Older people cared for in specialized geriatric hospital units tend to decline at a slower pace than those given conventional hospital care, recent research suggests.
Aging brings a certain amount of natural deterioration in cognitive performance, which can interfere with normal activities. However, in previous studies, a more powerful indicator of poor medical outcomes is “functional decline.”
Functional decline has been defined as “a reduced ability to perform tasks of everyday living, for example, walking or dressing, due to a decrement in physical or cognitive functioning.” Up to half of geriatric patients have either loss of or reduced ability in at least one activity of daily living. The decline can begin as early as the second day in hospital.
Dr. Leocadio Rodriguez-Manas and colleagues from Getafe Universitary Hospital in Madrid say that hospital care for people over 65 years old requires “a thorough assessment to assess the risk of functional decline,” which they state is the main determinant of quality of life, cost of care, and prognosis.
Delaying such decline and helping patients return home are at least as important as reducing mortality, the researchers believe. They analyzed 11 studies on the outcomes of specialized acute geriatric units compared with conventional hospital care. Patients were at least 65 years of age and had medical problems which did not necessitate treatment in other specialized units.
There was an 18 percent lower risk of functional decline at discharge, and in the next three months, following care in a specialized unit. The patients were more likely to remain mobile and be able to carry out usual daily activities. They also had a 30 percent higher chance of returning home after leaving the hospital. There was no difference in mortality rates or cost of care between the two groups.
Each of the individual studies showed similar results, the team reports on the website of the British Medical Journal: “Since admission to hospital is a risk factor for case fatality, functional decline, and admission to a nursing home, any intervention that helps reduce this risk is potentially important.”
They add that the 18 percent reduction in functional decline associated with specialized geriatric units is similar to that found in an earlier study of similar patients who received multidisciplinary care. Future studies should examine whether the reduction in functional decline persists in the medium-term after discharge, they write. Ideally, more patients would be involved, and they would be randomly allocated to standard or specialist care.
However, commenting on the study, Dr. Graham Ellis of Monklands Hospital in Lanarkshire, Scotland points out that specialized units may not be necessary for all patients over 65. Those without evidence of frailty, disability or multiple problems may not benefit, he writes. “Future research should focus on whether or not it is possible to accurately identify frail and at-risk groups,” he states.
The original researchers responded by saying that their study did not aim to identify the characteristics of patients who get more benefit from specialized units. They agreed that trials are needed to examine whether the effectiveness of these units varies with frailty, disability or co-morbidity.
Previous studies on geriatric units have shown benefits lasting up to a year after discharge, compared with usual hospital care. These units either improve functional status or reduce the rate of decline, and cut the likelihood of admission to a nursing home. The new research adds to the evidence that specialized geriatric units can improve outcomes without an increase in mortality, repeat hospital admissions, or costs.
This opinion is shared by nurse researcher Erin Sarsfield of Penn State College of Medicine. She writes: “The demographics of our country are changing. With increased life expectancy comes more elderly critical care patients whom may have never sought medical care until a critical event has occurred.
“We must pay close attention to this group of patients and continually strive to give them the best care possible. By utilizing continuous process improvement strategies, which are similar in many ways to the nursing process, we can best meet their needs.”
Sarsfield believes that a complete functional and clinical evaluation on admission to hospital is crucial for uncovering medical and socioeconomic problems, like social isolation, that can cause disability and interfere with quality of life and survival.
Bazta, J. J. et al. Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: Meta-analysis. The British Medical Journal, 2009;338:b50.
Sarsfield, E. Continuous process improvement and the elderly critical care patient. Critical Care Nursing Quarterly, Vol. 31, January-March 2008, pp.79-82.
Inouye, S. K. et al. Program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Hospital Elder Life Program. Journal of the American Geriatrics Society, Vol. 48, December 2000, pp. 1697-1706.