Acute Care of the Elderly As A Health Care and Nursing Challenge

Acute Care in Old Age

 

Acute Care of the Elderly As A Health Care and Nursing Challenge, Need Of Nursing Services For Elderly Care, Outcomes or Results Of ACE.

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.