Sunday, January 16, 2011

Hospitalization for seniors

If you, or someone you love, is hospitalized you know you are at risk for many complications. The first one is, of course, Superbugs. However, if an elderly relative is put into hospital there are many things you can do to prevent some complications. There are new studies to demonstrate that post-ICU care is crucial.

You are at risk for a number of issues once hospitalized. These demand that family members get involved and be proactive as a friend or caregiver. You want to reduce your stress, improve and maintain physical and cognitive function, reduce falls, and prevent admission to LTC while having improved quality of life. Placement in a hospital can lead to poor nutrition, dehydration, immobilzation, sleep deprivation and unnecessary Rx. As we age, there are changes in our muscles, joints tighten up, blood pressure, lung function, bone strength, bladder control, our skin declines, poor nutrition is a risk as our appetite decreases, fractures immobilize us and lowered cognition is a possibility.

The Aging Process
Be vigilant about all bodily functions: as we age we naturally have loss in muscle mass, strength and energy. High or low blood pressure is a predictable risk as we age. Also, our rib cages become more stiff, with reduced oxygen in our blood, complicated by dizziness, osteoporosis - decreased bone strength, poor nutrition, and an inability to get to the bathroom, hospital rest can increase stress and exacerbate the normal aging process. As we age or skin gets thinned, we have a poorer blood supply and a slower rate of skin cell replacement. This results in skin ulcers and infections for those who are "bed ridden".

Be Present
Hospitals are place for those with acute illnesses. They do not deal well with those who are frail. Firstly, expect that you will be of benefit to them if you are present at their bed-side. There is much to do. It is important to advocate for them; record treatment plans, medications, test results. Be proactive. As Why, How often and How much? With 3 new medications, seniors are at high risk for complications. About 50% of those with dementia are at home. Of these, 2/3 of them remain undiagnosed.
It is estimated that dementia is present in:

* 23% of seniors aged 85-89
* 40% of seniors aged 90-94
* 55% of seniors aged 95-99
* 85% of seniors aged 100-106

Liquids and food
Make sure that they are getting enough fluids and food.
Ensure that they have all their senses available and provide them with glasses and hearing aids.
Look at their medications. Determine is they are a) getting required Rx, i.e., cholesterol, blood pressure. When you first go in to the hospital bring along all of the medications.
b) On the other hand, check that they are not unduly restrained, or overmedicated.

Mobility
Next, make sure that they are kept mobile. (See Get Seniors Moving to Prevent Falls)
If they cannot walk, they can have physiotherapy, massage. Restraints should only be used if necessary. (They were in my Dad's case. He fell out of his wheelchair all the time.) With insufficient physio, restraints, bladder catheters and bed rest we risk impaired mobility, which may lead to falls, difficulty with stair climbing.

Activities
Keep minds active by playing cards, reading aloud, looking at photo albums, playing board games. Create a memory album. Take in an iPod with family photos, favourite music, a stuffed animal. My father always clutched his in LTC.

Prevention of chronic disease
Of course, prevent hospitalization by eating well, staying active, exercising mind, body & spirit, and being informed about health risk factors through screening and immunizations. Well-known complications in patients who require ICU care include myocardial infarction, pneumonia, and stroke.

Be Aware
Be vigilant and take note of new symptoms: confusion, falls, loss of independence, incontinence, depression. Create a visitors list, ask for help from CCAC, Red Cross, respite care from non-profits institutions. Look for generalized weakness or fatigue, which mandates assessment for anemia, nutritional deficits, sleep disturbance, muscular deconditioning, medication adverse effects, and/or neurologic impairment.

If patients have a history of delirium, then prolonged sedation, mechanical ventilation, and acute respiratory distress syndrome, they are at risk psychologically: comorbidities may include posttraumatic stress disorder (PTSD), anxiety disorder, and depression. Families and caregivers may also have depression and anxiety, as I well know.

Discharge
Do not permit them to be discharged if you cannot look after them, or if you have no plan for Home Care through CCAC. Ask for a referral to a geriatrician for a geriatric assessment before you take them home. A comprehensive assessment can identify and assess medical, psychological, environmental and social factors that contribute to frailty, dementia and delirium. Nutritional deficiency, lack of sunlight, and use of corticosteroids can cause bone demineralization and vitamin D deficiency, so be vigilant.

Finally, ensure that you know the difference between dementia and delirium. The latter is due to drug interactions, or infections, etc., and can be cured, but dementia can have serious implications for home care. Dad was discharged from emergency with delirium and became incontinent. He had a bladder infection from his radiation treatments and was in a bad way. Totally curable, but undiagnosed. It broke my heart.
See also: Before you dial 911
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Resources
  1. Prescription for Excellence: How Innovation is saving Canada’s Health Care System, by Michael Rachlis MD, Harper Collins 2004.
  2. Sharon K. Inouye et al. Delirium: A symptom of how hospital care is failing older persons and a window of opportunity to improve quality of hospital care. Am J Med 1999;106:565.
  3. John A. Rizzo et al. Multicomponent targeted intervention to prevent delirium in hospitalized older patients: What is the economic value? Medical Care 2001;39:740.
  4. Désirée Lie, MD, MSEd ,Outpatient Management of the Post-ICU Patient Reviewed
  5. Get Seniors Moving to Prevent Falls
  6. Primary source: Journal of the American Geriatrics Society
    Kenny RAM, et al "Summary of the updated American Geriatrics Society/British Geriatrics Society Clinical practice guideline for prevention of falls in older persons" J Am Geriatr Soc 2010; DOI:10.1111/j.1532-5415.2010.03234.x. 

1 comment:

Anonymous said...

Hi Jennifer,
It is an excellent article and I would love to be able to make a copy to leave for my family as they are all out of town, I have sent it to them, but if possible would like to leave it with our other info for them.I can read it from my computer for helping my clients for now.
Happy weekend
Barb