Providing Best Care for Older People in a Hospital Setting

Hospitalisation is an overwhelming event for older people that places them at significant risk of complications and deterioration at the best of times (QUT 2017).

Older adults face a unique set of risks and challenges in hospital settings. Therefore, knowing how to care for these vulnerable people is crucial (QUT 2017).

The Risks of Hospitalisation for Older Adults

Older adults may feel highly distressed coming into an acute care setting. In addition to the pain or illness they are experiencing, they may also be concerned about the implications of being hospitalised and how it will affect their independence, routine and sense of self (Commission on Dignity in Care 2012).

Older patients may be frightened, confused, frustrated or angry. It’s important to empathise with these emotions and care for them in a way that is sensitive to their distress (Commission on Dignity in Care 2012).

Older adults are also at high risk of developing complications during a hospital stay. These include:

• Falls
• Disorientation
• Delirium
• Healthcare-associated infections
• Malnourishment or dehydration
• Depression
• Incontinence
• Pain
• Pressure injuries.

(Health.vic 2015; RACGP 2019)

They may face other challenges that impede their lifestyle, including:

• Loss of confidence
• Loss of independence
• Change of routine
• Reduced activity and stimulation
• Overall functional decline.

(QUT 2017)

When caring for an older adult in hospital, the aim is for them to return home at the level of functioning they had before admission or better (QUT 2017).

Specific Issues Related to the Hospitalisation of Older People

Transfer of Care

Transitions between aged care and acute care, or any other settings, are high-risk and can result in miscommunication or other adverse consequences such as:

• Delayed treatment
• Delayed follow-up of test results
• Unnecessary repeats of tests
• Medication errors.

(ACSQHC 2017; RACGP 2019)

Dignity and Autonomy

All patients have the right to dignity and autonomy, regardless of age. However, in acute care settings, this may be a low priority for staff (Tauber-Gilmore et al. 2017).

Generally, older adults are at a high risk of losing dignity when in care (Šaňáková & Čáp 2018).

Dignity and autonomy play a significant role in a patient’s overall condition. Positive, respectful interactions will increase the patient’s confidence, motivating them to maintain independence and stay physically and mentally active. On the other hand, neglectful, condescending or apathetic care will quickly correlate to deterioration and functional decline (Commission on Dignity in Care 2012).

A literature review identified the following key components of dignity, based on the views of older adults:

• Autonomy and control
• Privacy
• Relationships
• Care and comfort
• Communication
• Identity.

(Šaňáková & Čáp 2018)

Empowering older adults, providing them with choice and treating them with dignity is essential in reaching desirable patient outcomes. Older adults want to be treated as people, not nuisances (Commission on Dignity in Care 2012).

(Commission on Dignity in Care 2012)

Cognitive Impairment

Over 30% of older adults present with or experience confusion during hospitalisation, usually due to dementia or delirium (ACI 2015).

These patients may be particularly overwhelmed. In addition to pain, illness or emotional distress, they may also:

• Experience disorientation, fear, anxiety or drowsiness
• Experience hallucinations
• Display uncharacteristic behaviours
• Refuse care
• Try to leave the facility
• Become disruptive or aggressive
• Display responsive behaviours such as wandering, yelling, hitting, kicking, sexually inappropriate behaviours and restlessness that can be difficult for staff to manage.

(ACI 2015; Yous et al. 2019)

The risk of complications is even higher among older patients with cognitive impairments (Bail & Grealish, cited in Cook et al. 2020).

Read: Dementia Awareness and Delirium Awareness and Cognitive Impairment

Acute Care Environment

Research suggests that only 14% of hospitals have physical environments that are appropriate for patients with a cognitive impairment (Alzheimer's Australia 2014).

Acute care facilities are busy and fast-paced environments, with noises, lights, signage and room layouts that can be highly confusing for older adults and significantly contribute to distress and disorientation, especially for patients with a cognitive impairment (Alzheimer's Australia 2014).

Patients need to feel safe, secure and oriented, which can be very difficult if the toilet is hard to find, or the patient does not know how to get back to their room (Alzheimer's Australia 2014).

Practical Tips When Caring for Older Adults

When caring for older adults in acute settings, consider the following:

• Ensure age-friendly principles are in place. These may include:
  • Written information in large print
  • Adequate lighting at night
  • Beds and furniture at a suitable height
  • Access to mobility aids
• Always practice consumer-directed care
• Identify what is important to the patient; what are their physical, mental, emotional and social needs?
• Monitor the patient for signs of clinical deterioration
• Encourage independence. Support the patient to practise self-care and dress, mobilise and toilet themselves
• Ensure adequate nutrition and hydration
• Monitor the patient’s cognitive status
• Involve the patient’s family and carers as much as possible
• Manage any pain that the patient is experiencing; this can adversely affect self-care
• Review the patient’s medications.

(QUT 2017; Health.vic 2015)

Caring for Older Adults With a Cognitive Impairment

Older adults with a cognitive impairment require extra support and orientation. In addition to the practical tips above, you should:

• Ensure the patient’s glasses, dentures, hearing aids etc., are clean, working and easily accessible
• Minimise bed moves
• Try to use non-pharmacological strategies when possible to treat confusion
• Encourage the patient to participate in success-based therapeutic activities, considering their interests (e.g. music, games)
• Avoid restrictive practices
• Create a comfortable, safe and relaxing physical environment for the patient, considering privacy, orientation, lighting, noise etc.
• Involve family and carers in reorientation and reassurance strategies
• Normalise sleep patterns
• Address any underlying causes of the patient’s behaviour (e.g. physical illness or pain)
• Speak to the patient gently, calmly and reassuringly, using simple language
• Encourage continence through access to toilets and visual signage.

(ACI 2015; Alzheimer's Australia 2014; ACSQHC 2014)

Conclusion

Older adults who become hospitalised may be highly distressed and are vulnerable to complications, especially if they have a cognitive impairment. Caring for these patients appropriately is essential in achieving positive outcomes and preventing deterioration or functional decline.