Providing Best Care for Older People in a Hospital Setting
Published: 11 August 2020
Amidst large-scale outbreaks of COVID-19 in aged care, Victoria’s State Government has transferred residents from affected facilities to acute care settings in a drastic effort to protect them from the virus (Tsirtsakis 2020).
Hospitalisation is an overwhelming event for older people that places them at significant risk of complications and deterioration, at the best of times (QUT 2017).
Being evacuated from a COVID-19-affected facility, on top of this hospitalisation, will understandably heighten the distress of these residents, as well as challenge acute care staff who have minimal experience in aged care.
Older adults face a unique set of risks and challenges in hospital settings. Therefore, it is crucial to know how to care for these vulnerable people appropriately, regardless of whether they are acutely ill or have been admitted in response to the COVID-19 crisis (QUT 2017).
The Risks of Hospitalisation for Older Adults
Older adults may feel highly distressed coming into an acute care setting. In addition to the pain or illness they are experiencing, they may also be concerned about the implications of being hospitalised, and how it will affect their independence, routine and sense of self (Age UK 2012).
The patient may be frightened, confused, frustrated or angry. It is important to empathise with these emotions and care for them in a way that is sensitive to their distress (Age UK 2012).
Older adults are also at high risk of developing complications during a hospital stay. These include:
Malnourishment or dehydration;
(VIC DoH 2015; RACGP 2019)
They may face other challenges that impede on their lifestyle, including:
Loss of confidence;
Loss of independence;
Change of routine;
Reduced activity and stimulation; and
Overall functional decline.
When caring for an older adult in hospital, the aim is for them to return home at the level of functioning they had before admission, or better (QUT 2017).
Specific Issues Related to the Hospitalisation of Older People
Transfer of Care
Transitions between aged care and acute care, or any other settings, are high-risk and can result in miscommunication or other adverse consequences such as:
Delayed follow-up of test results;
Unnecessary repeats of tests; and
(ACSQHC 2017; RACGP 2019)
Dignity and Autonomy
All patients have the right to dignity and autonomy, regardless of age. However, in acute care settings, this may be a low priority for staff (Tauber-Gilmore, Norton & Proctor 2017).
Generally, older adults are at a high risk of losing dignity when in care (Šaňáková & Čáp 2018).
Dignity and autonomy play a significant role in a patient’s overall condition. Positive, respectful interactions will increase the patient’s confidence, motivating them to maintain independence and stay physically and mentally active. On the other hand, neglectful, condescending or apathetic care will quickly correlate to deterioration and functional decline (Age UK 2012).
A literature review identified the following key components of dignity, based on the views of older adults:
Autonomy and control;
Care and comfort;
(Šaňáková & Čáp 2018)
Empowering older adults, providing them with choice and treating them with dignity is essential in reaching desirable patient outcomes. Older adults want to be treated as people, not nuisances (Age UK 2012).
Care that promotes dignity
Care that reduces dignity
Responding to the patient’s needs, wants and fears.
Using respectful language.
Being empathetic to the patient’s distress due to life changes, loss of independence etc.
Involving the patient in decisions.
Explaining concepts to the patient.
Treating the patient as part of a partnership.
Treating the patient as an individual.
Providing care that is accessible to all patients regardless of sensory impairment, language barriers etc.
Being culturally aware.
Engaging with the patient.
Asking how the patient would like to be addressed.
Ignoring the patient’s comments or complaints.
Speaking to the patient like a child.
Treating the patient like a burden or nuisance.
Telling the patient what to eat or when to go to bed.
Neglecting the patient or rushing care to save time.
Treating the patient as a passive recipient (e.g. feeding the patient rather than helping them eat).
Treating the patient in a way that humiliates or degrades them.
Treating the patient in a way that humiliates or degrades them.
Reducing the patient to their condition or illness.
Using offensive or condescending language.
(Age UK 2012)
About 40% of older adults over 65 experience confusion during hospitalisation, usually due to dementia or delirium (Murray et al. 2019).
These patients may be particularly overwhelmed. In addition to pain, illness or emotional distress, they may also:
Experience disorientation, fear, anxiety or drowsiness;
Display uncharacteristic behaviours;
Try to leave the facility;
Become disruptive or aggressive;
Display responsive behaviours such as wandering, yelling, hitting, kicking, sexually inappropriate behaviours and restlessness than can be difficult for staff to manage.
(ACI 2015; Yous, Ploeg & Kaasalainen 2019)
The risk of complications is even higher among older patients with cognitive impairments (Bail & Grealish, cited in Cook et al. 2020).
Research suggests that only 14% of hospitals have physical environments that are appropriate for patients with cognitive impairments (Alzheimer's Australia 2014).
Acute care facilities are busy and fast-paced environments, with noises, lights, signage and room layouts that can be highly confusing for older adults and significantly contribute to distress and disorientation, especially for patients with cognitive impairments (Alzheimer's Australia 2014).
Patients need to feel safe, secure and oriented, which can be very difficult if the toilet is hard to find, or the patient does not know how to get back to their room (Alzheimer's Australia 2014).
Practical Tips When Caring for Older Adults
When caring for older adults in acute settings, consider the following:
Ensure age-friendly principles are in place. These may include:
Written information in large print;
Adequate lighting at night;
Beds and furniture at a suitable height; and
Access to mobility aids.
Always practice consumer-directed care.
Identify what is important to the patient; what are their physical, mental, emotional and social needs?
Encourage independence. Support the patient to practice self-care and dress, mobilise and toilet themselves.
Ensure adequate nutrition and hydration.
Monitor the patient’s cognitive status.
Involve the patient’s family and carers as much as possible.
Manage any pain that the patient is experiencing; this can adversely affect self-care.
Review the patient’s medications.
(QUT 2017; VIC DoH 2015)
Caring for Older Adults with Cognitive Impairment
Older adults with cognitive impairment require extra support and orientation. In addition to the practical tips above, you should:
Ensure the patient’s glasses, dentures, hearing aids etc. are clean, working and easily accessible;
Minimise bed moves;
Try to use non-pharmacological strategies when possible to treat confusion;
Encourage the patient to participate in success-based therapeutic activities, considering their interests (e.g. music, games);
Avoid restrictive practices;
Create a comfortable, safe and relaxing physical environment for the patient, considering privacy, orientation, lighting, noise etc.;
Involve family and carers in reorientation and reassurance strategies;
Normalise sleep patterns;
Address any underlying causes of the patient’s behaviour (e.g. physical illness or pain);
Speak to the patient gently, calmly and reassuringly, using simple language; and
Encourage continence through access to toilets and visual signage.
(ACI 2015; Alzheimer's Australia 2014; ACSQHC 2014)
Older adults who become hospitalised may be highly distressed and are vulnerable to complications, especially if they have a cognitive impairment. Caring for these patients appropriately is essential in achieving positive outcomes and preventing deterioration or functional decline.