There is increasing evidence that the outcomes of hospitalization of older people could in many cases be improved through greater attention to their unique needs and vulnerabilities, particularly of the frail older patient. Excess nosocomial infections, incontinence, confusion, activity limitations, skin breakdown, and increased posthospitalization mortality have been noted as untoward outcomes of hospitalization (Foreman, 1986; Holmes, 1990; Kosecoff, 1991; Lofgren, 1989). Many of these untoward events could be prevented or minimized by vigorous nursing intervention. The purpose of this article is to review mis evidence and discuss the implications for nursing practice.
An analysis of recent research indicates that there is a particular segment the older population that is especially vulnerable to adverse outcomes from hospitalization. For example, a recent study of the effects of the prospective payment system - which is based on diagnostic related groups (DRGs) - on the quality of hospital care of Medicare patients compared pre-DRG outcomes (1981 to 1982) with post-DRG outcomes (1985 to 1986) (Rogers, 1990). Overall, the processes of care as documented in the records were found to be better and mortality rates at both 30 and 180 days postdischarge were the same or lower than pre-DRG rates. (Emphasis was on medical care and the medical portion of the record.)
However, the outcomes for a subset of these Medicare patients were different - and are relevant to the concerns of this review. Comparison with data from records prior to DRGs indicated that 15% of this over-65 population (with diagnoses of congestive heart failure, pneumonia, acute myocardial infarction, cerebrovascular accident, and hip fracture) were sent home in unstable condition in 1981 to 1982compared with 18% post-DRG. (This jump of 3 percentage points represents a 20% increase.) A 93% increase in the rate of instability at discharge was found in the hip fracture subsample.
These increases are of concern because patients discharged in unstable condition have a higher relative risk (ratio) of dying postdischarge (1.6); the highest among these subsamples is again hip fractures (2.0). Kosecoff and associates (1991) noted that instability not only resulted in lower quality of Ufe for both the patient and his or her family, but also was clearly linked to subsequent death. Because reimbursement levels have become more stringent since the 1985 to 1986 studies, it is possible that this problem is even greater now than the data suggest (Kosecoff, 1991).
In addition to increased instability and mortality, increased iatrogenesis also was noted (Kosecoff, 1991). Ten percent of the 10,913 patients studied (excluding those who died in the hospital, had do not resuscitate orders, or were transferred to another acute care setting) were discharged with new problems of incontinence, and 4% had new problems of confusion.
These results led the researchers to raise a number of serious questions about what occurs during hospitalization. Was the increase in instability due primarily to early discharge? Are too many tests being conducted within the shortened hospital stay? Are there changes in nursing practice due to fewer nurses per patient or to less time to assess and treat incontinence or disorientation? Is there adequate educational preparation and/ or training in nursing assessment and care of these patients?
Additional evidence regarding the effects of hospitalization on one segment of this vulnerable population came from a study of 287 residents from 10 nursing homes who had been hospitalized and subsequently returned to the nursing home (Holmes, 1990). Following a period of stabilization after return from the hospital, it was found that 57% were still more impaired in their performance of the basic activities of daily living than they had been prior to hospitalization. Thirty-three percent more experienced activity limitations, 15% had more difficulty eating, 15% more were incontinent, 18% had new or increased restraint usage, and 28% had new or larger decubitus ulcers. Those who were deemed to be physically frail on hospital admission were noted to have been at greater risk for these untoward events.
Another study of a relatively large community sample of 5,704 persons over 65 indicated that a decline in cognitive function was related to increased frequency of hospitalization and prolonged hospital stay (over 20 days) (Binder, 1990). The authors noted, however, that it was not possible to determine from their nonexperimental data whether decreased function was the cause, consequence, or both, of hospitalization. They believed that specific practices occurring during hospitalization may be implicated in the occurrence of cognitive decline.
Further evidence of iatrogenesis in this population comes from a prospective study of 1,661 patients, average age 75, who were admitted to general medical units in the Midwest. Older patients who were restrained for a prolonged period (over 4 days) had a higher relative risk of developing nosocomial infections (1.8) and new pressure sores (1.4) (Lofgren, 1989). It was suggested by the researchers that physical restraint use may create a kind of medical and social isolation in which patients are not turned, examined, or given routine care as often as they should be. Loss of autonomy occurs and communication between patient and caregivers is diminished, threatening both the physical and social integrity of the patient.
DISCRIMINATORY HEAlTH CARE PRACTICES
It is interesting to note that the Special Report on Aging 1990, from the National Institute on Aging (NIA) (1990), includes a section on discriminatory health care practices experienced by older persons. Among the examples drawn from various NIAsupported research studies were reduced access to cardiac rehabilitation programs, physicians' beliefs that older patients should not receive maximum evaluation and treatment for acute illnesses, and failure to offer rehabilitation to older stroke patients.
Such practices reflect an underlying assumption that older patients lack the ability to return to normal functioning following an acute episode. This assumption virtually precludes their being offered the kind of care necessary to help them return to their prior level of function - which poses a considerable threat to maintaining their optimal level of function and health.
There is some additional evidence of age bias leading to treatment decisions based on age in acute care. For example, Binstock (1990) noted a pattern of clinical decision making based upon age rather than individual diagnosis or identified needs. Once a patient is labeled a "geriatric" case, the practitioner's perspective seems to become constricted. A similar effect has been noted in nursing care; nurses in acute care settings are beginning to voice their concerns about the effect of age bias on delivery of care to older persons (Roberge, 1990).
In an article entitled Ration or Rescue, Levine (1989) appealed for adequate treatment of the older person in critical care. High-tech, high-risk care is being rationed and euthanasia is being promoted in the elderly - disguised as outrage at the prolongation of dying. According to Levine, to create a separate ethic for older people is to deny them their humanity.
THE CHALLENGE FOR NURSING
This group of frail, multiproblem older adults poses a considerable challenge to nursing practice if we are to achieve the goals of gerontological nursing articulated by Eliopoulos (1979) and Gunter (1979) years ago: to help older adults minimize healthrelated losses and increase their capacities. Older patients have complex biopsychosocial needs that require specialized knowledge and skill to deal effectively with them. Brower (1985) has long advocated special preparation in care of the older person. She writes that practicing nurses know less than they need to know about the older patient and that there are perceptions and attitudes regarding older patients that also must be changed.
A small qualitative study of hospital nurses found that nurses, too, believed that they were able to fill some, but not all, of the older patient's needs (Huckstadt, 1990). Most voiced concern over their lack of preparation in gerontological nursing, a concern that is justified by the literature. There is preliminary evidence that hospital stays may be shorter and functional status may be improved when the older patient's care is supervised by health care professionals specially trained in gerontology/geriatrics (Pawlson, 1988; Wanich, 1992).
In a survey of nurse administrators, Heine (1988) examined the role of the gerontological nurse specialist in three settings: acute care hospital, nursing home, and home health care. Nurse administrators in acute care hospitals perceived the greatest need to be that of fulfilling specific role behaviors related to care of the elderly, especially those related to identifying the special needs of the elderly clients. Development and implementation of programs to meet those needs were believed to be of high priority. Heine (1988) concluded that "The complex, comprehensive, and multifaceted nursing care that older people required necessitates highly skilled and knowledgeable gerontological nurses."
Brower described a program at a Veterans Administration Medical Center where geriatric evaluation units were put in place. In these units, the use of gerontological nurse specialists resulted in improved orientation, better continence, and greater ambulation and independence.
An innovative approach to improving preparation of nurses already in practice was launched at Yale-New Haven Hospital in 1988 (Fulmer, 1991). Nurses volunteer to become geriatric resource nurses and to acquire advanced knowledge in gerontological nursing, which is then shared with their colleagues. Benefits of the program include increased sensitivity to the needs of older patients and more effective prevention of the iatrogenic problems associated with hospitalization. The success of these programs supports the need for specialized preparation in the care of the hospitalized older adult.
The introgenic problems of confusion, incontinence, activity limitation, skin breakdown, excess nosocomial infection, and increased posthospitalization mortality can arise either from incorrect treatment or from the failure to provide treatment to the hospitalized older person. AU these untoward outcomes could be prevented, or at least minimized, by appropriate vigorous nursing assessment and intervention by nurses prepared to care for the multiproblem older adult.
For example, a problem such as incontinence in the hospitalized older person is too often assumed to be normal for that age. The result of such an assumption is the failure to diagnose and treat the underlying condition responsible for the incontinence. A change in focus in acute care to emphasize the basics of nursing care, as well as advanced technology, also is necessary. Fulmer talked about nurses being "swept up by the technology and quick pace" of acute care settings (Goldenberg, 1992). The result can be a failure to tend to such basic needs as adequate nutrition and hydration, which exacerbate vulnerability to infection, confusion, skin breakdown, and other problems.
Appreciation of the mulriproblem older adult's increased vulnerability can prevent much of the iatrogenesis that occurs. Attention to basic needs and an immediate response to any indication of an untoward reaction - whether to medication, to the hospital environment or to other treatments - are essential elements in the care of the hospitalized older adult. Failure to do so may produce a cascade of increasingly severe, multiple interacting problems.
For example, agitated behavior due to medication-induced confusion may be incorrectly treated with physical or chemical restraints. The restrained person cannot reach the bathroom in time and becomes incontinent of urine, leading to use of an indwelling catheter and increased risk for urinary tract infection. The restraints also reduce the ability to turn and relieve pressure on heels and buttocks, resulting in skin breakdown in both areas. Finally, the restraint-related inactivity increases the weakness associated with illness and stiffness in arthritic joints so the patient is placed in a wheelchair. The result is an unnecessarily confused, incontinent, immobile individual with two new decubitus ulcers that will require weeks of additional care to heal.
Finally, a sufficient staff is necessary to attend to these nursing care needs. In a study of randomly selected nurses from seven western state hospitals, Nyberg (1990) found that while most nurses valued this type of care, they did not have time to meet these needs. One nurse, for example, indicated that she had been advised by her hospital employer to provide safe, not quality, nursing care. Under such circumstances, it would be difficult, if not impossible, to provide the level of care needed by the hospitalized multiproblem older adult.
The literature reviewed highlights the concern about the negative outcomes of hospitalization of frail, elderly patients. Evidence is mounting that the older patient has unique needs and increased vulnerabilities necessitating comprehensive assessment and specific interventions related to these needs and vulnerabilities. It is hoped that this review will stimulate nurses to initiate and test a variety of differentiated practice models that address the particular needs of this vulnerable population.
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