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

Lost in Translation: Google’s Translation of Palliative Care to ‘Do-Nothing Care’

by: Cynthia X. Pan, MD, FACP, AGSF (@Cxpan5X)

My colleagues often ask me: “Why are Chinese patients so resistant to hospice and palliative care?” “Why are they so unrealistic?” “Don’t they understand that death is part of life?” “Is it true that with Chinese patients you cannot discuss advance directives?”

As a Chinese speaking geriatrician and palliative care physician practicing in Flushing, NY, I have cared for countless Chinese patients with serious illnesses or at end of life.  Invariably, when Chinese patients or families see me, they ask me if I speak Chinese. When I reply “I do” in Mandarin, the relief and instant trust I see on their faces make my day meaningful and worthwhile.

At my hospital, the patient population is about 30% Asian, with the majority of these being Chinese. Most of these patients require language interpretation.  It becomes an interesting challenge and opportunity, as we often need to discuss advance directives, goals of care, and end of life care options…

Elderhood: Podcast with Louise Aronson

In this week's podcast we talk with Louise Aronson MD, MFA, Professor of Geriatrics at UCSF about her new book Elderhood, available for purchase now for delivery on the release date June 11th.

We are one of the first to interview Louise, as she has interviews scheduled with other lesser media outlets to follow (CBS This Morning and Fresh Air with Terry...somebody).

This book is tremendously rich, covering a history of aging/geriatrics, Louise's own journey as a geriatrician facing burnout, aging and death of family of Louise's members, insightful stories of patients, and more.

We focus therefore on the 3 main things we think our listeners and readers will be interested in.

First - why the word "Elder" and "Elderhood" when JAGS/AGS and others recently decided that the preferred terminology was "older adult"?

Second - Robert Butler coined the term ageism in 1969 - where do we see ageism in contemporary writing/thinking?  We focus on Louise's…

Psychedelics: Podcast with Ira Byock

In this week's podcast, we talk with Dr. Ira Byock, a leading palliative care physician, author, and public advocate for improving care through the end of life.

Ira Byock wrote a provocative and compelling paper in the Journal of Pain and Symptom Management titled, "Taking Psychedelics Seriously."

In this podcast we challenge Ira Byock about the use of psychedelics for patients with serious and life-limiting illness.   Guest host Josh Biddle (UCSF Palliative care fellow) asks, "Should clinicians who prescribe psychedelics try them first to understand what their patient's are going through?" The answer is "yes" -- read or listen on for more!

While you're reading, I'll just go over and lick this toad.


You can also find us on Youtube!

Listen to GeriPal Podcasts on:
iTunes Google Play MusicSoundcloudStitcher
Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, I spy someone in our …