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Hospitals struggle to keep elderly patients moving

 

By ANNA GORMAN

For Kaiser Health News

BIRMINGHAM, Ala. — Thelma Atkins ended up in the University of Alabama at Birmingham (UAB) Hospital-Highlands after a neighbor in her senior living center ran over her feet with a motorized scooter.

Terri Middlebrooks, a nurse at the hospital, tried to figure out how active the 92-year-old Atkins was before the incident. “Are you up and moving at home?” she asked.

“I can manage, but I have to have help sometimes,” Atkins replied.

Atkins said she uses a walker to visit friends and to get to the communal dining room. But she’s also fallen a few times in recent years.

“Don’t quit walking here,” Middlebrooks told her. “It’s the most important thing you can do. … This bed is not your friend.”

Middlebrooks is the coordinator of a unit designed to address the challenges specific to caring for the elderly. She told her new patient that throughout her stay, one of the main goals would be to keep her active.

The medical center’s effort to get older patients up and moving while they are in the hospital is far from typical. Despite a growing body of research that shows staying in bed can be harmful to seniors, many hospitals still don’t put a high priority on making them walk.

At UAB Hospital-Highlands’ s 26-bed geriatric unit, known as the Acute Care for Elders unit, or ACE, patients are encouraged to start moving as soon as they arrive. The unit is one of a few hundred around the U.S. that is attempting to provide better and more tailored care to geriatric patients.

The hospital opened the unit in 2008 with the recognition that the elderly population was growing and that many older patients didn’t fare well in the hospital. ACE units are based on the idea that if the unique needs of seniors are met, they will have better outcomes and their care will be less costly.

Research has shown that the units shorten patients’ stays in the hospital, reduce their likelihood of returning too soon after discharge and make it less likely they will be sent to a nursing home.

Thelma Atkins, 92, talks to Terri Middlebrooks, a nurse who manages the geriatric unit at UAB Hospital-Highlands. Atkins’ daughter and son-in-law listen in. Middlebrooks says that “patients walk in the door of a hospital and think it’s OK to stay in a bed. It’s not.”

In addition to employing specially trained staff who work together as a team, the Alabama unit has special handrails attached to the walls, low-glare lighting and non-skid floors. Every room has a walker and plenty of space to move around. Volunteers walk with patients, and therapists work with them on maintaining their strength.

Staff members try to disabuse patients of the idea that they are there to rest. “People walk in the door of a hospital and think it’s OK to stay in a bed. It’s not,” said Middlebrooks.

Andres Viles, a nurse coordinator, said nurses at other hospitals are often so busy administering medications and tending to wounds that they don’t make time to walk with their charges. The emphasis on patient mobility is “a culture change” for most hospitals, he said.

At UAB Hospital-Highlands, that shift took a lot of education. Staff members in the new unit attended workshops that included role playing and sensitivity training. The hospital also trained “geriatric scholars,” who became advocates for addressing the particular physical and cognitive needs of seniors.

The Affordable Care Act explains some of the reluctance by staff at many hospitals to get patients moving, experts say. Under the law, hospitals are penalized for preventable problems, including falls. Researchers believe that hospital staffers, to ensure their patients don’t fall, often leave them in their beds.

“We are doing an awful lot to prevent falls, but there is a cost,” said Heidi Wald, an associate professor at the University of Colorado School of Medicine. “The cost is decreased mobility.”

Researchers said there are other explanations for the failure of hospitals to get elderly patients moving. They may not have enough staff, for example, or they may fear lawsuits.

Families won’t sue if their mom gets weaker in the hospital, but they may if she falls, said Cynthia Brown, director of the Division of Gerontology, Geriatrics and Palliative Care at the UAB School of Medicine.
Brown added that hospital staffers around the country generally do not consider walking with patients to be as important as their other duties. “It is just one more thing on a list of a whole lot of things,” she said. “Often times, walking falls to the bottom.”“Why would the hospital want to put themselves at risk for litigation or the CMS [Centers for Medicare and Medicaid Services] coming back and biting them?” she said.

It’s also harder for patients to walk around if they are attached to IV lines or oxygen tanks, or if they take drugs that make them sleepy. Such medication or equipment is not always necessary.

The very layout of hospitals and the way they operate makes it too easy for patients to remain stationary. They can control their televisions by raising a finger, and they typically get their food in bed.

On average, hospitalized older patients spend just 43 minutes a day standing or walking, according to a study by Brown published in the Journal of the American Geriatrics Society. They are in bed more than 80 percent of their hospital stay, she found.

The impact of remaining so sedentary in the hospital can be devastating for older patients: It is puts them at greater risk for blood clots, pressure ulcers and confusion.

Immobility can also reduce patients’ ability to take care of themselves when they go home — a difficulty that persists a month after their discharge, according to Brown. And it puts them at higher risk of readmission to the hospital, according to research.

Immobility hurts older patients more than younger ones, in part because the elderly are generally weaker, have less bone density and are at higher risk of falling. Ironically, keeping a patient in bed, which is often intended to prevent falls in the hospital, can increase their risk of falling after they are discharged, experts said.

“They don’t bounce back,” Landefeld said. “The pneumonia is better, but Aunt Mary is not walking and talking the same as before.”

Landefeld said hospitals frequently take the “smart bomb” approach to illness. “We blow away the disease, but we leave a lot of collateral damage,” he said.

Making sure hospitalized patients spend sufficient time out of their beds can save money, keep them mobile after they return home and improve their overall health. Researchers in Texas found that increasing the number of steps elderly patients took on their first and last days in the hospital reduced their risk of dying over the following two years. A study of pneumonia patients of all ages showed that walking early in their hospital stay shortened its duration, saving an average of $1,000 per patient.

The hospital hosts a twice-weekly session called “Move and Groove,” designed to get older patients dancing. At a recent session, a music therapist played the piano as the patients held tambourines or bells and moved their feet to the beat. All of the patients used walkers. A few had oxygen tanks and most wore bracelets indicating they were at risk of falling.

Occupational therapist Linda Pilkerton said she doesn’t give patients a choice of whether to participate.

“We don’t ask them if they want to do an X-ray or if they want a CT scan,” she said. “This is ordered by the doctor. If they don’t get up and move, they start the death spiral.”

After Atkins was admitted to the unit following the scooter mishap, Middlebrooks told her it would only take two days of lying in bed to lose muscle mass. “And if you lose muscle mass, you get weaker and you’re more apt to fall,” the nurse explained, adding that Atkins had done enough of that.
But she said she’s determined to keep walking — at home and in the hospital.Atkins, who has a pacemaker and has had hip and hernia surgeries, said she has lived alone a long time and doesn’t want to end up in a nursing home. As she pushed her walker down the hospital corridor, she acknowledged that she’s gotten weaker as she’s gotten older and that her arthritis makes it more difficult to shower and dress by herself.

“I don’t want to lose more independence,” she said. “I’ve already lost a lot of it.”

But even if patients spend a lot of time out of bed while they are in the hospital, it does not guarantee they will recover.

Willie Mae Rich, 86, came to the Alabama hospital this spring because her doctor was concerned about her heart. Rich knew her bones wouldn’t withstand a fall, so she worried about walking around too much.

“I’ll break up like peppermint candy,” she said.

But the hospital staff didn’t give her a choice. They urged her to eat meals while sitting in a chair, get herself dressed and get up as often as possible.

“The more time you spend out of this bed, the healthier you’ll be,” Viles told her.

Despite staying active in the hospital, Rich, a great-grandmother, became more sedentary over the next several weeks. Her daughter, Debra Rich-Horn, said her mother continued to walk when she first came home, but soon she could barely get out of bed.

In May, she passed away.

“Her heart was already at a bad stage,” Rich-Horn said. “By the time [the hospital] got her, it was too late.”

 


Anna Gorman: Hospitals rethink care for elderly

hand

By ANNA GORMAN

For Kaiser Health News
Ron Schwarz, 79, was hospitalized after falling in the shower. Schwarz is a patient in a special ward at the San Francisco General Hospital known as the Acute Care for the Elderly unit, or ACE.
Janet Prochazka was active and outspoken, living by herself and working as a special-education tutor. Then, in March, a bad fall landed her in the hospital.

Doctors cared for her wounds and treated her pneumonia. But Prochazka, 75, didn’t sleep or eat well at Zuckerberg San Francisco General Hospital and Trauma Center. She became confused and agitated and ultimately contracted a serious stomach infection. After more than three weeks in the hospital and three more in a rehabilitation facility, she emerged far weaker than before, shaky and unable to think clearly.

She had to stop working and wasn’t able to drive for months. And now, she’s considering a move to Maine to be closer to relatives for support.

“It’s a big, big change,” said her stepdaughter, Kitty Gilbert, soon after Prochazka returned home. “I am hopeful that she will regain a lot of what she lost, but I am not sure.”

Many elderly patients  such as  Prochazka deteriorate mentally or physically in the hospital, even if they recover from the original illness or injury that brought them there. About one-third of patients over 70  and more than half of patients over 85 leave the hospital more disabled than when they arrived, research shows.

As a result, many seniors are unable to care for themselves after discharge and need assistance with daily activities such as bathing, dressing or even walking.

“The older you are, the worse the hospital is for you,” said  Ken Covinsky, M.D., a physician and researcher at the University of California at San Francisco’s division of geriatrics. “A lot of the stuff we do in medicine does more harm than good. And sometimes with the care of older people, less is more.”

Hospital staff often fail to feed older patients properly, get them out of bed enough or control their pain adequately. Providers frequently restrict their movements by tethering them to beds with oxygen tanks and IV poles. Doctors subject them to unnecessary procedures and prescribe redundant or potentially harmful medications. And caregivers deprive them of sleep by placing them in noisy wards or checking vital signs at all hours of the night.

Interrupted sleep, unappetizing food and days in bed may be merely annoying for younger patients, but they can cause lasting damage to older ones. Elderly patients are far different than their younger counterparts — so much so that some hospitals are treating some of them in separate medical units.

San Francisco General is one of them. Its Acute Care for Elders (ACE) ward, which opened in 2007, has special accommodations and a team of providers to address the unique needs of older patients. They focus less on the original diagnosis and more on how to get patients back home, living as independently as possible.

Early on, the staff tests patients’ memories and assesses how well they can walk and care for themselves at home. Then they give patients practice doing things for themselves as much as possible throughout their stay. They remove catheters and IVs, and encourage patients to get out of bed and eat in a communal dining area.

“Bed rest is really, really bad,” said the medical director of the ACE unit,  Edgar Pierluissi, M.D. “It sets off an explosive chain of events that are very detrimental to people’s health.”

Such units are still rare — there are only about 200 around the country. And even where they exist, not every senior is admitted, in part because space is limited.

Prochazka went to the emergency room first, then intensive care. She was transferred to ACE about a week later. The staff weaned her off some of her medications and got her up and walking. They also limited the disorienting nighttime checks. Prochazka said she got “the first good night of sleep I have had.”

But for her, the move might have been too late.

“She will not leave here where she started,” Pierluissi said several days before Prochazka was discharged. “She is going to be weaker and unable to do the things you really need to do to live independently.”

Not A Priority

How hospitals handle the old — and very old — is a pressing problem. Elderly patients are a growing clientele for hospitals, a trend that will only accelerate as baby boomers age. Patients over 65 already make up more than one-third of all discharges, according to the federal government, and nearly 13 million seniors are hospitalized each year. And they stay longer than younger patients.

Many seniors are already suspended precariously between independent living and reliance on others. They are weakened by multiple chronic diseases and medications.

One bad hospitalization can tip them over the edge, and they may never recover, said Melissa Mattison, M.D., chief of the hospital medicine unit at Massachusetts General Hospital.

“It is like putting Humpty Dumpty back together again,” said Mattison, who wrote a 2013 report detailing the risks elderly patients face in the hospital.

Yet the unique needs of older patients are not a priority for most hospitals, Covinsky said. Physicians and other hospital staff focus so intensely on treating injuries or acute illnesses — such as pneumonia or an exacerbation of heart disease — that they can overlook nearly all other aspects of caring for the patients, he noted.

In addition, hospitals face few consequences if elderly patients become more impaired or less functional during their stays. The federal government penalizes hospitals when patients fall, get preventable infections or return to the hospital within 30 days of their discharge. But hospitals aren’t held accountable if patients lose their memories or their ability to walk. As a result, most don’t measure those things.

“If you don’t measure it, you can’t fix it,” Covinsky said.

Improving care for older patients requires an investment that hospital administrators are not always willing to make, experts said. Some argue, however, that the investment pays off — not just for older people but for hospitals themselves as well as for a country intent on controlling healthcare spending.

Though research on the financial impact of problematic hospital care for the elderly has been limited, a 2010 report by the Department of Health and Human Services’ Office of Inspector General found that more than a quarter of hospitalized Medicare beneficiaries had suffered an “adverse event,” or harm as a result of medical care.

Those events, such as bed sores or oxygen deficiency, cost Medicare about $4.4 billion annually, according to the report. Physicians who reviewed the incidents determined that 44 percent could have been prevented.

In addition to outright mistakes, poor or inadequate treatment in hospitals leads to needless medical spending on extended hospital visits, readmissions, in-home caregivers and nursing home care. Nursing-home stays cost about $85,000 a year. And the average hospital stay for an elderly person is $12,000, according to the Agency for Healthcare Research and Quality.

“If you don’t feed a patient, if you don’t mobilize a patient, you have just made it far more likely they will go to a skilled nursing [facility], and that’s expensive,” said  Robert Palmer, M.D., director of the geriatrics and gerontology center at Eastern Virginia Medical School and one of the brains behind the idea of ACE units.

ACE units have been shown to reduce hospital-inflicted disabilities in older patients, decrease lengths of stay and reduce the number of patients discharged to nursing homes. In one 2012 Health Affairs study, Palmer and other researchers found that hospital units for the elderly saved about $1,000 per patient visit.

A Different Life

After coming home, Prochazka said she felt weak. It took weeks of walking her labradoodle, Gino, to regain strength.

Her stepdaughter, Gilbert, said Prochazka has started to improve. “We knew she was getting better when she was getting ornery,” she said.

But Prochazka, who is highly educated, still has some short-term memory loss, Gilbert said.

Prochazka knows that her life after hospitalization is different than before — she will have to depend more on others. It’s not an easy adjustment, she said.

“I have been somebody who has always been both mentally and physically active,” she said. “Before I fell … I was respected for what I have and what I did and all of a sudden, I’m not.”

She said her time at San Francisco General was frustrating. Getting the infection just as she was starting to recover was especially hard, she said. “I felt like I had been dealt a blow I really didn’t need.”

For other patients, being admitted proactively to the special geriatric unit can stave off such precipitous declines.

Rosenda Esquivel, 80, spent 18 days at San Francisco General, much of it in the unit, this spring. She suffered no noticeable setbacks, physical or mental, during her time in the hospital, according to Annelie Nilsson, a clinical nurse specialist in the unit.

Esquivel, an animated woman who used to work as a home caregiver, was admitted with intense arthritic pain and, while hospitalized, underwent a procedure to address an abnormal heartbeat.

Soon after her arrival, Pierluissi, the ACE unit medical director, speaking to Esquivel in her native Spanish, sought to determine how independent she was at home. He learned that a friend helped take care of her but that she took pride in cooking and cleaning for herself.

The doctor noticed that Esquivel needed help to get up from a chair but that she could get around with a walker. Her memory, though, wasn’t too strong. A few minutes after hearing three words — “honesty,” “baseball” and “flower” — she could only recall one of them.

Pierluissi came up with a plan for her time in the hospital: Get Esquivel’s pain under control. Make sure she walks three or four times a day. Arrange for her to have a caregiver at home to remind her to take her diabetes and blood pressure medications.

Then, release her as fast as possible.

“The less time she spends here, the better,” Pierluissi said.

 


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