Hospital care for the elderly

Helping acutely ill aging patients to recover

Legendary nurse Florence Nightingale stated that the very first requirement in a hospital is that it should do the sick no harm.

This message resounded at the annual JGH Department of Nursing Symposium, The aging adult and critical illness: mastering the complexities of care. JGH staff including nurses, physicians, dieticians, occupational and physiotherapists and a clinical ethicist presented at the symposium along with nursing guest speakers from the University of Alberta, as well as the President of the Order of Nurses, who opened the conference. They came together to raise awareness among the equally inter-disciplinary audience members about the complex needs of older hospital patients.

At the JGH, 40 per cent of patients are over the age of 75, said keynote speaker Judy Bianco, the associate nursing director of Medicine, Geriatrics and the Emergency Department. These patients can be found throughout the hospital, not only on the geriatrics unit. Hospital protocols and practices do not necessarily reflect the health needs of these aging patients, however.

“One complication is the interplay between chronic illness and multiple medications,” stated Dr. Ruby Friedman, the JGH director of Geriatric Medicine, who presented alongside Ms. Bianco. “Most medical best-practice guidelines only explain what is recommended for a patient with a single chronic illness,” when there are a disproportionate number of elderly patients with multiple conditions.

“The fit between older patient and hospital isn’t always ideal,” agreed Ms. Bianco. For instance, elderly patients may find hospital noise overwhelming, clutter difficult to negotiate, and movement from one patient room to another disorienting.

To help aging patients recover and regain their autonomy during their hospital stay, Ms. Bianco and Dr. Friedman encouraged staff to make the best use of available resources. As an example, rather than connect a patient to an intravenous pole, which will limit their ability to get around, elderly patients should be mobilized at the earliest opportunity. That means making sure they eat their meals in a chair, and use the washroom when the need arises. Even in an ICU environment, where patients seem to be hindered by equipment such as feeding tubes, special efforts can and should always be made to mobilize the elderly, says conference organizer Valerie Frunchak, associate director of Mental Health and Training and Development.

The three afternoon sessions of the nursing conference offered a choice of three concurrent presentations, on a range of topics. Here are several highlights:

JGH Dieticians Angela Dease and Marissa Ranallo addressed malnutrition in the elderly in a critical care setting. Ms. Dease explained that changes that occur naturally in aged or ill people can put the elderly patient at a particularly high risk for poor nutrition and weight loss, which can hinder their recovery and diminish their quality of life.

“Staff should know their patient well and monitor them closely for changes in their eating habits, their chewing and swallowing ability, and their weight, and share this information with all appropriate team members in a timely manner,” said Ms. Dease. “Getting family and friends involved in the care of their loved one can also make a big difference. For example, asking them to encourage the patient to consume meals, snacks, fluids, and nutritional supplements, as well as to bring in favorite foods from home whenever possible.”

Dr. Céline Gélinas, a clinical researcher at the JGH Centre for Nursing Research and the Lady Davis Institute, spoke about the advantages of using pain assessment tools when measuring pain among the hospitalized elderly. While this population is less likely to report their pain, even patients with cognitive impairment or dementia can self-report. Family members can also assist the medical team by helping to identify a patient’s pain behaviours through such cues as facial expressions or body movements.

For older adults with Chronic Obstructive Pulmonary Disease, which Clinical Nurse Specialist in Pulmonary Diseases Esther Dajczman noted is the number one cause of hospital admission in Quebec, the inter-disciplinary approach to care practiced at the JGH involving a COPD nurse navigator, strong nurse-physician partnership, and smoking cessation counselling “significantly reduces total hospital days due to respiratory causes.”

Dr. Jonathan Afilalo of the JGH Division of Cardiovascular Medicine and Specialized Nurse Practitioner (Cardiac Surgery) Shannon McNamara discussed surgical outcomes for geriatric patients. Older patients who traditionally would have been considered at too high a risk to undergo cardiac surgery are now less likely to be considered inoperable because of emerging technologies that help to improve outcomes, explained Dr. Afilalo.

Ms. McNamara remarked that steps can be taken to improve a patient’s odds of recovery. “Before surgery, get your patients more active to improve their lung capacity, endurance and strength, make sure they’re well nourished, mobilize their social support, and educate them about their surgery to reduce stress,” she advised. “Following their operation, remove catheters and as many lines as is safe for the patient, to encourage mobility. The sooner the patient can perform their activities of daily living, the less muscle mass they’ll lose, the more optimistic they’ll feel, and the better quality of life they’ll experience.”

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