When you or a loved one enters the hospital, it can feel as though you've been transported to an entirely different world. Imagine being removed from all that is familiar and placed in an environment that feels as restrictive as a well-intentioned prison. Your movements are limited, your surroundings are unfamiliar, and your daily routines are dictated by the stringent policies of the hospital. This is not just about safety or recovery; it's about complying with procedures that ensure the hospital can provide high quality service and receive compensation. This analogy may seem strong, but it captures the sudden and profound disorientation many older adults experience during hospital stays.
From 2016 to 2021, an average of 25.1 million adults aged 65 and older went to emergency rooms annually, making up 18% of all ER visits. Of these, nearly 40% were admitted to the hospital for various reasons—most for medical conditions (67%), followed by injuries (6%), and a smaller percentage (2%) for mental health and substance use issues. Additionally, each year, another 3.3 million older adults (25%) are admitted for scheduled surgeries.
Once hospitalized, seniors often face the abrupt disappearance of their daily lives' hallmarks. They wake up isolated in a strange place, looked after by a constantly changing team of medical professionals. Moreover, hospital stays often involve sleep interruptions, and separation from family and beloved pets. Even small items like eyeglasses or dentures, often put away, can contribute significantly to feelings of disorientation.
As you enter this stressful environment, it's beneficial to have an effective advocate. Understanding the five most common hospital hazards and being prepared to act as vigilant eyes and ears can profoundly affect the overall hospital experience. This post aims to equip you with the knowledge and strategies necessary to identify potential problems and take action to minimize risks, ensuring a safer and more healing stay.
Understanding Hospital Risk Assessment Tools for Older Adults
Ideally, when you or a loved one is admitted to the hospital, your medical team will do an assessment using something like the Hospital Admission Risk Profile (HARP) or the Identification of Seniors at Risk (ISAR) screening tool to gauge your risk potential. These evaluations are fundamental in determining the likelihood you may experience of adverse events such as falls, infections, bed sores, and more serious conditions like strokes or heart attacks. They also help predict the need for additional medical and rehabilitation services post-discharge. Being familiar with these assessments allows you to understand why certain questions are asked and prepares you to provide the most current and relevant information. This is vital for planning both your goals of care and your eventual discharge destination.
How HARP Works and Its Impact on Your Care
HARP uses a set of criteria based on your initial admission information. The assessment includes evaluating your age, cognitive function from a Mini-Mental State Examination (MMSE), and your independence in performing instrumental activities of daily living (IADLs). Here’s how each risk score is determined:
Age at Admission is straightforward with points assigned based on age brackets. The older you are, the higher your risk score.
Cognitive Function is derived from 21 questions in the modified MMSE that focuses on orientation, attention, and recall, omitting complex language tasks to provide a clear measure of your cognitive state. If you’ve ever accompanied someone to the hospital and heard them asked questions like “What’s today’s date?” “Can you tell me where you are?” “Can you spell “____” word backward?” or “I’m going to ask you to remember “x” number of items and will ask you to recall them for me later,” then you’ve seen them administer this test.
IADL Function measures how well you performed seven instrumental activities of daily living—1) handling finances, 2) managing medications, 3) using the phone, 4) shopping, 5) traveling to desired locations, 6) housekeeping, and 7) food preparation—two weeks prior to coming to the hospital. A lower ability in these areas results in a higher risk score. For more background on IADLs refer to the GeriScope 8 IADLs to Assess Senior Autonomy and Care Needs post.
The total HARP score helps the medical team decide on the level of care you might need post-discharge to support your independence and desired quality of life. A higher score indicates a greater risk and might prompt early interventions such as physical therapy, occupational therapy, and specialized geriatric attention within ACE units or through Hospital Elder Life Programs (HELP). These interventions aim to prevent a decline that can lead to prolonged hospital stay or the need for facility-based support.
How the ISAR Tool Functions and Its Significance in Your Hospital Stay
The ISAR tool consists of six straightforward yes/no questions that help clinicians assess your risk of needing enhanced post-discharge supervision to prevent hospital readmission. These questions are designed to quickly evaluate your level of independence and health status before and after your illness or injury.
The scoring for the ISAR tool ranges from 0 to 6, with a higher score indicating a greater risk of problems post-discharge. Typically, a score of 2 or more is considered a meaningful risk threshold, prompting doctors and social workers to consider more intensive transition planning and post-discharge support.
Why Understanding Assessment Tools Matters to Seniors
Being aware of HARP, ISAR, and other hospital risk screening questions clarifies why precise and comprehensive answers are important to getting the care you want and need. It also reveals clues as to reasons for your medical team’s diagnosis and discharge planning recommendations.
By anticipating these inquiries, you can more effectively prepare to share all relevant information about your living situation, daily needs, and available assistance so you receive all the resources you require to 1) return home with support and home modifications or 2) transition to a senior living environment on a short-term or long-term basis. These responses are essential in advocating for a strategy that maximizes your independence and well-being, reducing the likelihood of hospital readmissions and promoting a safer, more effective recovery.
Understanding your specific results may allow you and your caregivers to proactively adjust your living environment and community network. Most importantly, these appraisals help you return home as quickly and safely as possible after your hospital stay. Additionally, continuing assessment of your situation can help you and your family come to terms with the need to explore other senior living options if returning home isn't feasible based on your assessed needs and risks.
Five Hospitalization Hazards Impacting Senior Health
Unfortunately, the hospital environment and processes can inadvertently pose significant risks to older adults during their stay that have long-term consequences. The five most common hazards include:
Sleep deprivation in hospitals, exacerbated by environmental factors like noise and light, disrupts rest essential for recovery, particularly affecting older adults. Delirium, often triggered by the hospital setting, can lead to severe cognitive fluctuations impacting mood, consciousness, and overall mental state. The restrictive nature of hospital safety measures, including bed rails and motion sensor alarms, often limits mobility, potentially leading to muscle atrophy. Receiving sufficient nutrition and hydration are also critical concerns, as illness, procedural fasting, and medication side effects can diminish appetite and disrupt normal digestion. Additionally, prolonged waits in the ER due to staffing challenges can leave older adults without necessary attention, exacerbating discomfort and delaying treatment. Understanding these risks is necessary for you to advocate effectively for the assistance and comfort of your loved ones. Let’s explore each risk in greater detail.
#1: Why Lack of Sleep Compromises Senior Health in Hospitals
In hospitals, sleep is a precious commodity that is often hard to come by, particularly for the elderly, with over 13 million older adults hospitalized annually in the United States—45 percent of whom report an average of less than four hours of sleep and experience up to 13 awakenings each night. The hospital environment, with its persistent beeps, chatter, code alarms, and general clatter, severely disrupts sleep, especially after dark. This problem is compounded for older adults whose sleep patterns naturally includes lighter and more fragmented sleep patterns as they age.
Sleep deprivation is linked to a host of adverse outcomes, including an increased risk of delirium, which increases in probability by 2% for each year of age after 65. Also factors like anxiety, depression, loss of social support, pain, and acute illness can intensify sleep disturbances, making your stay particularly challenging.
Sleep is a critical component for the healing process. It helps regulate key bodily functions such as the inflammatory response and hormone secretion that are vital for recovery. Growth hormones, essential for tissue repair and regeneration, are predominantly (90%) released during sleep. Without adequate sleep, the body's ability to repair itself is compromised, potentially prolonging hospital stays and leading to deterioration in overall wellbeing. Recognizing the principal role of sleep in your recovery, top hospitals are continuously exploring innovative strategies to minimize nocturnal disruptions and enhance sleep quality.
#2: Delirium's Disruptive Impact on Elderly During Hospital Stays
Delirium, a sudden and severe disturbance in mental abilities that results in confused thinking and reduced awareness of the environment, is a crucial concern for older adults during hospital stays. This condition manifests as a significant change in a one’s mental status, marked by confusion, disorientation, and fluctuations in consciousness, ranging from hyperalert to completely unarousable states. The common signs of delirium include an inability to focus, easy distraction, withdrawal, agitation, paranoia, hallucinations, and altered thought processes which may affect speech and memory.
In hospitals, delirium is the most prevalent complication among the elderly, particularly those undergoing major surgeries like hip replacements or heart procedures, or those admitted to intensive care units. Factors such as older age, pre-existing cognitive impairments like dementia, pain, underlying infections, metabolic imbalances, and the side effects of medications can all disrupt brain neurotransmitters and trigger delirium. Additionally, environmental stressors such as being in an unfamiliar setting and experiencing sleep disruptions contribute to its onset.
The implications of delirium are severe, with studies indicating that it occurs in 14% to 56% of hospitalized older adults, and it significantly increases morbidity and mortality rates—ranging from 25% to 33%. Notably, a vast majority (73% to 96%) of patients who experience falls in hospitals display symptoms of delirium. Alarmingly, in 75% of these cases, the delirium remains undiagnosed and untreated, compounding the risks and extending recovery periods.
The onset of delirium can exacerbate existing physical disabilities and precipitate a steep decline in cognitive functions such as memory, thinking, and concentration. This not only prolongs hospital stays but also diminishes the quality-of-life post-discharge, increasing dependence on others and escalating the caregiving burden. Understanding these risks and recognizing the signs of delirium early can be transformational in getting appropriate treatments and interventions, potentially mitigating its long-term impacts on wellbeing.
#3: The Consequences of Limited Mobility for Hospitalized Seniors
For older adults, hospital stays often mean prolonged periods of inactivity, primarily spent in bed, regardless of your ability to walk independently. This level of immobility is linked to “post-hospital syndrome,” a condition of generalized physical deconditioning that increases vulnerability after discharge. The consequences are significant, potentially leading to readmissions, lasting disabilities, increased needs for nursing home care, illness, or even death.
Research reveals that despite the capability to move, seniors spend an astonishing 83% of their hospital stay in bed, with active standing or walking averaging only 43 minutes per day. This inactivity is exacerbated by several perceived barriers such as symptoms like weakness, pain, and fatigue, medical interventions like intravenous lines and urinary catheters, and a prevalent fear of falls. Furthermore, a study highlighted a notable discrepancy in perceptions between patients and practitioners; while patients often recognize their own limitations, providers frequently attribute limited mobility to a lack of motivation or the absence of necessary ambulatory aids.
The fear of falls is a significant concern in hospitals due to its severe consequences and financial implications. Hospitals face penalties for falls under the Affordable Care Act, pushing many to adopt overly cautious measures. This "epidemic of immobility," (a.k.a. “pajama paralysis”) as some experts term it, sees people confined to their beds, equipped with bed alarms, and discouraged from getting up without assistance, which is often not readily available due to staffing issues. This approach, while intended to prevent falls, can lead to rapid muscle deterioration in older patients, who are already vulnerable to physical weakness. Such enforced immobility can quickly escalate into serious long-term problems, underscoring the need for a balanced approach to mobility and fall prevention in hospital settings.
#4: Risks of Poor Nutrition and Hydration for Elderly Hospital Patients
Nutrition and hydration issues often precede hospitalization but can worsen significantly during a hospital stay, particularly for those over 65. Many older adults arrive at hospitals already malnourished or dehydrated—between 20% and 50% of patients—a problem exacerbated by hospital routines and the environment. Factors like poor appetite, the impact of medication, and fasting for tests contribute heavily to deteriorating nutritional status during hospital stays.
Aging itself poses risks due to physical and social changes that affect eating habits and nutritional intake. Older adults often experience a loss of taste, decreased physical activity, and feelings of isolation, which can lead to reduced food intake and subsequent malnutrition. Women, in particular, face a higher malnutrition risk due to longer life expectancies and potential socioeconomic disadvantages in old age.
Social factors such as living alone, low educational levels, and limited social interactions further compound the risk of poor nutrition among the elderly. Marital status also plays a role, as unmarried older adults, living at home, without knowledge or access to available resources are more likely to suffer from malnutrition. Generally, social isolation and loneliness are recognized as independent factors associated with poor nutritional status.
Hospitalization introduces additional challenges to maintaining adequate nutrition and hydration. Restricted mealtimes, limited food choices, and necessary medical fasting disrupt regular eating patterns, while hospital food often does not appeal to patients, leading to meal refusal. Furthermore, location significantly impacts nutritional outcomes. Generally, medical intensity correlates with higher rates of malnutrition, particularly in geriatric and intensive care settings where the prevalence of malnutrition can reach up to 90%.
Malnutrition in hospitals is not just a problem of poor diet but also involves the physical barriers to eating, such as dysphagia (difficulty swallowing), cognitive impairments, and physical disabilities that affect an individual's ability to eat independently. Hospital-acquired malnutrition (HAM) often results from these compounded issues, with adverse effects such as increased risk of falls, septic shock, and even higher mortality rates. In fact, nutritionally at-risk patients are more likely to experience falls, with a significantly higher incidence in those aged 80 and above.
#5: How Staffing Shortages Affect Elderly Patient Care
Staffing shortages in hospitals significantly impact the quality of healthcare delivered to seniors, particularly in emergency rooms. The problem of ER boarding, where victims are left in corridors due to insufficient available beds, is exacerbated by staffing limitations. Physicians and nurses are often stretched thin, managing more patients than may be safely manageable, which not only increases the risk of errors but also leads to prolonged wait times for services.
The crisis is partly due to hospital administrators prioritizing beds for more lucrative procedures, creating bottlenecks that leave many people in limbo. Additionally, the growing demand for hospital services, fueled by an aging population and compounded by delays in discharging people from the hospital due to shortages in home health care and skilled nursing facilities, places further strain on available resources.
Nursing shortages, often cited as a consequential factor, are more accurately described by many nurses as an exodus from the profession. This exodus is not due to a lack of qualified personnel but rather to deteriorating working conditions and dissatisfaction with hospital management. Nurses frequently report moral injury—a deep sense of ethical conflict and distress because their working conditions prevent them from providing the help they aspire to deliver.
The pandemic has intensified these issues, leading to severe burnout among medical workers. Also, the high acuity of care needed during and following the pandemic has made previous staffing levels inadequate, yet adjustments to increase support have lagged. As a result, older adults, who require more complex and attentive support, often receive suboptimal treatment, impacting their recovery and overall results negatively.
This staffing turmoil means that older adults often face dangerously long waits for beds and medical attention, sometimes extending up to several days. Such delays can have dire consequences for seniors who are in urgent need of timely and specialized care.
Protect Yourself from Hospital Risk Through Proactive Steps
Hospitalization can be an arduous time for the elderly, exposing them to various problems that can impede recovery and affect quality of life. Understanding these risks allows you and your loved ones to take proactive steps to safeguard against potential hazards during hospital stays. Here’s what you can do to enhance your hospitalization experience.
Provide Continuous Advocacy and Support
It's imperative for family or friends to be present as much as possible. Being at the bedside allows you to make certain your loved one continues to eat, drink, use the restroom regularly, and take necessary medications. Your presence can help maintain a semblance of normalcy and vigilance, helping to avoid complications and to provide advocacy.
Enhance Sleep Quality
Poor sleep is a common issue in hospitals due to environmental noises and interruptions. To improve sleep quality:
Bring personal comfort items such as eye masks and earplugs to help shield against the typical disturbances of a hospital environment.
Ask if it is possible to be placed in Acute Care for Elders (ACE) ward or similar settings that caters specifically to the needs of those over 65 years of age with multiple chronic conditions, providing quieter and more restful environments.
Address and Monitor for Delirium
Delirium is a serious concern for hospitalized seniors, characterized by sudden confusion and changes in brain function. To manage this:
Accompany your loved one as much as possible, even overnight, to monitor for signs of delirium.
Make the environment less intimidating and more recognizable by placing personal items like photos or a favorite blanket around.
Regularly engage in gentle conversations about familiar subjects or current events to help maintain orientation.
Promptly inform the medical staff if you notice any signs of delirium or changes in mental status, to ensure appropriate interventions are considered. Because your healthcare providers have limited experience with how you behave normally, they may not perceive worrying changes.
Promote Mobility and Physical Activity
Extended periods of inactivity can lead to rapid physical decline during hospital stays. To help counter this, you should:
Assist your loved one with walking or other gentle exercises as permitted. Even moving from lying in bed to sitting in a chair can be beneficial in preserving mobility and preventing complications like bedsores.
Engage with medical team to develop a safe plan to move tailored to your current capabilities. Remember, as little as 25 minutes a day of slow walking can be enough to mitigate the detrimental physical effects of bedrest on older individuals.
Maintain Nutrition and Hydration
Hospital food may not always be appetizing, and medical conditions or treatments can reduce your appetite or make eating difficult. To address this:
Discuss with the nutritionist or medical team about enriching food with natural ingredients or nutrient preparations to improve intake.
Bring familiar and favorite snacks that are easy to consume, high in nutrients, and comply with nutritionist recommendations to supplement meals.
Make sure your loved one stays hydrated by frequently offering water and other preferred beverages. Hospital staff often welcome your assistance to keep their water jug filled, plus you can grab some water for yourself.
Leverage Hospital Resources
Utilizing the resources hospitals offer can significantly enhance your experience:
Elicit case manager help to navigate the broader healthcare system, both inside and outside the hospital itself, and make sure your concerns are properly addressed.
Welcome support services such as social workers, dietitians, and physical therapists to enrich your overall visit.
Observe and learn during hospital visits to understand how your loved one is being cared for, gaining insights from medical professionals on your needs for assistance with post-hospital recovery.
By taking these steps, you actively contribute to reducing the risks associated with hospital stays, enhancing both recovery and the overall hospital experience.
Optimizing Elderly Patients’ Hospital Experiences
Whether you're preparing for a planned surgery or facing an unexpected hospital admission after an emergency, understanding the standard assessment tools used in hospitals is vital. These tools, like the HARP and the ISAR screening tool, help clinicians assess your wellbeing and determine the care you'll need during your stay and after discharge. Knowing about these tools allows you to be better prepared and participate actively in planning for your post-hospital transition.
In this post, we've identified five significant risks to senior health during hospital stays: sleep deprivation, delirium, limited mobility, poor nutrition and hydration, and staffing issues. Awareness of these hazards is key, as they can have long-term negative impacts on your independence and quality of life.
By understanding these risks, you and your loved ones can take proactive steps to mitigate their effects, enhancing your recovery and overall hospital experience. So, we've also shared specific actions that you can take to minimize threats. The recommendations aim to empower you to be an effective advocate during your hospital stay, ensuring that both planned admissions and unexpected visits are managed as safely as possible.
Looking ahead, our next post will focus on your options after leaving the hospital. We'll cover the various discharge destinations, helping you understand where you might go when you leave the hospital, and how to choose the best option for your continued recovery and independence.
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