Clinical progress note: Interventions for improving outcomes among hospitalized older adults

Abstract

In 2020, one of our grandmothers fell while getting out of her car and was hospitalized with a nonoperable humerus fracture. Because of her fall risk, she barely moved unless with therapy services. She did not have her hearing aids or glasses. Due to the restrictions of the pandemic, she rarely talked to anyone and had no idea who her providers were. She did not know who to ask for water, ate poorly, could not control the lights in her room, and expressed fear and exhaustion over the phone, ultimately developing agitated delirium. Though physical and occupational therapy cleared her for subacute rehabilitation early in her hospital stay, her delirium took over 2 weeks to show any improvement, delaying her discharge. She never fully recovered and now resides in a skilled nursing facility permanently. This led us to question: how could this have been prevented?

Grandma's experience is a familiar tale. Though older adults account for an outsized proportion of hospitalizations, acute care settings often fail to meet their needs. In fact, for many adults over 65 years, hospitalization is a sentinel event, leading to persistent cognitive symptoms, institutionalization, and worse outcomes relative to younger patients, including higher mortality. For over two decades, interprofessional coordinated intervention programs such as the hospital elder life program (HELP) have demonstrated efficacy in reducing these hospital hazards through interventions such as sleep promotion, nutrition and hydration improvement, mobilization, and correction of sensory impairment.¹ Subsequent data have shown that even in isolation, these efforts improve outcomes. More recently, the age-friendly initiative has spurred health systems to provide patient-centered care to older adults across all settings by applying the framework of “four Ms”: Mentation, Medication, Mobility, and what Matters, to care decisions.² Although many hospitals do not have HELP or age-friendly designations, prioritizing sleep, nutrition, hydration, mobility, and correction of hearing loss can improve outcomes while also aligning well with what often matters most to older adults.

We searched PubMed and EBSCO for manuscripts published since 2018 using key search terms of improv* AND outcomes AND hospital* AND older adults to identify recent data regarding optimum hospital care among older adults. From these citations emerged four key themes: mobility, nutrition and hydration, correcting sensory loss, and sleep promotion. We then conducted individual searches for each theme (sleep, mobility OR walking, nil per os [NPO] OR nothing by mouth, hearing loss) combined with inpatients OR hospitalization OR ‘hospitalized patients’ to identify additional sources.

Low mobility in the acute care setting contributes to functional dependence and nursing home placement. Unfortunately, many aspects of acute care settings hinder mobility. While patient factors contribute, lower activity expectations for older adults, uncertainty about baseline function, lack of time or staff, fear of falls, hallway clutter, tethers (e.g., vitals monitors, intravenous lines), and infection precautions also impede regular activity in the hospital.³

Though substantial, these barriers are not insurmountable. Interventions like the STRIDE (assiSTed eaRly mobIlity for hospitalizeD older vEterans) program focus on increasing hospital activity and are feasible in staff-limited locations as they can be led by staff or volunteers.^{4, 5} These programs involve designated individuals who proactively engage patients in supervised walking or activity early in the hospital stay. Such interventions positively impact important outcomes like reducing nursing home discharges and do not increase rates of falls.^{4, 5} More data are needed to determine the right “dose” of ambulation, program cost-effectiveness, and how best to facilitate widespread adoption. Currently, hospital providers can help initiate unit-based mobility-enhancement projects, firmly set expectations that walking is a necessary part of recovery, and advocate for resources to do so with the knowledge that the benefits of small increases in activity go a long way.

Up to half of hospitalized older adults are malnourished on admission, and one-third older adults experience new malnutrition during hospitalization. This results in higher mortality, morbidity, infections, falls, length of stay, costs, and readmissions.⁶ Though we often blame unpalatable food and illness-related anorexia, restrictive diets and peri-procedural NPO orders are also factors. Revised guidelines recommend much shorter NPO durations than previously utilized, but clinical practice has lagged behind.⁷ For many patients, a new dysphagia diagnosis can result in the use of thickened liquids despite known harms and limited evidence of benefit.⁸ Similarly, patients with heart failure presenting with volume overload often endure fluid restrictions that lead to dehydration, even though this has not been proven to be beneficial in the absence of hyponatremia.⁹ Other restrictive diets are often poorly tolerated and lead to inadequate intake. Current evidence gaps include identifying effective measures to address illness-associated anorexia and clarifying which hospitalized older adults—if any—benefit from enteral feeding in the setting of malnutrition.⁹

Fortunately, small systems-based interventions improve the approach to nutrition in older adults. Incorporating evidence-based NPO guidelines into electronic ordering systems may reduce unnecessary NPO orders by as much as 50%.⁷ Providers can also raise awareness about the limited evidence for interventions like thickened liquids and fluid restrictions to encourage more palatable and tolerable diets in the hospital.^{8, 9} Proactive nurse-led malnutrition screening, early dietician involvement, and systems to prioritize meal times and make up for missed meals can all help improve nutrition.⁶ Encouraging older adults to eat and drink provides more than just calories—it is a source of comfort, a connection to one's culture, and a means of social engagement. Although few consider hospital food a source of merriment, the benefits of eating and drinking are certainly meaningful.

While over half of patients over 70% and 81.5% of patients over 80 years have at least mild hearing loss, less than 20% seek out hearing assistance devices, and most are unaware of their impairment.^{10, 11} Sadly, adults with age-related hearing loss (ARHL) are more likely to be hospitalized, accrue higher healthcare costs, and have higher 30-day readmission rates.¹¹ Ninety-three percent of inpatient providers associate ARHL with some negative impact on the quality of care of older patients.¹⁰ Given the prevalence of hearing loss and low risk of screening, we recommend presuming all of your older patients have hearing loss until proven otherwise.

Although there are many barriers to treating ARHL including cost, access to care, and the adaptation required to optimally use a device, mitigating the impact of hearing loss in the inpatient setting is more straightforward.¹¹ Techniques such as minimizing background noise, improving lighting to augment lip-reading, and speaking face-to-face are effective interventions. In clinical situations that require provider masking, the use of voice-to-text and video conference technology, preprinted large font placards with frequently asked questions, and clear masks to facilitate lip-reading have been suggested as safety-sensitive interventions.¹¹ Use of portable amplifying devices, patient education, and cerumen removal are part of the HELP program, which has been shown to decrease delirium, lower readmissions, and decrease mortality.¹ However, there are limited data regarding whether correcting for hearing loss with amplification devices or other compensatory strategies fully mitigates hospital outcome disparities among those with ARHL.

Sleep disruption in the hospital increases delirium, pain intensity, and fall risk. It also impacts glucose control, blood pressure, and respiratory status.¹² Though experts agree that adequate sleep is important for health, numerous studies show that hospitalized persons have highly fragmented, poor-quality sleep, mainly caused by hospital noise, frequent awakening for cares, uncontrolled pain, and light levels.¹³

Historically, pharmacologic sleep interventions have been standard of care, but a growing body of research shows that commonly used classes such as benzodiazepines, nonbenzodiazepine hypnotics (e.g., zolpidem), and off-label use of medications like trazodone are associated with increased falls, fractures, and delirium. Additionally, these medications may not actually be more effective for sleep than a placebo, though melatonin has increasingly been found to be safe and no less effective than other medications.¹³ Nonpharmacologic methods are now considered as first-line therapy. These include eye masks, ear plugs, relaxation techniques, music interventions, and massage, with the most evidence supporting multi-modal interventions.¹ However, these can be difficult to implement, and patient acceptance is highly variable.¹³

Improving sleep in the hospital may require larger system-level interventions. Studies support that relatively small changes such as adjusting overnight lighting, shifting medication administration times, reducing overnight vitals checks, and delaying lab draws and morning rounds by only an hour or two can have profound benefits on patients' sleep duration and quality.¹³ One nurse-led, team-based intervention creating a “no wake zone” for patients significantly reduced delirium and increased cost avoidance.¹⁴ Another large trial that delayed morning lab draws, reduced vitals checks, and encouraged darkness at night improved both LOS and readmission rates.¹⁵ These were cost-effective and relatively easy interventions without complete overhauls of care infrastructure. Additional data are needed to clarify whether these benefits persist in more medically acute patients and how delays in obtaining data from lab studies and vital signs checks affect provider decision-making. Still, one can dream that better sleep will improve hospital experiences for many older adults.

Despite getting what is considered standard of care, Grandma struggled, and she is not alone in her experience. All hospitalized older adults are at higher risk for poor outcomes. Evidence supports emphasizing mobility, encouraging adequate oral intake, accounting for hearing loss, and promoting good sleep to avoid many of the hazards of hospitalization. While we know that each individual intervention and comprehensive multicomponent interventions provide benefit, it remains to be determined how each intervention impacts the other, and if there is a quantifiable additive effect to using more than one intervention. Ultimately, improvement will require system-level change, but there are many small, easily feasible interventions that can be implemented relatively quickly. These interventions align well with the movement toward age-friendly care, but—more importantly—they keep patient-centered goals at the forefront, improving outcomes so they can maintain independence, be an active participant in their care, and have an acceptable quality of life (Figure 1). So, keep your older patients moving, eating and drinking, hearing, and sleeping–it matters!

The authors declare no conflict of interest.