Strategies for Preventing Needless Hospitalisation in the Elderly

In essence, hospitals pose risks and evoke fear for older adults. The adverse effects of hospitalisation, including confusion, infections, bed sores, weakness, and falls, are well-documented. Drawing on two decades of community-based practice, we emphasise the real concerns people face when a loved one is admitted to a hospital, particularly the ICU. To prevent hospitalisation and ensure the best care, consider the following tips.

Reducing hospitalisations among the elderly has become a significant focus in the health policies of many developed countries in recent years. This shift is driven by the recognition that unintended consequences, including medical errors, hospital-acquired infections, delirium, patient falls, and nutritional problems, frequently emerge in hospitalised elderly individuals. Moreover, cognitive and functional losses after discharge can be inevitable. Hospitalisations not only contribute to medical issues but also bring about social problems and financial burdens for patients and their families. The escalating health expenditures associated with increased hospitalisations significantly impact an individual’s finances as well as the country’s health expenditure. A well-designed care plan for the elderly is believed to be a key strategy in preventing most hospitalisations, potentially eliminating the negative outcomes and unnecessary expenditures.

Years ago, during my tenure managing several hospitals, I began pondering whether hospitals, at times, created as many issues as they resolved. Candidly, I witnessed older patients admitted for one ailment like pneumonia or congestive heart failure end up facing complications such as falls, bedsores, leading to conditions like septicemia or blood clots from prolonged bed confinement. Since those days, I recognised that numerous hospitalisations are unnecessary, prompting me to explore ways to avoid hospitalisation in the elderly. Establishing ‘advantAge seniors’ later on was driven by this insight, aiming to support elders during their twilight years. Observing closely, I concluded that some doctors opt for ‘needless treatment’ due to pressures within the medical industry, treatments that only worsen elders’ quality of life, leading to an unhappy outcome.

You mean to say, avoid the hospital altogether? Our answer is, if possible!

Myself and my co-author Sowmya Lakshmi both continue to practice social gerontology and understands the truth that sometimes it is unavoidable – and can provide important information, treatment and life-saving care. At other times it may not be what the patient benefits or wants.

As our population ages, it’s crucial to consider a care system focused on minimising hospitalisations for older adults or even keeping them out of hospitals altogether. Despite my background in hospital management, I can’t ignore the glaring issues within our healthcare system, witnessing older adults ending up in hospitals due to preventable reasons like infections or falls—often stemming from subpar care, incorrect medications, untreated high blood pressure, or infections caused by unhygienic practices. Many of these instances could have been avoided, yet they persist.

Take Nagarajaih, once a content retiree until diagnosed with prostate cancer. Now, in a modest room in Bangalore’s Kengeri satellite town, he lies with closed eyes and laboured breathing. His setback, a relapse of prostate cancer, resulted in an inability to swallow or speak. Unfortunately, his wife, Vimala, faced challenges, leading to maggots infesting bedsores. Surprisingly, no proper guidance was provided by the doctor who operated on him or the hospital, despite multiple hospitalisations in the past two years. The lack of ‘transitional care’ from doctors or nurses is disheartening.

Vimala, now harbouring resentment towards hospitals, feels deceived and attributes her dissatisfaction to frequent hospitalisations. She believes that if she had received guidance upon the initial discharge regarding identifying danger signs and managing temporary health crises at home, many hospital readmissions could have been avoided. Vimala expresses regret for not being informed about the option of skilled nursing home care.

Hospitals often treat older adults without special categorisation, neglecting preventive measures that could minimise extended stays and readmissions. Simple actions, like ensuring patients adhere to prescribed medications and scheduling follow-up appointments shortly after discharge, could significantly reduce the likelihood of readmission. The myth portrayed as ‘universal truth’ is that frail, old patients will inevitably get sick, even if physicians and nurses do the best possible job taking care of those patients. We don’t subscribe to this because we know a good reasonable ‘health’ can be maintained provided good nursing care is extended along with appropriate nutrition and mobility.

There are often allegations that doctors knowingly provide unnecessary treatment to many dying patients. A couple of years ago, doctors were pressuring one of our elderly patients to undergo a liver transplant, even though neither the patient nor the family desired it. The influence from the doctors was strong. When they sought our expert opinion, we advised them to inquire about the chances of success. The doctors were unsure, often responding with the vague “fifty-fifty.” Malpractices are common in many corporate hospitals, and families need to be vigilant to avoid potential pitfalls. Similarly, a 78-year-old patient who underwent colostomy was pushed for chemotherapy, which the family outrightly rejected. They chose alternative medicine, and both patients now lead comfortable lives with no major complications. Worldwide, on average, one-third of patients near the end of their life receive non-beneficial treatments in hospitals.

Commonly, initiating or continuing chemotherapy or radiotherapy in the last weeks of life for patients with advanced irreversible disease was a widespread practice. Families were led to believe in false prognoses, leaving bewildered relatives with insufficient time to react appropriately to this barrage of interventions. This ranged from surgical procedures to ventilator support, prescribing costly medications, tube-feeding, performing CPR on patients with not-for-resuscitation orders, and providing blood transfusions or dialysis in the final days of life. Additionally, we discovered evidence of unnecessary imaging, such as MRI or PET scans, and extensive laboratory tests.

In recent years, due to advances in medical technology, the common man often harbours unrealistic expectations regarding the miraculous healing power of doctors, viewing technology as a magic wand. Suchitra exemplifies this belief, thinking doctors possess magical abilities. Let me share the story of 76-year-old Sulochanamma, Suchitra’s mother, who grapples with multiple conditions like mild CHF, obstructive sleep apnea, fibromyalgia, depression, and IDDM. Suchitra’s overenthusiastic nature, stemming from her unfamiliarity, became the cause of her mother’s suffering.

When Sulochanamma developed aspiration pneumonia, our facility’s doctor and nursing supervisor explained the treatment and protocols. However, Suchitra doubted the competence of our skilled nursing home, opting instead to admit her mother to a multi-speciality hospital. Driven by anxiety, Suchitra’s hasty decision had unintended consequences. While antibiotics controlled the pneumonia, collateral damage manifested as two fourth-grade pressure sores. The hospital was reluctant to discharge, leading to a prolonged stay in the ICU. Finally, Suchitra insisted and her mother was discharged, marked as DAMA (Discharge Against Medical Advice).

Older patients, especially the old and very old, tend to fare poorly in hospitals, experiencing high rates of fresh infections. Suchitra’s case study highlights the family’s ignorance and the tendency to admit older adults hastily, often causing more harm than good.

Ensuring our senior loved ones stay out of the hospital through preventive measures enhances their quality of life as they age independently in their own homes. While family caregivers who are in close proximity can actively monitor their seniors for early signs of health issues, in today’s world, many individuals live elsewhere and may not be available for caregiving. This is where a well-managed ‘care home’ becomes invaluable.

‘Ageing in Place’ carries risks when appropriate care and support systems are lacking. Relying on sporadic monitoring, such as a friend visiting once a week, may not suffice. Swift access to medical care increases the likelihood of avoiding hospitalisation, especially for infirm elders with multiple conditions. Beyond the age of 80, life expectancy continues to rise, making it crucial to help seniors maintain wellness and independence through a healthy lifestyle.

Drawing from our extensive experience in social gerontology, we offer a few tips to help older adults from preventable hospitalisation, allowing them to continue enjoying life and creating lasting memories.

Physical Activity

It’s common for seniors to feel lethargic and adopt an ‘I have no energy’ attitude. As older adults age, they often reduce their physical activity, which unfortunately can lead to issues causing hospitalisation. In our skilled nursing home, we actively promote mobility through assisted walks, tailored to each individual’s level of infirmity.

Nutrition

Many elders struggle to get proper nutrition, especially if there’s no one available to cook for them. Grocery shopping and cooking become challenging for seniors living alone, leading to skipped meals or inadequate nutrition. Elders who maintain a well-balanced diet can expect better health and a reduced likelihood of hospitalization. Nutrition plays a significant role in overall health, emphasizing the importance of ensuring the right levels of vitamins and nutrition daily.

Medication Management

Co-morbidities are common in older adults, resulting in a medicine chest full of different medications. Poly-pharmacy is a necessary evil, and we employ strategies to manage it effectively. Encouraging elders to take each tablet individually with a time gap is crucial, avoiding instances of swallowing multiple tablets at once. Regular reviews with doctors are essential, as some elders may continue medications even when no longer needed. When starting a new medication, discuss potential side effects, proper administration, and interactions with existing medications with your doctor. While your regular doctor is the most knowledgeable about your medication history, it’s essential to communicate and seek clarification on any concerns.

Socialisation and Hobbies

Loneliness poses a significant challenge for older adults, particularly the very old, as the younger generation often lacks the time for interaction. As friends gradually enter eternity, loneliness can negatively impact health and motivation for staying healthy. Engaging with friends and family can help maintain mental and physical activity, contributing to a youthful spirit. While we don’t prescribe a specific socialisation plan, we encourage you to create your own. For introverted individuals who shy away from others, finding a hobby can be an excellent way to fill their time, offering a sense of fulfilment and engagement.

Reduce Fall Risks

Falls can be perilous at any age, but for elders, they can be fatal. Falls are a leading cause of hospitalisations among the elderly, yet they can be prevented with simple structural modifications and lifestyle changes at home.

Don’t Ignore Symptoms

The majority of seniors tend to overlook or conceal symptoms, often responding with a casual “I am okay.” This reluctance to acknowledge symptoms hinders timely intervention, leading many seniors to end up in the hospital for issues that could have been managed through early diagnosis and treatment. It’s crucial to open up, seek treatment promptly, and avoid unnecessary delays. Most of the chronic conditions need regular attention and if addressed on time can prevent hospitalisation.

Ambulatory care sensitive conditions (ACSC), including hypertension, diabetes, chronic heart failure, chronic obstructive pulmonary disease, and asthma, are manageable with timely and effective outpatient care, thereby reducing the necessity for hospitalisations. Complications related to ACSC that lead to hospitalisations can be avoided with proper access to ambulatory care services, the timely delivery of care, and high-quality care coordination. Hospital stays contribute significantly to the overall healthcare costs for older adults and pose risks such as delirium, infection, and a decline in functional ability. Lowering the rate of hospitalisation for older adults holds the potential to enhance patient health, decrease costs, and improve overall quality of life.

In a healthcare system where gerontology and geriatrics are unfamiliar terms, age-friendly systems are yet to develop. Clinical staff remains untrained in caring for older adults, with nurses often limiting their role to nursing procedures. Proven geriatric care models are yet to be incorporated to address specific issues faced by elders. There is a lack of strategies to support and coordinate with family caregivers, and transitional care is often reduced to a mere document called the ‘discharge summary.’ The current system leans heavily towards clinical approaches, which may be inappropriate for seniors.

We envision an elder-friendly care model that involves specially trained doctors, paramedical professionals, and nurses. This model includes tools to reduce complications common in hospitalised older patients, identification and treatment of depression, proper medication management, smooth transitions from hospital to home or care settings, improved primary care for seniors, and the option of intensive skilled home-based care to replace lengthy hospital stays. In essence, focusing on getting medication and nutrition right, improving mobility, enhancing mental well-being, and tailoring care to suit the needs of elders is the best way to prevent non-beneficial hospitalisations.