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
• 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)
• older patients spending the night in the emergency department waiting for admission to a hospital ward are increased risk of morbidity & mortality

Complications

• hospital-acquired infection
• 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)
• risk factors for in hospital functional decline & nursing home placement
  • advanced age
  • dependence in iADLs
  • delirium
  • cognitive impairment
• risk factors for rehospitalization (inpatients):
  • advanced age
  • multiple comorbid conditions
  • cognitive impairment
  • depression
  • living alone
  • recent hospitalization
  • impaired physical function
• "never events" such as falls & pressure ulcers
  • more common after weekend hospital admissions
  • weekend & public holiday hospitalization associated with higher 30 day mortality than hospitalization on weekdays (5.1 & 5.8% vs 4.7%)
  • 4.3% vs 3.6% 30 mortality for weekend admissions vs weekday admissions
  • adverse events associated with longer length of hospital stay (2-fold)
• depression is common among hospitalized elderly (30%)
  • depression persisting after hospital discharge increases risk of functional dependence & death
• nursing (RN) staffing below target levels & high patient burden associated with increased in-hospital mortality
• hospitalization of community-dwelling elderly is associated with accelerated cognitive impairment
  • executive dysfunction & diminished ventricular size after hospitalization of older adults
• 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
• sleep disturbance: patients awakened on average once an hour
• 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

Management

• assess functional status in hospitalized elderly
  • 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)
  • see functional status in hospitalized elderly
• guidelines for improving outcomes in hospitalized elderly
  • recommended noise levels
    • background: < 35 dB day, < 30 dB night
    • peak: < 40 dB night
  • optimize the environment to promote mobility & orientation
    • carpeting
    • raised toilet seats
    • low beds
    • clocks
    • calenders
    • pictures
    • adequate daytime lighting
  • interdisciplinary team-based care with protocols for
    • independent self-care
    • nutrition
      • individualized diet plans improve outcomes vs hospital food
      • unclear whether thickened liquid diet benefits patients with Alzheimer's disease & related dementias & dysphagia
    • sleep hygiene
    • skin care (prevention of pressure ulcers)
    • mood assessment
    • cognitive assessment
    • early discharge planning with social work intervention
  • medication reconciliation
  • assessing mobility on admission assists in discharge planning
  • mobilize within 48 hours for prevent ICU admission
  • walk 2-3 times/day to prevent functional decline
  • an individualized, multicomponent in hospital exercise program may mitigate functional decline associated with acute hospitalization in very elderly patients
  • supervised walking programs improve mobility of hospitalized elderly & may prevent discharge to skilled nursing facility
  • structured mobility program that includes early mobilization & walking to facilitate maintainence of prehospital walking ability
  • no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements of protein or energy
• 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)
• reducing unnecessary hospitalization
  • preventing unnecessary hospitalizations & ED visits in nursing home patients involves more than just staff education & care planning
• 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
• intensive antihypertensive treatment of hospitalized older adults with elevated blood pressures is associated with a greater risk of adverse events
  • treatment associated with higher risks of acute kidney injury & myocardial injury
• malignant hypertension (BP > 180/120 with end-organ damage) is treated with intravenous antihypertensive agents in intensive care settings
• no consensus on treatment (or not) of hypertensive urgency
• maintain prehospitalization blood pressure regimen at hospital discharge unless hypotension contributed to hospital admission
  • avoid intensification of blood pressure medications at hospital discharge
• as needed blood pressure medication is associated with risk of rapid drop in blood pressure, acute kidney injury, & composite outcome of stroke, myocardial infarction, or death

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

• in hospital strategies that reduce mortality (example = MI)
  • monthly meetings to review myocardial infarction cases with hospital clinicians & staff who transport patients to the hospital
  • having an on-site cardiologist at all times
  • cultivating an environment in which clinicians are encouraged to solve problems creatively
  • avoiding cross-training of intensive care unit nurses for cardiac catheterization laboratories
  • having at least one quality-improvement champion who is a physician rather than a nurse
• in hospital coordinated discharge planning with follow-up at home reduces subsequent hospitalization
• the KELS evaluates needs of patient in the community after hospital discharge
• multicomponent interventions at the healthcare systems level are required to influence care outcomes associated with hospital discharge
• higher quality of care for hospitalized elderly by ACOVE measures results in lower one year post-hospitalization mortality
• specialized care units for cognitively-impaired patients does not improve patient outcomes, but slightly improves family caregiver satisfaction
• single room accomodations do not improve safety outcomes
• quality sleep should be treated as fundamental to recovery from illness, rather than a casualty of other priorities
• sleep disruption is common in hospitalized patients & is a risk factor for delirium (see in-hospital sleep disruption)
• early involvement of an endocrinologist & diabetes nurse improves glycemic control but not most clinical outcomes

More general terms

• transition of care; health care transition

More specific terms

• hospitalization from the emergency department

Additional terms

• 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