community. The admission of elderly patients to hospital, their treatment and subsequent discharge can prove challenging. Whilst self-sufficiency depends a lot on the underlying condition, delivering a package of care to an acceptable standard can make the difference between an individual who is a self-sufficient functioning member of the community and one who is disabled and dependent.

The Department of Health recognise the importance of providing quality care to the elderly and have produced a raft of guidelines outlining the sort of issues which need to be considered when planning services. Many of these are enshrined in the National Service Framework for Older People.¹ A White Paper addressing the social aspects of elderly care - Our health, our care, our say: a new direction for community services - has also been published.²

Patients should be treated according to clinical need rather than age. This might seem self -evident, but may present pragmatic difficulties. Some clinicians might balk at the idea of referring an 85 year old for coronary artery bypass surgery, but if the patient is otherwise fit for surgery and wants the operation they should be offered the chance to have it.

Patients should be treated as individuals and empowered to make choices about their own care. This involves providing information in a form that patients can understand, and listening to their views and the views of their carers. Preserving dignity in a hospital setting is a major objective, and includes separate toilet and washing facilities, single-sex wards and safe care for patients will mental disorders. Most, but not all, NHS hospitals now meet these criteria. Another raft of guidance involves the provision of end of life care, and whilst this may be of more relevant to community and palliative care services, it will also impact on community hospitals.³

The aim here is to relieve pressure on acute hospital beds and provide care in a more community-based setting. The principles are the same whether care is provided by intermediate care teams in the patient's own home or in an intermediate care facility. The goal is to restore the patient to full function and avoid the need for long-term care by providing integrated rehabilitative support.

With the change in demography in the UK, a significant proportion of people in hospital are now over 65, and secondary care needs to provide services tailored to the needs of its elderly population. The emphasis has been on improving access to care, and the last few years have seen a significant increase in the number of elderly patients being admitted for cataract surgery, hip or knee replacements, and interventional cardiac surgery. Many hospitals have set up specialist multidisciplinary teams led by nurses ('modern matrons' or nurse consultants) focussing on the needs of the elderly whilst in hospital and on discharge.

Evidence suggests that stroke patients fare best when admitted to specialised stroke units. The aim is to provide rapid access to diagnostic services, care provided in stroke units led by specialised physicians, and multidisciplinary intervention to enable early discharge, rehabilitation and secondary prevention. Provision across the UK is patchy, but there has been a significant increase in the number of dedicated units and stroke specialists.

Falls are the leading cause of mortality in the over 75 age group. All patients who have had a fall should be offered a multifactorial risk assessment and multifactorial interventions. NICE recommends the following:⁴

Multifactorial risk assessment

• Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by healthcare professionals with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention.
  Multifactorial assessment may include the following:
  • Identification of falls history
  • Assessment of gait, balance and mobility, and muscle weakness
  • Assessment of osteoporosis risk
  • Assessment of the older person's perceived functional ability and fear relating to falling
  • Assessment of visual impairment
  • Assessment of cognitive impairment and neurological examination
  • Assessment of urinary incontinence
  • Assessment of home hazards
• Cardiovascular examination and medication review

Multifactorial interventions

• All older people with recurrent falls or assessed as being at increased risk of falling should be considered for an individualised multifactorial intervention.
• In successful multifactorial intervention programmes the following specific components are common (against a background of the general diagnosis and management of causes and recognised risk factors):
  • Strength and balance training
  • Home hazard assessment and intervention
  • Vision assessment and referral
  • Medication review with modification/withdrawal

Elderly patients may have a different pattern of disease and different response to treatment than younger patients.

• Multiple pathology: the symptoms resulting in hospital admission may be caused by a combination of several disease process, and it important to identify which is contributing the current difficulties (e.g. cataracts and arthritis resulting in falls). Multiple causes may need to be treated in order to relieve the presenting problem.
• Nonspecific symptoms: older patients may develop incontinence, immobility, instability, acute dementia or confusion in response to virtually any disease.
• Atypical presentation: myocardial infarction may occur without chest pain, and chest infection may present without cough or sputum.
• Lack of physiological reserve: this phenomenon of older people results in rapid onset of illness, delayed recovery rate and increased incidence of complications compared to younger patients.
• Pharmacokinetics: a reduction in excretion and impaired metabolism of drugs may require a reduction of dosage. There may be less tolerance to side-effects, and the problems presented by polypharmacy may also be an issue.⁷

A significant proportion of patients who experience delayed discharge are elderly. Poor hospital bed management and a failure of communication between health and social care are the principle contributing factors. Hospital discharge should be a planned event and the planning of a discharge care package should begin at the point of hospital admission in partnership with the patient and their carer(s).
Issues to be considered include:

• Medicines management
• Equipment provision - wheelchairs, hoists, grab rails, beds
• Accommodation issues - stairs, access to toilet, portable alarms, ability to use the phone
• Social network - family, friends, regular visitors, neighbours
• Care in the community - the need for district nurses, community psychiatric nurses, social workers, information to GP
• Nutritional needs - can the patient open tins, use a kettle, are Meals-on Wheels required?
• Needs of the carer