Acute Care in Old Age

What is Acute
Care of the Elderly

    Older
people have a greater prevalence of chronic diseases and disorders that lead to
hospitalization. On average, people over 65 are hospitalized more than three
times as of- ten as younger individuals, and the length of their stay is
estimated to be 50% longer than that of younger individuals. 

Need Of Nursing Services For Elderly Care

    Nursing research
that defines the evidence for practice interventions is needed for patients of
all ages, and especially for the elderly (Fulmer & Mezey, 2002). Nursing
research that provides the basis for best practice for hospitalized elders is
often embedded in interdisciplinary studies. 

    For example, in one study, 244
patients aged 70 years and older were enrolled in a geriatric care program
which used a geriatric resource-nurse intervention to improve the quality of
care received by the hospitalized elderly. The intervention decreased patients’
length of stay and improved quality indicators (Inouye et al., 1993a, 1993b). 

    In another study, Palmer and colleagues were able to demonstrate improved care
through the use of an ACE (Acute Care of the Elderly) unit, in which protocols
for skin care, urinary-incontinence management, and pressure-ulcer prevention
were used (Palmer, Landefeld, Kresevic, & Kowal, 1994).

Outcomes or Results Of ACE

    ACE
units have shown improved out- comes among older patients who have been
hospitalized. A widely cited study conducted by Landefeld, Palmer, and Kresevic
(1995) demonstrated that patients admitted to an ACE unit were more likely to
improve in activities of daily living (ADL) and were less likely to be institutionalized. 

    Asplundh, Gustafson, and Jacobson (2000) also demonstrated that ACE units
reduce the institutionalization rate of hospitalized elders. Siegler, Glick,
and Lee (2002) found that the commonality of the ACE unit was their
interdisciplinary care and focus on functional improvement, patient and staff
satisfaction, and reduction of length of stay. 

    In a prospective study of 804
patients 80 years of age or older, 42% of the elderly patients with no baseline
dependencies at admission had developed one or more limitations within 2 months
(Hart, 2002). Individuals older than 65 years of age are more likely to be
admitted to acute care from the emergency department than other age groups. 

    The
hospitalized elderly is at an increased risk for poor outcomes such as
increased length of stay, readmissions, functional decline, and iatrogenic
complications, as compared with other age groups. There is a 33% rate of
readmission within 3 months and complications such as acute confusion and
nosocomial infections, which are common among the elderly, resulting in
increased morbidity and mortality. 

    Fifty-eight percent of patients who are
hospitalized will experience at least one iatrogenic complication (Hart).

Research Results

    Data
for acute care are also found in research that looks at “nurse
sensitive” indicators for patient outcomes. For example, hospital staff
has been shown to make a difference in patient outcomes (Aiken, Sloane, Lake,
Sochalski, & Weber, 1999; Kovner & Gergen, 1998). 

    Nurse accountability
and models of patient and nursing administration have also been examined (Mark,
Salyer, Geddes, & Smith, 1998; Scherb, Rapp, Johnson, & Maas, 1998).
These studies provide some information regarding outcomes for the elderly, but
intensive effort needs to be focused on understanding the differences between
outcomes for younger individuals versus older individuals in the case of
hospital care. 

    For example, do older adults have different cardiac output after
coronary artery bypass surgery than younger individuals when other variables
are held constant, such as premorbid conditions? Such parameters are needed for
the improvement of care for the elderly. 

    A study conducted by Kleinpell and
Ferrans (1998) explored functional status and quality of life outcomes for
elderly patients after ICU hospitalization; Survival rates 4 to 6 months after
discharge were examined in patients aged 45 and older. In this study, the
severity of the illness was a predictor of ICU outcome; age was not.

 Review of Past

    Historically,
elders were not considered to be “suitable candidates” for surgeries
and treatments that today are considered routine. In the early 1970s,
individuals over the age of 65 were excluded from surgical intensive care
units, as it was felt that the cost-benefit was not going to be in favor of the
older patient. 

    Today individuals in their 80s and 90s undergo open-heart
surgery and require appropriate postoperative care that only a surgical
intensive care unit can provide.

Ethical Considerations

    Ethical
issues abound regarding elders during a hospitalization. For example, if there
is an insufficient number of beds in an intensive care unit, should older
individuals be sent out to the floor before younger individuals? 

    Are scarce
resources allocated to younger individuals before they are used to care for the
elderly? Furthermore, elder abuse, a serious and potentially fatal syndrome, is
frequently over-looked when elders come into the hospital with severe symptoms,
such as bilateral bruising, histories incompatible with injuries, and overt
fear of caregivers. 

    These issues are a part of acute care of the elderly and
need to be addressed with rigorous research studies. Studies involving younger
individuals need to be replicated among older adults to discern differences
between the age cohorts.