Hospitalization of the Elderly

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Author(s): 

Kathleen A. Walsh, DO, and John M. Bruza, MD

“The hospitalization, not the illness, may be the deciding factor in the functional ability of the frail, elderly at discharge”1

As the number of older adults increases, it is our duty to provide them with comprehensive care, namely in the acute setting. Vulnerable, frail individuals are at increased risk for worsening functional status and delirium, falls, medication toxicity, nosocomial infections, malnutrition, dehydration, immobilization, and decubitus ulcers while in the hospital.2 Elderly patients are susceptible to complications not directly related to the illness for which they are hospitalized. These complications begin immediately upon admission.3 Geriatric consultation teams and geriatric care unit models have been designed and studied over the years to improve patient functioning and prevent deleterious events in acutely ill older adults.4 This article will review the history of acute care of the elderly, discuss alternative methods of acute care, and examine functional decline, delirium, and transitions of care.

In the early 20th century during World War II, a geriatric unit was formed in Great Britain. Dr. Marjory Warren5 described the structural alterations made to a part of a hospital to improve the lighting, widen the doorways, and install handrails. On this unit, elderly patients with various conditions that included malnutrition, anemia, dementia, cerebral thrombosis, arthritis, chest disease, and neoplasms were cared for. Patients were transferred from the surgery and orthopedics services to this special unit. The importance of physiotherapy, social work, and an interdisciplinary team was clearly recognized. Dr. Warren wrote, “As the department gains experience, confidence and skill, it should be able to prevent a great number of the conditions which are so prevalent and so crippling amongst elderly persons today.”5 Her observations have withstood the test of time and are as relevant today as they were in 1935.

Geriatric Consultative Services
In 1979, Burley et al6 studied a geriatric consultative service for patients with incontinence and difficulty ambulating, in addition to multiple medical problems. These patients with “geriatric features” were more likely to be discharged to home, as opposed to another ward, which resulted in an overall decrease in length of stay.6 A randomized controlled Veterans Administration trial in the 1980s showed a trend toward greater improvement in functional status in patients evaluated by a geriatric consultative team. This study concluded that geriatric consultants, in order to show meaningful improvements, should offer direct care and services.7 Another study showed significantly greater improvement in mental status, a decrease in number of medications upon discharge, and lower short-term death rates when care was received from a geriatric consult service.8 In the mid-1990s, a randomized controlled trial compared a comprehensive geriatric assessment in the form of consultative versus usual care.9 There was no difference in functional status at 3 and 12 months or in 1-year survival; however, they concluded that the consultative service is only as good as the implementation of its recommendations.9,10 Frail, hospitalized elders may benefit more from comprehensive geriatric assessment and management in the form of continuous, rather than consultative, care.

Geriatric Units
Saunders et al11 describe the Geriatric Special-Care Unit (GSCU) at the University of Massachusetts that opened in 1980. Modifications were made to an existing unit, including communal dining areas with adaptive feeding equipment, call bells with long cords, and alarm signals on stairway exit doors.

References: 

References
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