The missing link: active ageing within the hospital environment

The hospital environment is important in maintaining the harmony of older adult life and function. There are two pillars of active ageing – health and participation – which are affected during and after admission. Part one of this two-part article looks at the long-term impact of hospitalisation on older patients.

Introduction

“Age before beauty” is quite a popular idiom; it evokes the feeling of respect for older people. However, is this true in real life?

Many people believe that being old means to be more dependent on others in every aspect of life. A simple example is the signage for older people in the streets, at restaurants, or public transports – mostly, a man or a woman wearing glasses walking with a stick and a curved back. This exactly fits the common picture of older people in our minds. However, as people nowadays live longer than before and in reasonably better health, this image will hopefully change.

The Covid-19 pandemic has put the global health system under tremendous pressure. During this crisis, there is an urgent need for ICU beds and ventilators everywhere and the mortality rate especially among older adults was expected to be high due to the comorbidities that they usually have.¹ Therefore, there were more restrictions on them as a way to protect them.

An Italian study found that the fatality rate among Covid-19 patients who are between 40-49 years was only 0.4% in contrast to those who are >80 years which was 20.2 %. Maria and her colleagues did a twitter analysis for ten days, by posting tweets to the public about Covid-19 and older adults.² They found that one in four of the tweets were offensive to people of an older age.

The impact of Covid-19 emphasises that this age group is vulnerable and needs special care compared to others.

Greying planet and active ageing initiatives

The World Health Organization (WHO) considers ageing as a great success, but at the same time, the biggest challenge to humanity.³ Many countries experience a paradigm shift in the population pyramid from the triangular pyramid to a cylindrical one.

This major change is attributed partially to the reduction in fertility and mortality rates,³ for example, in Oman the fertility rate (birth per woman 15-49 years old) was dropped by almost 50% in 2019 compared to 1995 (3.7, 6 respectively).⁴

The death rate per 1,000 people followed a nearly similar reduction rate (from 6.1 in 1995 to 2.7 in 2019).⁴ Consequently, life expectancy also showed a significant increment for both sexes; for males, it increased from 66.8 years in 1995 to 75.2 in 2019, and for females from 67.7 years to 79.2 respectively.

The number of people who are more than 60 years old is estimated to have a steady rise over the coming ten years.

These figures “from the economics perspective” carry a fear of increasing pension and medical care costs⁵ because as people get older, they are more likely to have multiple complex health issues related to non-communicable diseases, falls, hearing impairment, and cognitive impairment.⁶ Consequently, they need more support from society and the government.

For the above reasons, initiatives to help this age group remain active and healthy are important, as growing old is not a choice. One day, we may find them representing 50% of the population or even higher!

To ameliorate the effect of the ageing population worldwide, WHO started to raise awareness of ‘active ageing’ in 1990. Since then, it has received a lot of interest. It is defined as ‘the process of optimising opportunities for health, participation, and security to enhance the quality of life as people age’.³ It aims to provide older people with a long, healthy and good quality of life as they get older.³

WHO’s active ageing policy is based on three pillars: health, security, and participation. The roles of all these pillars were explained in detail in the WHO 2012 report.

WHO view of health system role in active ageing

First, what is ‘health’? It is defined by WHO as ‘physical, mental, and social wellbeing’. The core concept is that to adopt a healthy lifestyle early in life, to enjoy a healthy good quality life during the later stages of life.

The role of the health system in the WHO report mainly involves four parts: health promotion, disease prevention, primary health care, and long-term care.

Health promotion focuses mainly on the strategies that should be adopted by any individual and society to help prevent ill health in addition to disease treatment and cure.

Disease prevention comprises averting communicable diseases through strategies such as vaccines and non-communicable diseases by early screening, proper treatment, and follow up.

The primary health care system is expected to provide a high quality of care and to communicate with secondary and tertiary health facilities, if required.

Long-term care involves the support that is provided by informal or formal carer for older adults who are not able fully to take care of themselves. The informal care giver includes family members or friends whereas, the formal carers includes community health services such as primary care, home care, and institutional care such as nursing homes.

Mental health services, which is promoted to be integrated within the long-term care system, plays an important part of active ageing. It aims to diagnose mental illnesses, for example: depression and suicide ideation, This will help to prevent their negative consequences.

The role of the health system according to the WHO report is completed at this stage. So, what is the role of hospitals in active ageing? Is it important or can we ignore it? Is it logical to have policies to help older individuals be active at home and once they are hospitalised to have no policies for that?

How do you think the older body reacts to long-term admission with no initiative or encouragement to be active? Is the hospital environment safe for an older adult? Answers to these questions are not easy to find.

Old age and hospitalisation

In the US, 40% of hospitalised adults were 65 years and older in 2008.⁷ Therefore, a significant number of hospital admissions are people of older age. They are admitted with acute illness in addition to their background functional impairment. One of the fundamental roles of hospitals is to maintain the functional abilities of patients or even to enhance them.⁸ However, is this truly what happens to old adults after hospitalisations?

The following case scenarios will give an idea about a few outcomes that some of older adults gain after hospitalisation.

Case study one: functional decline

Mrs Al Jahwari was a 90-year-old woman. She lived with her daughter, she was able to walk, eat and dress all by herself. One day she had a fever, cough and shortness of breath. Her daughter took her to the hospital; she enters the hospital walking by herself. The doctor decided to admit her for intravenous antibiotic. She stayed in the hospital for about three weeks. Upon discharge, she was not able to walk or feed herself. A few months later, she developed pressure ulcers at the trochanteric area on both sides, these ulcers later became infected and then she died.

Case study two: decline after a fall

‘The older you are, the worse the hospital is for you.’ This was a title for a report in a CNN health report by Anna Gorman.⁹ In this report she described a case of an older lady who was living independently and worked as a special educator tutor. She was admitted in the hospital for more than three weeks after a fall. Upon discharge, she was not able to walk and her thinking process was impaired.

She required three weeks of rehabilitation. She stopped working and was not able to drive for months. Anna later interviewed Dr Covinesky, a physician at California University, and he said that statement, by which Anna titled her report. She reported that 13 million old adults are hospitalised annually.¹⁰ Some of them may lose their functional abilities and may never recover. “It is like putting Humpty Dumpty back together again”.

Conclusion

The hospital environment is important in maintaining the harmony of older adult life and function. There are two pillars of active ageing – health and participation – which are affected during and after admission. Usually people spend a very short time in the hospital throughout life but this short-term stay in the hospital has a tremendous long-term impact.

Adopting strategies to prevent these deteriorations during hospitalisation is “a necessity not a luxury.” Think who is at risk, what factor predisposes them to functional deterioration, and what we can do to forestall it.

Implementing active ageing within the hospital environment will help to change the attitudes of healthcare workers towards this vulnerable group. This will decrease medical care costs as there will be efforts to maintain their baseline activity level with no urgent need for rehabilitation post-discharge.

Remember that ‘Age before beauty’ is a way to express gratitude to our nation builders and prioritise them when they need help the most.

Part two of this article will look at what factors contribute to functional impairment after hospitalisation of older adults.

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Dr R Majdah, Cardiff University

This assessment is submitted to Cardiff University as part of the Masters in Ageing Health and Disease programme and is solely the original work of its author, except where clearly specified otherwise. It has not been previously submitted to this or another university and no plagiarism has been committed.

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References

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2. Jimenez-Sotomayor MR. et al. Coronavirus, Ageism, and Twitter: An Evaluation of Tweets about Older Adults and COVID-19. J Am Geriatr Soc 2020; 68(8): 1661-1665
3. WHO. 2002. Active ageing. https://extranet.who.int/agefriendlyworld/wp-content/uploads/2014/06/WHO-Active-Ageing-Framework.pdf (Accessed: 15/07/21)
4. Oman Health Report 2019. https://www.moh.gov.om/en/web/statistics/annual-reports (Accessed: 15/07/21)
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8. Sager MA, et al. Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med 1996; 156(6): 645-652
9. Anna G. 2016, August 15. ‘The older you are, the worse the hospital is for you’.  Available at: https://edition.cnn.com/2016/08/15/health/elderly-hospital-patients/index.html (Accessed 15/07/21)
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