The missing link: functional impairment after hospitalisation of older adults

The hospital environment is important in maintaining the harmony of older adult life and function. Part two of this two-part article looks at the risk factors that can cause functional impairment after hospitalisation in older adults.

Introduction

The World Health Organization (WHO) considers ageing as a great success, but at the same time, the biggest challenge to humanity. Many countries experience a paradigm shift in the population pyramid from the triangular pyramid to a cylindrical one.¹

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

The first part of this article looked at active ageing and how 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.

Part two will assess questions such as how the older body reacts to long-term admission with no initiative or encouragement to be active. This raises the question of whether the hospital environment is safe for an older adult?

What factors contribute to functional impairment after hospitalisation of older adults?

Many factors in the hospital environment negatively affect the health of older adults even after the successful treatment of their acute medical condition. Many researchers have argued that hospital admission could be a crucial event in converting an older person’s independent life into a dependent one.^2-4

This definitely has a major impact on individuals, their families, and society, as being dependent not only requires constant help from others, but may result in losing their effective participation in the community.⁵

We know that participation in the community is one of the active ageing  pillars. The baseline activity of daily living (ADL) for many older patients deteriorates after hospitalisation.^2,6. Moreover, in 2008, Boyd and his co-workers found that the need of special care for older people after admission are significantly higher and, even worse, they may get new disabilities which will impact their functional outcome in the short and long term.⁷

In fact, it is estimated that one in two of those who are 85 years or older are discharged with new disabilities in ADL.⁶ Regarding functional abilities of the older patient during hospitalisation, there are three scenarios:

• Improvement in the functional abilities
• Worsening of the baseline abilities
• Regaining baseline abilities.

It has been reported that two-thirds of discharged older people become dependent.² Palleschi and associates attempted to identify the factors that help in improving the functional abilities, and they found that the baseline functional level before the acute illness and the high level of functional loss during the acute illness predict recovery during hospital admission.⁸

Other investigators have shown that baseline vulnerability (reflected by three factors: age, physical performance, and cognitive status) and the nature of the acute events predispose for the functional dependence.⁹

Convisky and his colleagues found that disabilities due to hospitalisation that occur after treating the acute illness is not uncommon. It occurs whether the hospitalisation period was long or even short.⁶

Sarcopenia due to hospitalisation

Fortunately, many modifiable risk factors have a significant impact on functional ability during and after discharge from hospitals. The first fundamental contributory factor for functional deterioration is the loss of muscle mass that results from inactivity during hospitalisation.¹⁰

This can explain the acute sarcopenia that some patients experience due to hospitalisation.¹¹ It plays a role in pressure sore development which itself is multifactorial in origin. Resistance exercise training in some medical conditions is not possible to help prevent and treat muscle disuse atrophy.^11,13 However, if a patient could exercise, this should be combined with a high protein diet for the synergistic effect.¹²

Malnutrition and hospitalisation

The second modifiable risk factor is malnutrition. Pennington and his co-workers have shown that 40% of hospitalised elderly people in an acute teaching hospital where they conducted the research, are malnourished, and more than 50% of them had no nutritional information documented in their case notes.¹⁴ They reported that “Malnutrition remains a largely unrecognised problem in the hospital”.

Their population of interest was chosen from different wards: medical, surgical, orthopaedic, geriatric, and respiratory medicine. This gives the impression that malnutrition is not confined to one department. In the study, 66% of their population lost weight during hospitalisation.

Sullivan and his colleagues have reported that a significant number of hospitalised older adults were served nutrition under their estimated requirements.¹⁵ They have shown that the main contributory factors for this was the following: first, nil by mouth order, due to reduced level of consciousness or awaiting diagnostic investigations; second, dislike of the served food and insufficient feeding assistance. Moreover, they demonstrated a significant correlation between undernutrition and inpatient mortality.

Other investigators have demonstrated that the majority of inpatient with deconditioning have malnutrition, which negatively affect their rehabilitation programme as well.¹⁶ Incalzi and his associates recommended malnutrition screening for every geriatric patient upon admission to the hospital because they found commonly that many older patients have low protein-energy intake due to  dislike of food provided and different timing from their usual feeding time.¹⁷

Other investigators recommended a high protein diet or diet rich with an essential amino acid with each meal to facilitate protein synthesis¹² in conjunction with exercise.

Falls and hospitalisation

Falls is the third modifiable risk factors. Older adults have a high risk of falls in hospital environments. Being in an unfamiliar place, weakness due to acute illness and medication side effects all contribute to it. It may result in a serious illness such as a fractured limb, intracerebral haemorrhage or simple aches and pain that will disturb them and render them more functionally disabled.

Delirium and hospitalisation

Delirium is another important modifiable risk for functional deterioration during and after hospitalisation. It is defined as a state of acute confusion. it has a significant role in hospital outcomes, especially in functional disabilities and even death.^18,19

Mcavoy and co-workers have demonstrated that there is a high mortality risk over one year for older people who are discharged with delirium.²⁰ Delirium is less in the older adults admitted in geriatric wards compared to those admitted in general medical wards, and this is attributed to many factors such as early detection, less use of medications and physical restraints, management of sleep disturbance via the non-pharmacological method, and the presence of healthcare staff with geriatric experience.²¹

Therefore,  decision-makers should consider organising geriatric wards equipped with relevant expertise. Inouy and his associates have stated that primary prevention of delirium is probably the most effective treatment strategy.²² They suggested the Elder Life Program as an intervention strategy to prevent delirium. The programme targets six of the delirium predisposing factors: sleep debridement, impaired cognition, impaired hearing, impaired vision, and immobility.

The multidisciplinary team runs this programme compromising a geriatric nurse specialist, two specially trained Elder Life specialists, a certified therapeutic recreation specialist, a physical therapy consultant, a geriatrician, and trained volunteers. It is a challenge to have all these experts in every hospital, but it is worth starting with some of them and monitoring the effect.

Admission in the general medical ward is found to be a risk for functional deterioration. Ellis and his co-workers found in their metanalysis that admitting frail elderly patients in a geriatric ward will most likely lead to their survival and discharge home compared to admission in the general medical ward.²³ Interestingly, they found the cost is lower compared to that in the general medical ward.

Another French study showed that a comprehensive multidimensional geriatric assessment programme had a significant effect on hospital stay in the medical ward for a non-medical reasons although it didn’t influence the length of stay.²⁴ Asplund and his colleagues have shown that length of hospital stay is reduced in the acute geriatric unit that focuses on early rehabilitation and an early plan for discharge.

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. I agree that 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 the medical care cost as there will be efforts to maintain their baseline activity level with no urgent need for rehabilitation post-discharge.

They should be kept as active as possible during hospitalisation by involving in regular active and passive exercises with the help of a physiotherapist. Encourage them to walk to the activity room or coffee room or even to the toilet if they are able to do so.

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 one of this article looks at the World Health Organization healthy ageing policy and the importance of keeping patients active in hospital.

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Dr R Majdah, Cardiff University

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References

1. WHO. 2002. Active ageing. https://extranet.who.int/agefriendlyworld/wp-content/uploads/2014/06/WHO-Active-Ageing-Framework.pdf (Accessed: 15/07/21)
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17. Incalzi RA, et al. Energy Intake and In-Hospital Starvation: A Clinically Relevant Relationship. Archives of internal medicine (1960) 1996; 156(4): 425-429
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19. McCusker J, et al.Delirium Predicts 12-Month Mortality. Archives of internal medicine (1960) 2002;162(4): 457-463
20. McAvay GJ. et al. Older Adults Discharged from the Hospital with Delirium: 1-Year Outcomes: ONE-YEAR OUTCOMES FOR PATIENTS DISCHARGED DELIRIOUS. Journal of the American Geriatrics Society (JAGS) 2006; 54(8): 1245-1250
21. Bo M, et al. Geriatric Ward Hospitalization Reduced Incidence Delirium Among Older Medical Inpatients. The American journal of geriatric psychiatry 2009; 17(9): 760-768
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24. Ledesert B, et al. The impact of a comprehensive multi-dimensional geriatric assessment programme on duration of stay in a French acute medical ward. Age and Ageing 1994; 23(3): 223-227

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.