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Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr.

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses.

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Chapter 11Reducing Functional Decline in Hospitalized Elderly

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Author Information

;1 ;2 .3

1 Ruth M. Kleinpell, Ph.D., R.N., F.A.A.N., Rush University College of Nursing, Chicago, Illinois. E-mail: ude.hsur@llepnielK_M_htuR
2 Kathy Fletcher, R.N., G.N.P., A.P.R.N.-B.C., F.A.A.N., University of Virginia Health System, Charlottesville, Virginia. E-mail: ude.ainigriv@d8frk
3 Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N., Colonel, U.S. Army (Retired), and health care consultant. E-mail: ten.xoc@sgninnejmb

Background

The elderly, or those older than 65 years, currently represent 12.5 percent of the U.S. population, and are projected to increase to 20 percent of the population by 2030—growing from 35 million to 72 million in number.1, 2 By 2050, 12 percent of the population, or one in eight Americans, will be 75 years of age or older.3 In 2002, the elderly accounted for 12.7 million (41 percent) of the 31.7 million hospitalizations in the United States,4 and these numbers are expected to increase significantly as the population ages. Targeting the care needs of the hospitalized elderly and awareness of risks for illness-related complications are urgent concerns for managing acute health care conditions in this population.4

Hospitalization and Patient Safety Considerations for the Elderly

It is estimated that almost half of adults who are hospitalized are 65 years of age or older, although those older than 65 years represent only 12.5 percent of the population. The proportion of hospitalized adults who are elderly is only expected to increase as the population ages.4 The average hospital length of stay for patients age 65 and older has decreased to 5.7 days, down from 8.7 days in 1990.3 Shorter lengths of stay heighten the challenge to properly assess and address the care needs of older adults during hospitalization as well as their discharge needs. The focus of assessment and care is generally on resolving the immediate problem that triggered hospitalization; less attention is given to the underlying risk of functional decline and the vulnerability to hospital-associated complications.

A primary focus for improvement in health care is on promoting patient safety and avoiding injuries to patients.5 This becomes especially important for hospitalized elders, who are at risk for functional decline due to altered mobility levels as well as iatrogenic risks. For the frail elderly in particular, hazards of hospitalization include falls, delirium, nosocomial infections, adverse drug reactions, and pressure ulcer development.6–8

A dissonance exists between the hospital environment and therapeutic goals for the hospitalized elderly. The hospital environment, a tertiary ca re setting, has traditionally focused on medically managing illness states, not on improving patient functioning. The environment is designed for the rapid and effective delivery of care—not for enhancing patient function. Hospital redesign to address the care needs of the elderly have been proposed.9, 10 Consideration of the milieu as well as age-related physiological changes are important aspects of creating a safe hospital environment for the hospitalized elderly.

Age-Associated Changes

A number of known physiological changes occur with aging, including reduced muscle strength and aerobic capacity, vasomotor instability, baroreceptors insensitivity and reduced total body water, reduced bone density, reduced ventilation, and reduced sensory capacity.4, 11, 12 Comorbid conditions and chronic illness may heighten these changes. Muscle mass and muscle strength are reduced with aging and contribute to a reduction of physical activity.12 With aging, alterations in autonomic function, including baroreceptor insensitivity, occurs. Age-associated reduction in body water and plasma volume may predispose the elderly to syncope. Respiratory mechanics are also altered with aging, with reduced ventilation, increased residual capacity, and reduced arterial oxygen tension.12 Other age-associated changes include reduced bladder capacity and increased urine production, prostrate enlargement, bone demineralization, loss of taste and smell, decreased skin integrity, and reduction in sensory input.12, 13

As a result, the elderly are at higher risk for adverse physiological consequences during acute illness, including impairment in functional status. Frailty—a state of musculoskeletal weakness and other secondary, widely distributed losses in structure and function—has been found to be attributed to decreased levels of activity and has been linked to the process of aging.14 Advanced age, acute and chronic disease and illness, functional limitations, and deconditioning all contribute to the older adult’s vulnerability to functional decline during hospitalization. Functional decline—the inability to perform usual activities of daily living due to weakness, reduced muscle strength, and reduced exercise capacity—occurs due to deconditioning and acute illness during hospitalization.15

Functional Status

Functional status is determined by the ability to perform activities of daily living (ADLs)—eating, dressing, bathing, ambulating, and toileting—and instrumental ADLs (IADLs)—shopping for groceries, meal preparation, housework, laundry, getting to places beyond walking distance, managing medications, managing finances, and using a telephone.4 It is estimated that up to 8 percent of community-dwelling elders need assistance with one or more ADLs. Among those age 85 and older, the percentage who live at home but need assistance or who live in a nursing home increases significantly to 56 percent of women and 38 percent of men.4 Chronic illness and comorbidities can directly impact functional status in the elderly. Chronic health care conditions that are most prevalent in the elderly include heart disease, hypertension, arthritis, diabetes, and cancer.3 Acute illness due to chronic disease and chronic comorbidities accounts for a significant number of hospitalizations in the elderly.

Functional Decline During Hospitalization

During hospitalization, the elderly patient often experiences reduced mobility and activity levels. Functional decline, including changes in physical status and mobility, has been identified as the leading complication of hospitalization for the elderly.16 The hazards of bed rest during hospitalization are well established and include immobility, accelerated bone loss, dehydration, malnutrition, delirium, sensory deprivation, isolation, sheering forces on the skin, and incontinence (see Table 1).12, 17

Table 1

Table 1

Effects of Bed Rest

Bed rest results in a reduction of exercise capacitydue to several physiologic changes that occur, including reductions in maximal stroke volume, cardiac output, and oxygen uptake.17 The muscle fatigue that results is associated with reduced muscle blood flow, red cell volume, capillarization, and oxidative enzymes.17 Accelerated bone loss can le ad to a higher risk for injury to bones and joints, including hips and spine.18

Deconditioning, which results in a decrease in muscle mass and the other physiologic changes related to bed rest, contributes to overall weakness.19 Functional decline can then occur as a consequence of those physiologic changes and result in inability to perform usual ADLs.19

Low levels of mobility and bed rest were common occurrences during hospitalization for the elderly.20 Deconditioning and functional decline from baseline was found to occur by day 2 of hospitalization in elderly patients.21 Loss of functional independence during hospitalization resulted from not only the effects of acute illness, but also from the inability to maintain function during hospitalization.22 In assessing physical activity of 500 hospitalized elderly patients, those who remained in bed or who had chair activity rarely received physical therapy, had physician orders for exercises, or performed bedside strengthening exercises.21 Comparisons of functional assessment at baseline and day 2 of hospitalization in 71 patients over the age of 74 years demonstrated declining ability in mobility, transfer, toileting, feeding, and grooming.23 Between day 2 and discharge, 67 percent demonstrated no improvement and 10 percent experienced further decline, highlighting the potential for delayed functional recovery in the hospitalized elderly.23 A followup of 489 hospitalized elders age 70 years and older revealed that the prevalence of lower mobility in hospitalized elderly was significant, with 16 percent experiencing low levels of mobility, 32 percent experiencing intermediate levels of mobility, and 29 percent experiencing a decline in an ADL activity.20 Yet for almost 60 percent of bed-rest episodes, there was no documented medical indication for limiting mobility status.

Preadmission health and functional status of the elderly can indicate risk of further functional decline associated with hospitalization. In examining the baseline functional status of 1,212 hospitalized patients age 70 years and older, the use of ambulation assistive devices, such as canes and walkers, was predictive of functional decline associated with hospitalization.24 Use of a walker was associated with a 2.8 times increased risk for decline in ADL function by the time of hospital discharge (P = 0.0002). Moreover, 3 months after discharge, patients who had used an assistive device prior to hospitalization were more likely to have declined in both ADL status (P = 0.02) and IADL status (P = 0.0003).24 Other risk factors found to be predictive of functional decline in the elderly during hospitalization included having two or more comorbidities, taking five or more prescription medications, and having had a hospitalization or emergency room visit in the previous 12 months.25

Associations between functional status and other risk factors such as cognitive status must also be considered. Hospital-related complications or inadequate hospital care have been linked to the development of delirium in the hospitalized elderly.26 Impairment in cognitive status was found to be associated with changes in functional status in the hospitalized elderly. A study of 2,557 patients from two teaching hospitals examined the association between level of impaired performance on a cognitive status screen and maintenance and recovery of functioning from admission through 90 days after discharge. Performance on a brief cognitive screen on admission was strongly related to subsequent change in function. Among patients who needed help performing one or more ADLs at the time of admission, 23 percent of patients with moderate to severely impaired cognitive performance, 49 percent of patients with mildly impaired cognitive performance, and 67 percent of patients with little or no impairment in cognitive performance recovered the ability to independently execute an additional ADL by discharge (P < 0.001).22 Additional studies identified that prolonged recovery and continued ADL limitations occurred after hospitalization. In following 1,279 patients age 70 years and older after hospital discharge, a study found that 59 percent reported no change in ADL status, 10 percent reported improvement, and 39 percent reported declined ADL status at discharge when compared to preadmission status. At 3 months after discharge, 40 percent reported a new ADL or IADL disability compared with preadmission, reflecting the potential for continued functional decline after hospitalization for acute illness.27

Yet, the loss of functional independence is not an inevitable consequence of hospitalization for the elderly.28, 29 Evidence exists that targeted interventions can impact the degree of functional independence for hospitalized elders.30

Research Evidence

Targeted measures that have proven beneficial in mitigating functional decline during hospitalization have included comprehensive geriatric assessments to identify patients at risk, structured geriatric care models, dedicated hospital units for acute care of the elderly, and the use of specific resources to enhance care for the hospitalized elder.

Comprehensive Geriatric Assessment

Comprehensive geriatric assessment (CGA) is used to create a plan of care for hospitalized elders. A specific goal of the CGA is early identification of elder care needs in order to provide interventions to minimize high-risk events such as falls or the onset of delirium.31

A CGA should include assessment of ADL and IADL performance as well as assessment of cognition, vision and hearing, social support, and psychological well-being.19 A number of geriatric assessment tools can be used to make initial and ongoing evaluations of hospitalized elders. Commonly used tools include the Katz Index of Independence in Activities of Daily Living,32 the Lawton Instrumental Activities of Daily Living Scale,33 and the Hospital Admission Risk Profile (HARP), among others (see Table 2).

Table 2

Table 2

Commonly Used Geriatric Assessment Measures

As part of CGA, baseline admission assessments have proved beneficial in identifying patients at risk for functional decline during hospitalizations. The HARP was used in one study to assess preadmission risk factors among more than 800 patients age 70 years and older who were hospitalized for acute medical illness.34 The HARP includes assessment of ADL status, IADL status, and cognitive status. Researchers found that three factors independently predict functional decline: increasing age, lower admission cognitive status, and lower preadmission IADL function. Patients at low risk of functional decline were more likely to recover ADL function and avoid nursing home placement at 3 months after discharge.

Another functional status instrument that can be used to assess baseline activity and functional levels is the Mobility Classification Tool, described by Callen and colleagues.35 The tool may prove useful for nurses to assess, quantify, and communicate baseline levels and changes in mobility. Baseline assessments can provide useful information for structuring care during hospitalization and establishing goals for the care.

Aside from the use of formal assessment instruments that measure ADL and IADL function, a general idea of functional status can be ascertained by assessing mobility and activity performance during hospitalization. The frequency of hallway ambulation in hospitalized elders was examined in an observational study of 118 patients age 55 years and older in a single setting.36 While all patients were considered by their primary nurse as able to walk the hallways, 72.9 percent did not walk at all per 3-hour period of observation, 18.6 percent walked once, 5.1 percent twice, and only 3.4 percent walked more than twice.35 The median time of ambulation was 5.5 minutes. Of the 32 patients who walked in the hallways, 46.8 percent (n = 15) did so alone, 41 percent (n = 13) walked with a therapist, 41 percent (n = 13) walked with a member of the nursing staff, and 18.8 percent (n = 6) walked with a family member.

Based on the results of the CGA, functional problems or potential problems are identified and specific interventions can be implemented to promote functional ability in hospitalized elders. A number of interventions, including structured exercise, progressive resistance strength training, and walking programs, have been implemented to target elder care functioning during hospitalization.35, 37, 38 A randomized control trial of a hosp ital-based general exercise program with 300 hospitalized elders that was started during hospitalization and continued for 1 month after discharge did not affect length of stay, but did demonstrate better IADL function at 1 month after discharge.38 Measures to improve endurance—including exercise to enhance orthostatic stability, daily endurance exercise to maintain aerobic capacity, or specific resistance exercises to maintain musculoskeletal integrity17, 39, 40—need further study on their impact in reducing functional decline in hospitalized elders. As hospital-based exercise programs require coordination and focused implementation plans, strategies for adopting them need to recognize the shortened length of hospital stay and the effects of acute illness on the patients’ ability to participate.

In addition to utilizing tools to assess the elderly hospitalized patient, assessments of the hospital culture for providing elder care can also be beneficial. The Geriatric Institutional Assessment Profile was specifically developed to assess hospital workers’ knowledge, attitudes, and perceptions of caring for elders, as well as the adequacy of the institutional environment to meet hospitalized elders’ needs.41 It is recommended to help identify both the strengths in elder care and the opportunities for improvement.42

Structured Geriatric Care Models

For more than 20 years, the concept of hospital-based geriatric assessment and interdisciplinary team care to improve outcomes for hospitalized elders has been implemented in various models. Early studies on the use of geriatric evaluation and geriatric evaluation units demonstrated an impact on reducing disability and nursing home placement.43–45 Several hospital-based geriatric resource models of care have also demonstrated benefits in promoting evidence-based care for hospitalized elders, including the use of geriatric interdisciplinary team training46 and the use of a geriatric resource nurse.47 National programs for geriatric interdisciplinary team training were created in 1997 to enhance the knowledge of caring for elders among a variety of health professions. While evaluation data have demonstrated improvement of geriatric interdisciplinary team trainees, most notably in attitudinal measures,46 further study on the impact on geriatric care planning is needed.

Several focused models of care designed to prevent functional decline of the hospitalized elderly have demonstrated significant results. The Hospital Elderly Life Program, a structured screening program for hospitalized patients age 70 years and older, concentrates on admission screening of six risk factors: cognitive impairment, sleep deprivation, immobility, dehydration, vision loss, and hearing impairment.16 More than 1,500 patients were screened, and targeted interventions based on the presence of admission risk factors were instituted. Patients were followed by an interdisciplinary team that included a geriatric nurse specialist, Elderly Life specialists, and geriatricians who worked in conjunction with the patient’s primary care nurse to formulate an individualized plan of care. Use of the program demonstrated significant results: only 14 percent of patients had a decline on ADL scores, compared to a decline in 33 percent of the control group.

Acute Care for Elderly (ACE) units

Models of care incorporate a variety of interventions to promote positive outcomes for the hospitalized elderly. Specific programs have also been tested on specialized units within the hospital setting. These units, termed Acute Care for the Elderly (ACE units), provide dedicated care to the hospitalized elderly.

Originating in the early 1990s, the ACE unit concept has been adopted by organizations as a strategy to provide care to elderly patients during hospitalization.48–49 ACE units promote a focused model of care that integrates geriatric assessment into medical and nursing care of patients in an interdisciplinary environment.50 The focus is to provide expert care while simultaneously keeping patients mobile and preventing the loss of normal daily routines.49 ACE units include specially designed environmental changes to promote activity such as ambulation in hallways, exercise facilities, and social gathering areas.51 Multidisciplinary teams composed of geriatric physicians; nurses; dietician; social worker; pharmacist; and occupational, speech, and physical therapists regularly discuss the plan of care for each patient.49 Major components of the ACE unit concept include patient-centered nursing care (daily assessment of functional needs by nursing, nursing-based protocols to improve outcomes, daily rounds by a multidisciplinary team), a prepared environment, planning for discharge, and medical care review.10, 52

Another model, designed to improve functional outcomes of acutely ill hospitalized elders, was tested in a randomized control trial with 1,794 patients 70 years of age and older in one unit of a hospital. A number of interventions were implemented under the direction of the primary nurse, including baseline and ongoing assessment of risk factors; following protocols to improve self-care, continence, nutrition, mobility, sleep, skin care, and cognition; conducting daily rounds with a multidisciplinary team; and environmental enhancements such as handrails, uncluttered hallways, large clocks and calendars, elevated toilet seats, and door levers.29 Results indicated that 21 percent of intervention patients were classified as much better in ADL activity abilities, 13 percent as better, 50 percent as unchanged, 22 percent as worse, and 9 percent as much worse. In the control group, 13 percent were classified as much better, 11 percent as better, 54 percent as unchanged, 13 percent as worse, and 8 percent as much worse (P = 0.0009). While the program interventions improved functional status in a significant percentage of the patients, the majority of the patients in both the intervention and control groups were unchanged or worse at the time of discharge. At 3 months after discharge, the groups did not differ significantly in terms of ADL or IADL abilities.29 The results of this study suggested that while targeted interventions can improve functional independence in the hospitalized elderly, some patients will continue to experience functional decline, despite focused interventions.

Research comparing ACE units and standard medical care units has demonstrated positive outcomes, with improvements in ADL function and fewer transfers to nursing home settings after discharge.29 A randomized controlled study of 1,531 elders age 70 years and older demonstrated that use of an ACE unit improved processes of care and promoted patient and provider satisfaction without increasing hospital length of stay or costs.51 Additional study on the cost effectiveness of ACE units has demonstrated significant reductions in average length of stay (0.8 day) and a cost savings of $1,490 compared to control patients on two medical-surgical units, a savings that translated to $1.3 million in 9 months48 as well as no increase in hospital costs.53

The NICHE model

An additional model focusing on improving hospital care for the elderly, the Nurses Improving Care of Health System Elders (NICHE) project, was initiated in the early 1990s. The project is a national program focused on promoting evidenced-based care for elders.42, 54 Resources include best practice protocols, educational materials, nursing care models to replicate, and assessment tools. A unique series of online assessment tools, Try This, is available at www.hartfordign.org/resources/education/tryThis.html. Assessments of the NICHE program indicate that fewer patients were acutely confused at discharge,55 restraint use was reduced by more than 60 percent, serious injuries related to falls were reduced by 30 percent, there were beginning signs of reduction in the incidence of aspiration pneumonia and urinary tract infection, and patient mobility equipment was standardized.56 Outcome reports from implementation of NICHE also included increased nursing knowledge of geriatric care, decreased length of stay, and reduced costs.42, 56–58 The NICHE model of care is currently a voluntary program, and while additional outcomes-based research is needed, implementation of the program components by all hospital settings would facilitate best practices for elder care.

The geriatric resource nurse model is the most widely used NICHE model. In the geriatric resource nurse model, unit-based nurses acquire competency in elder care and improve care by modeling best practices and providing consultation for elder care.42, 56, 57 Implementation reports highlight anecdotal evidence of benefit, but researched-based outcome evaluations is limited. One study of 173 hospitalized elders demonstrated improvements in outcome measures, including functional and cognitive status from admission to discharge when managed by the geriatric resource nurse model; however, a comparison of a subset of the intervention patients and a control group of patients revealed no differences in patient outcomes.30 Further research on this model of care for hospitalized elders is required.

Other Measures to Enhance Care for the Hospitalized Elder

Additional resources to promote hospital-based elder care that are evidence based include nursing staff education to enhance geriatric assessment and care, promotion of nursing certification in geriatric care, and promotion of family participation in caring for hospitalized elders.59–62 Other focused interventions—including geriatric consultation on specific units, comprehensive discharge planning, and nutritional support—have had beneficial effects on clinical outcomes of hospitalization of the elderly.63, 64 Ongoing initiatives that have the potential for impacting the care of hospitalized elders include strategies for enhancing geriatric content in nursing school curriculum, advanced practice nurse training in geriatric care, centers of geriatric nursing excellence, and geriatric nursing scholar work. Yet, much remains to be learned about not only the causes of functional decline during hospitalization for the elderly, but also the best approaches for comprehensively modifying the hospital care environment to promote best outcomes. As nurse staffing levels have been demons trated to impact the quality of hospital care,65 exploration of innovative models of nurse staffing to enhance care for the hospitalized elderly is also needed. In addition, there is limited research on hospital designs to improve functioning for hospitalized elders. Hallway walking is not always encouraged, and hospital hallways are often designed for transport of supplies, equipment, staff, and patients. The effect of environmental designs to enhance functioning of hospital elders, such as designated walking tracts on nursing units with shock-absorbing flooring and railings solely for patient use, require further exploration.

Table 3

Table 3

Summary of Key Points Based on Research Evidence

Evidence-Based Practice Implications

Table 4 outlines several evidence-based strategies for care of the hospitalized elder. A number of evidence-based practice guidelines that pertain to hospitalized elder care can be used to structure care to promote best practices in a variety of areas, including pain management, strategies for assessing and treating delirium, fall prevention for older adults, prevention of pressure ulcers, and changing the practice of physical restraint use in acute care. The guidelines can be found at www.guideline.gov.

Table 4. Evidence-Based Strategies for Care of the Hospitalized Elder.

Table 4

Evidence-Based Strategies for Care of the Hospitalized Elder.

A number of important considerations for addressing potential risks for the hospitalized elder are outlined in Table 5.

Table 5

Table 5

Practice Implications to Avert Potential Risks

Research Implications

To improve the quality and safety of care for hospitalized elderly patients, the following questions deserve further investigation:

  • What interventions are the most effective in enhancing functional status in the hospitalized elderly?
  • What is the impact of single-site successful models of care in multiple hospital care settings?
  • What is the cost effectiveness of intervention programs aimed at targeting functional decline in the hospitalized elderly?

Future research on reducing functional decline in the hospitalized elderly should target the following significant gaps in research:

  • Additional research on the impact of models of care for the hospitalized elderly (including NICHE) is needed to build evidence-based practice recommendations. Most of the existing “evidence” comes from small randomized studies, nonrandomized studies, case studies, and expert opinion.
  • Hospital design outcomes research is warranted to further evaluate the impact of redesign interventions in enhancing outcomes for hospitalized elders.
  • Most research on interventions targeting functional status during hospitalization of the elderly was conducted at single-site locations. Therefore, it is not clear if the findings can be generalized to other settings. Additional research is needed that focuses on multidisciplinary interventions with larger sample sizes and in multicenter, randomized clinical studies.
  • A conceptual model for targeting functional decline in the hospitalized elderly is needed. Factors to be considered include the fact that the elderly are a heterogeneous group—some are frail upon admission and others are robust. The hospitalized elderly come to the hospital with different comorbidities and reasons for admission. Polypharmacy in the elderly needs to also be considered. In addition, the tertiary care environment is not a living environment, creating a dissonance between the goals of restorative care and environmental function.
  • While structured models of care focusing on assessment, physical therapy, ADL protocol use, and multidisciplinary team care have demonstrated significant benefits on independence for hospitalized elders, relatively simple interventions such as hallway walking, communal dining, and group therapy need to be further examined.
  • Nursing-focused interventions aimed at promoting functional independence for hospitalized elders need further exploration in formal research studies.

Conclusion

This chapter has presented an overview of research and evidence-based practices for elderly care during hospitalization to prevent functional decline. A number of other chapters in this book further address related areas, such as averting patient falls, preventing pressure ulcers, symptom management, and other aspects of care for the hospitalized elder. Continued research and dissemination of best practices will lead to additional strategies that nurses can use to improve the quality of health care and outcomes for hospitalized elders. Assessment of function and targeting interventions during hospitalization are critically important to acute care of older adults.71 The impact of functional decline on resource utilization and health care costs may further reinforce the need to assess and intervene to prevent functional decline.72 Additional research on factors influencing functional decline will also provide information for nurses to present to administrators to develop programs to identify and mitigate functional decline in the hospitalized elderly.

Acknowledgments

The authors would like to acknowledge Mary H. Palmer, Ph.D., R.N.C., F.A.A.N., Helen W. & Thomas L. Umphlet Distinguished Professor in Aging, University of North Carolina at Chapel Hill, and Eileen M. Sullivan-Marx, Ph.D., C.R.N.P., F.A.A.N., associate professor, associate dean for Practice & Community Affairs, and Shearer Endowed Term Chair for Healthy Community Practices, University of Pennsylvania School of Nursing, for their review and suggestions for editing of the chapter.

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