Skip to main content

The Hospital Disability Syndrome

Ken Covinsky previously posted on GeriPal a while back about the dangers of hospitalization in older adults.   Ken notes in that post that hospitalization is a vulnerable period leading to major new disability for many older adults.  More recently, Ken, GeriPal contributor Bree Johnston, and honorary GeriPal member Edgar Pierluissi authored a terrific article about hospital-associated disability in one of those pre-blogging era, old-fashioned periodicals...JAMA.

I'm not going to be able to sum up this meaty piece of scholarship in this post.  Let me say only that if you care for hospitalized older adults, and can only read one article that changes for the better how you care for them, this would be that article.   Let me relay some of the disruptive perspectives offered:

  • Move over traditional geriatric syndromes, and make way for the newcomer:  hospital-associated disability should be considered a geriatric syndrome (the "hospital disability syndrome").  Hospital-associated disability shares hallmark features with the well-established geriatric syndromes, such as falls, delirium, and incontinence.  The etiology of hospital-associated disability is nearly always multifactorial.  These syndromes occur in older adults who have accumulated impairments across multiple domains, and are vulnerable to the stress of an acute illness or hospitalization.  
  • Stop using "the one-point restraint."  By that they mean a urinary catheter (Foley).  Much of what is routine about hospitalization impairs older adults ability to recover and promotes additional functional decline.  Some key examples: bed rest to prevent falls (immobility leading to loss of function), diphenhydramine to help the patient sleep (delirium leading to loss of function), and a urinary catheter (restraint leading to immobility leading to loss of function).  They suggest that the benefits of accurate measurement of urinary output with a catheter are outweighed by the risks of infection and immobility in the elderly.  Next time you admit that 80 year old with a CHF exacerbation, rely on daily weights rather than putting in a catheter.  Help them walk to the scale.
  • Let them eat food, and food with taste.  Have you ever had a no-salt, low carb, fat free meal?  How about being offered that for breakfast, lunch, and dinner for days on end?  No wonder nutritional status drops quickly with hospitalization, and that doesn't even count the nothing by mouth (NPO) order that older adults are often slapped with until the speech and swallow folks can assess them (on hospital day 3).
  • "Discharge rounds" should be renamed "going home rounds."  "Discharge" is utilization focused, and aligns with the hospital's financial interests, as they are generally paid a set amount of money for a given admitting diagnosis.  The shorter the hospitalization, the greater the profit for the hospital.  "Going home rounds," in contrast, is patient centered, and recognizes that return home from hospitalization is an important transition that requires proper planning and support.
  • Mortality is high for older adults with hospital-associated disability.  As high as 40% at one year!  Palliative care should be a key part of the care plan.  So what is palliative care for disabled elders?  Yes, pain is mentioned, but so are several features that certainly weren't on the palliative care boards when I took them last year: motorized scooters to make getting around easier; home modifications such as support bars and a shower chair to promote independence at home; and paratransit services to facilitate independence outside of the home.  These features support disabled older adults' dignity at a vulnerable time, in what may their last months of life.  Sounds like palliative care to me.

by: Alex Smith


Anonymous said…
Though many of us are aware of the risks of hospitalization in our elderly population (I always advise my SNF residents to "stay out of that place")talk about this as a syndrome really draws attention to the problem.Bringing this problem out for discusion and hopefully action is a good thing. j dolan
Charla said…
Under the fifth bullet: "So what is care for disabled elders?" Palliative care in our clinic-based program also includes assignment of a volunteer phone companion. The phone companion contacts the patient on a regular basis to help decrease hospitalizations and emergency department visits as well as to provide companionship.
Anonymous said…
Perfectly stated!!! It's about time someone actually drew attention to this, and pointed out the obvious

Popular posts from this blog

Dying without Dialysis

There is a terrific article in this weeks Journal of Pain and Symptom Management by Fliss Murtagh of King's College in London about the epidemiology of symptoms for patients with advanced renal failure who die without dialysis.  This study is important because while we know that patients with advanced renal failure have a limited life expectancy and the average age of initiation of hemodialysis is increasing, we know little about the alternatives to hemodialysis.  Specifically, we know nothing about symptoms affecting quality of life among patients who elect not to start dialysis (so called "conservative management" - is this the best label?).  This article provides a terrific counterpoint to the article in last years NEJM showing that nursing home residents who initiated hemodialysis tended to die and decline in function (see GeriPal write up here). 

The study authors followed patients with the most advanced form of chronic kidney disease (the new name for renal failu…

Language Matters: Podcast with Brian Block and Anna DeForest

One of our first GeriPal posts was titled "Rant on Terminology," by Patrice Villars, NP.  In the spirit of looking back over our first 10 years, here is the opening paragraph to that post:

News Headlines read: Sen. Edward Kennedy loses battle with cancer. Really, he lost? I thought he died from a malignant brain tumor, an “aggressive” brain tumor. The median survival is less than a year for people for his particular tumor. Kennedy was diagnosed in May of 2008. He lived over 15 months after diagnosis. What a loser. He must not have fought hard enough. Huh? I thought he spent most of his life battling for social and health care reform in America. In this week's GeriPal podcast we take a deeper dive into this issue of language and medicine.  We are joined by guests Anna DeForest, MD, MFA, a resident in Neurology at Yale, and Brian Block, MD, a pulmonary critical care fellow at UCSF.  

Anna recently published a paper in the NEJM describing her reaction to hearing terms like, &…

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …