Making hospital geriatrics work

Why is there a lower prevalence of chronic immobility in geriatric departments with a high turnover of patients?

There is little information available about the characteristics of patients admitted to geriatric units with high and low turnover rates of patients. It is often suggested that high turnover units do not admit the more physically disabled person. This study set out to investigate whether this view is true. Six geriatric units with different patient discharge rates were investigated. Those units with a high turnover of patients tend to admit more severely immobile people per bed, when compared to those units with below average throughput. Although these immobile people admitted to high turnover units suffered a higher mortality rate, a significantly greater proportion regained the ability to transfer themselves independently from bed to chair and to the toilet.

Review of accelerometry for determining daily activity among elderly patients

OBJECTIVES

To review studies that used accelerometers to classify human movements and to appraise their potential to determine the activities of older patients in hospital settings.

DATA SOURCES

MEDLINE, CINAHL, and Web of Science electronic databases. A search constraint of articles published in English language between January 1980 and March 2010 was applied.

STUDY SELECTION

All studies that validated the use of accelerometers to classify human postural movements and mobility were included. Studies included participants from any age group. All types of accelerometers were included. Outcome measures criteria explored within the studies were comparisons of derived classifications of postural movements and mobility against those made by using observations. Based on these criteria, 54 studies were selected for detailed review from 526 initially identified studies.

DATA EXTRACTION

Data were extracted by the first author and included characteristics of study participants, accelerometers used, body positions of device attachment, study setting, duration, methods, results, and limitations of the validation studies.

DATA SYNTHESIS

The accelerometer-based monitoring technique was investigated predominantly on a small sample of healthy adult participants in a laboratory setting. Most studies applied multiple accelerometers on the sternum, wrists, thighs, and shanks of participants. Most studies collected validation data while participants performed a predefined standardized activity protocol.

CONCLUSIONS

Accelerometer devices have the potential to monitor human movements continuously to determine postural movements and mobility for the assessment of functional ability. Future studies should focus on long-term monitoring of free daily activity of a large sample of mobility-impaired or older hospitalized patients, who are at risk for functional decline. Use of a single waist-mounted triaxial accelerometer would be the most practical and useful option.

Using a queueing model to help plan bed allocation in a department of geriatric medicine

By integrating queuing theory and compartmental models of flow we demonstrate how changing admission rates, length of stay and bed allocation influence bed occupancy, emptiness and rejection in departments of geriatric medicine. By extending the model to include waiting beds, we show how the provision of extra, emergency use, unstaffed, back up beds could improve performance while controlling costs. The model is applicable to all lengths of stay, admission rates and bed allocations. The results show why 10-15% bed emptiness is necessary to maintain service efficiency and demonstrate how unstaffed beds can serve to provide a more responsive and cost effective service. Further work is needed to test the validity and applicability of the model.

Mortality rates of patients admitted to a psychogeriatric assessment unit

Admission of elderly people to a geriatric hospital may carry an increased risk of death. In this study 355 admissions of 243 elderly persons with dementia to a purpose built psychogeriatric unit were studied and the mortality rate found to be 8.2%, which is less than that reported elsewhere. Admission for the purpose of respite (holiday) relief is a safe procedure and should not be discouraged.

Outcome of patients admitted to an acute geriatric medical unit

To find out what happens to patients admitted to an acute geriatric medical unit, all admissions during 1982 were reviewed. Demographic features were compared with those of the community served, and rehabilitation, inpatient mortality and mortality in the year following discharge were assessed. Inpatients accounted for 4% of the community aged over 65, and most patients were discharged back to the community. Inpatient mortality was 25% and mortality in the year following discharge was 23%, giving a two year mortality of 42%, which was similar in all age groups. The achievement of high rehabilitation rates was tempered by the considerable mortality rates following discharge.

Who should provide hospital care of elderly people?

Since 1980 Islington Health District has appointed one consultant physician trained in geriatric medicine and three general physicians. The effect of these appointments on health care of the elderly in hospital was studied by means of Hospital Activity Analysis data for 1980-83. There were significant reductions in length of stay and in numbers becoming long stay among elderly patients admitted to the geriatric department. There was little change in these variables for elderly patients in general medical beds. The reduction in length of stay was achieved by the geriatric medicine department despite a lower staff/bed ratio and negative skewing in favour of acute medicine, and without any significant increase in the rates of readmission or mortality within 2 weeks of admission.

Alive and well: geriatric medicine in the U.K. in 1984

The function of the hospital geriatric service in the U.K. is described within the context of the overall support for the frail, disabled, and sick elderly in this country. It plays an important part in the secondary care of the very old, and perhaps an even more important part educating the public and the profession to the needs of this rapidly expanding section of the population. A short account is given of the nature of geriatric medicine and the role of the consultant geriatrician. The history, achievements, and current status of the specialty are briefly reviewed, and some of the directions which future developments may take are indicated. Whether or not a comprehensive separate service on the U.K. model emerges in other countries, it is certain that they will need centres of geriatric expertise to pursue research and to provide education and enlightenment for all concerned with the medical problems of old age.

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The author reviews two syndromes which affect the elderly in a general hospital: “dumping” and “blocked beds”. The term “dumping” is often misused for the aged becoming increasingly dependent and who require assessment, treatment and active rehabilitation. “Blocked beds” not only result from insufficient home care resources, but also from inadequate services offered by the hospital to senior citizens. The proposed solutions are the implementation of geriatric assessment units where global and multidisciplary care are best suited to meet the specific needs of the elderly. The multidisciplanary team also works as a consultant, especially in the emergency room, to assess and take care of the aged who are at risk, and whose cases are wrongly labelled as “dumping”.

Benefits of access to on-site acute and critical care for the residential section of a multi-level geriatric center

Of 220 residents living in the residential unit of a multi-level geriatric center, 95 required a total of 131 transfers to other facilities over a one-year period. Fifty-three of these patients were transferred to the associated chronic-care hospital for short-term acute medical investigation or treatment. The average length of stay of 17 days was similar to that of patients of comparable age with comparable medical conditions admitted to an affiliated acute general hospital from the community. In addition to continuity of medical care and the social and psychologic advantages of remaining within the geriatric center, this transfer potential resulted in substantial financial savings. The cost of hospitalization in the general hospital would have been more than twice that of the geriatric unit.

A geriatric rehabilitation and assessment unit in a community hospital

This report describes functional status at admission, discharge, and six months later for 100 elderly persons treated at a community hospital assessment and rehabilitation unit. The goal of the unit is to prevent institutionalization of frail elderly persons considered at risk for nursing home placement. Characteristics of the first 100 admissions include the following: average age, 79 years; female, 77 per cent; length of stay, 23 days; average number of admitting diagnoses, 3.4. Ninety-one new diagnoses of treatable conditions were made. On admission, 81 per cent of patients were confined to bed or chair or needed assistance with ambulation, compared with 27 per cent at discharge and 22 per cent at six months. Activities showing significant improvement include dressing, housekeeping, use of toilet, and ambulation. At six months, 15 per cent had died, 67 per cent were living in the community, and 19 per cent were institutionalized. It is concluded that care at the geriatric unit probably resulted in improved function and decreased nursing home placement.

Factors influencing admission or nonadmission of the aged to the hospital

A prospective study was carried out to determine which social, functional, or medical factors influenced the decision to admit or not to admit aged people to a general hospital in Israel. The study also focused on characteristics of patients admitted to the geriatric ward of the medical division as distinct from those sent to the internal medicine ward. Two hundred patients over the age of 65 were examined during ten consecutive intake days for the internal medicine ward over a period of five weeks. One hundred and sixty-seven were interviewed in the emergency departments, and the others after transfer from other departments by prearranged consultation. Thirty-five per cent were not admitted, 28 per cent were admitted to internal medicine, and 26 per cent were admitted to the geriatric department. Social factors played little part in the selecting process, the dominant need being acuteness and severity of illness. However, patients in the geriatric ward were found to be functionally much more disabled in regard to mobility, mental state, and incontinence. This was also reflected in a longer average stay of 15 days compared with nine in internal medicine, a higher mortality (19 per cent as against 7 per cent) and a higher degree of disability on discharge from hospital.

Improved care for patients on a new geriatric evaluation unit

An analysis is presented of a geriatric evaluation unit (GEU) established at the Sepulveda VA Medical Center in 1979 to provide comprehensive interdisciplinary assessment and treatment of geriatric inpatients. The data on 74 patients admitted during the first year show that major improvements can occur in several outcome areas. Placement location was improved over expectations in 48.4 percent of patients, thus permitting a higher level of independence with a lower level of care requirements. Functional status (Katz ADL scale) improved in two-thirds of the patients who could have shown improvement. An average of almost four new treatable disorders not noted by previous physicians were diagnosed per patient. The mean daily number of prescribed drugs was reduced by 32 percent per patient, and the total number of drug doses by 43 percent. Though limited by the unique aspects of the vA situation and by lack of a control group, the findings lend support to the efficacy and value of the GEU concept. (A randomized controlled study is in progress.)

An evaluation of home visiting of patients by physicians in geriatric medicine

The practice of preadmission home visiting of patients referred to geriatric medicine units has in recent years been criticised as being unnecessary on the grounds that if there is no waiting list there is no need for allocation of priority for admission; as being wasteful of doctors' time; as being resented by general practitioners; and as failing to provide adequate clinical information. The geriatric medicine department at the City Hospital with no waiting list for patients referred by general practitioners has retained home visits for most referrals because of the advantages in terms of acceptability to general practitioners (98-100%); the quantity and quality of information obtained; the usefulness of this information in deciding appropriate management and in planning discharge from hospital; and the provision of a unique teaching opportunity, which is highly valued by students and teachers alike.

Modern ideas about organization of services for elderly patients in hospitals and nursing homes in the Netherlands

The system of nursing homes in the Netherlands, and the advantages of the new department for geriatric assessment in the Municipal Hospital in Amsterdam are discussed. Included are admission and discharge data on 694 patients in the Geriatric Department in 1977, and also a list of the more common diagnoses, classified according to body system and disease.

Geriatric medicine in Hull: a comprehensive service

A partially age-related admission policy coupled with a "single-ward" scheme for treatment and rehabilitation was introduced by the Hull geriatric department in 1970. With rare exceptions, elderly patients needing hospital care have been admitted directly to the geriatric unit, and the proportion of the retired population admitted by the general physicians has been greatly reduced. The proportion of inpatients needing continuing care has been reduced to less than 20%, the mean length of inpatient stay has fallen to under 30 days, and separate long-stay wards are no longer needed. More than 91% of patients are admitted without preceding domiciliary assessment, and only 5-6% of admissions are transferred from other units within the area.

What is the function of a hospital for geriatric and chronic diseases?

The functioning of a hospital for chronic diseases was examined in terms of the type of patient referred, the course in the hospital and the eventual outcome, in a prospective study of a year's admissions to one department of Harzfeld Hospital in Israel. Of the 191 patients admitted, 55 percent were assessed as possible candidates for rehabilitation, and two-thirds were discharged. Among those admitted primarily for nursing reasons, the mortality was 76 percent. The average stay was 68 days for the 47 percent who were discharged and 95 days for the 45 percent who died; 8.4 percent remained as long-stay patients. Mobility improved in 37 percent and deteriorated in 8 percent; independence in self-care increased from 13 percent on admission to 51 percent on discharge. Thirty percent of the discharges occurred in the first month, and further 30 percent in the second month; 85 percent of these patients returned to their own homes. The hospital stay exceeded 6 months in 18 percent, of whom 7 percent died and 3 percent were later discharged. The possibility of release from the hospital was influenced by the degree of disability rather than the social circumstances. The best change for improvement was among the patients who required only partial help on admission. The most important tasks of the hospital were: intensive and sometimes prolonged rehabilitation; basic nursing care; medical reevaluation and sometimes referral for surgical salvage operations; attention to acute and subacute medical problems, some of which occurred as complications, including accidents; and the concentration of physiotherapy and occupational therapy where most needed. Achievement of these aims was based on fostering a cooperative spirit between patients and staff, adjusting to the problem of re-integrating the long-stay patient, and coordinating specialist services from other hospitals when needed.

Screening for hypothyroidism in elderly inpatients

Routine biochemical screening for hypothyroidism in 2000 geriatric inpatients proved valuable and practicable and yielded 46 cases (2.3%). A non-specific clinical picture was particularly common, with less than a third of the cases showing "typical" signs and symptoms. Psychiatric manifestations, especially depression, were important and frequent and responded well to thyroxine. There was a preponderance of female cases of hypothyroidism and a strong association with other autoimmune diseases, notably pernicious anaemia and rheumatoid arthritis.

Screening for hypothyroidism in elderly inpatients

Routine biochemical screening for hypothyroidism in 2000 geriatric inpatients proved valuable and practicable and yielded 46 cases (2.3%). A non-specific clinical picture was particularly common, with less than a third of the cases showing "typical" signs and symptoms. Psychiatric manifestations, especially depression, were important and frequent and responded well to thyroxine. There was a preponderance of female cases of hypothyroidism and a strong association with other autoimmune diseases, notably pernicious anaemia and rheumatoid arthritis.

No apology for geriatrics

A geriatric department is described where turnover has more than kept pace with demand over a period of 17 years. The department provides two basic services-a hospital service to the pensionable population in the community, and support to other hospital departments that care for the elderly.Community emphasis is on a high turnover of patients, enabling early contract and treatment. Over the years a fall in the proportion of "chronic" to "acute" beds has occurred and this has been achieved by having the majority of beds in the general hospital, where it is possible to provide a comprehensive medical service. The hospital role has been to prevent overloading acute resources with potential long-stay cases, and this has been possible without compromising our community obligations.