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hospitalization

Epidemiology: - adults >= 65 years of age comprise 13% of the population, account for 36% of hospitalizations, & 50% of hospital costs - hospitalized elderly with lower risk of mortality (11.1% vs 11.5%) when treated by female internist rather than male internist [20] - older patients triaged in the emergency department as less urgent or not urgent, are much more likely than younger patients to be admitted at the initial presentation (5% vs 0.6%) or over the next 14 days (4% vs. 0.7%) - the oldest patients (>85 years) were most likely to be admitted (9% vs 2% of those aged 65-74 years) [27] - older patients spending the night in the emergency department waiting for admission to a hospital ward are increased risk of morbidity & mortality [41] Complications: 1) hospital-acquired infection 2) loss of ability to perform basic activities of daily living (bADLs) during hospitalization portends substantial 1-year morbidity & mortality in older patients (see functional status in hospitalized elderly) 2) risk factors for in hospital functional decline & nursing home placement a) advanced age b) dependence in iADLs c) delirium d) cognitive impairment 3) risk factors for rehospitalization (inpatients): a) advanced age b) multiple comorbid conditions c) cognitive impairment d) depression [11,12] e) living alone f) recent hospitalization g) impaired physical function 4) "never events" such as falls & pressure ulcers - more common after weekend hospital admissions [15] - weekend & public holiday hospitalization associated with higher 30 day mortality than hospitalization on weekdays (5.1 & 5.8% vs 4.7%) [22] - 4.3% vs 3.6% 30 mortality for weekend admissions vs weekday admissions [24] - adverse events associated with longer length of hospital stay (2-fold) [42] 5) depression is common among hospitalized elderly (30%) [11,12] - depression persisting after hospital discharge increases risk of functional dependence & death [11,12] 6) nursing (RN) staffing below target levels & high patient burden associated with increased in-hospital mortality [2] 7) hospitalization of community-dwelling elderly is associated with accelerated cognitive impairment [13] - executive dysfunction & diminished ventricular size after hospitalization of older adults [14] 8) slightly higher risk (RR=1.18) for cardiac arrest or intensive care unit transfer in the 6 hours after an index patient's critical event [21] 9) sleep disturbance: patients awakened on average once an hour [32] 11) cognitive decline - hospitalization (> 2 nights) for surgery, medical conditions, or stroke associated with excess cognitive decline, equivalent to 5 months, 1.4 years, & 13 years of aging, respectively [36] Management: 1) assess functional status in hospitalized elderly a) admission of hospitalized elderly to an acute geriatric unit is associated with lower risk of functional decline & greater chance of discharge to home from the hospital (GRS9) [1] b) see functional status in hospitalized elderly 2) guidelines for improving outcomes in hospitalized elderly [1] a) recommended noise levels [25] - background: < 35 dB day, < 30 dB night - peak: < 40 dB night b) optimize the environment to promote mobility & orientation - carpeting [1] - raised toilet seats - low beds - clocks - calenders - pictures - adequate daytime lighting [25] c) interdisciplinary team-based care with protocols for - independent self-care - nutrition [8] - individualized diet plans improve outcomes vs hospital food [34] - unclear whether thickened liquid diet benefits patients with Alzheimer's disease & related dementias & dysphagia [44] - sleep hygiene - skin care (prevention of pressure ulcers) - mood assessment - cognitive assessment - early discharge planning with social work intervention d) medication reconciliation [1] e) assessing mobility on admission assists in discharge planning [37] f) mobilize within 48 hours for prevent ICU admission [16] f) walk 2-3 times/day to prevent functional decline [1,10] g) an individualized, multicomponent in hospital exercise program may mitigate functional decline associated with acute hospitalization in very elderly patients [31] i) supervised walking programs improve mobility of hospitalized elderly & may prevent discharge to skilled nursing facility [38] j) no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements of protein or energy [19] 3) triage to appropriate hospital ward (level of care) - patients placed on off-service units (non-internal medicine wards) at higher risk of in-hospital mortality (RR=3.3) [26] 4) reducing unnecessary hospitalization - preventing unnecessary hospitalizations & ED visits in nursing home patients involves more than just staff education & care planning [23] 5) prophylaxis for venous thromboembolism with LMW heparin if patient immobilized for >= 4 days === hypertension in hospitalized patients === - hospitalized patients with asymptomatic elevations in blood pressure do not require treatment with IV antihypertensive medications [33,46] - intensive antihypertensive treatment of hospitalized older adults with elevated blood pressures is associated with a greater risk of adverse events [39] - treatment associated with higher risks of acute kidney injury & myocardial injury [40] - malignant hypertension (BP > 180/120 with end-organ damage) is treated with intravenous antihypertensive agents in intensive care settings [43,46] - no consensus on treatment (or not) of hypertensive urgency [43,46] - maintain prehospitalization blood pressure regimen at hospital discharge unless hypotension contributed to hospital admission [45] - avoid intensification of blood pressure medications at hospital discharge [45,46] === communication with outpatient physician(s) === - preferred mode of communication varies with primary care practice type - most primary care providers prefer communication at admission & prior to discharge - discharge summary alone is insufficient Notes: 1) in hospital strategies that reduce mortality (example = MI) a) monthly meetings to review myocardial infarction cases with hospital clinicians & staff who transport patients to the hospital b) having an on-site cardiologist at all times c) cultivating an environment in which clinicians are encouraged to solve problems creatively d) avoiding cross-training of intensive care unit nurses for cardiac catheterization laboratories e) having at least one quality-improvement champion who is a physician rather than a nurse 2) in hospital coordinated discharge planning with follow-up at home reduces subsequent hospitalization 3) the KELS evaluates needs of patient in the community after hospital discharge 4) multicomponent interventions at the healthcare systems level are required to influence care outcomes associated with hospital discharge [4] 5) higher quality of care for hospitalized elderly by ACOVE measures results in lower one year post-hospitalization mortality [6] 6) specialized care units for cognitively-impaired patients does not improve patient outcomes, but slightly improves family caregiver satisfaction [5] 7) single room accomodations do not improve safety outcomes [18] 8) quality sleep should be treated as fundamental to recovery from illness, rather than a casualty of other priorities [29] 9) sleep disruption is common in hospitalized patients & is a risk factor for delirium [30] (see in-hospital sleep disruption) 10) early involvement of an endocrinologist & diabetes nurse improves glycemic control but not most clinical outcomes [35]

Related

3-day hospital stay rule functional status in hospitalized elderly hospital hospital discharge justification for hospitalization Kohlman Evaluation of Living Skills (KELS) length of stay (LOS) preventing hospitalization; reducing hospitalization

Specific

hospitalization from the emergency department

General

transition of care; health care transition

References

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