Published On September 28, 2017
IRIS RINKE-HAMMER DIDN’T mind getting the call in the middle of the night. Her partner, Lewis White, suffered from advanced dementia and was in the hospital for a severe urinary tract infection. White, 82, would sometimes walk restlessly for hours, and the nurses often engaged him by asking him to sit with them at their station. “I was so impressed that they didn’t even consider restraining Lewis or sedating him, which would have clouded his mind even more,” says Rinke-Hammer. The nurses also knew that the best way to soothe an agitated patient with dementia and to prevent delirium was to have a loved one with him—which is why they had asked Rinke-Hammer to come to the hospital.
White was in an “acute care for elders” (ACE) unit at the University of Alabama Hospital in Birmingham, which provides specialized care to frail older adults. The primary goal of ACE is to preserve vulnerable patients’ physical and cognitive faculties, which are often jeopardized by a stay in the hospital, and to avoid what the majority of patients fear most—being discharged to a nursing facility instead of being able to go home. During White’s four admissions to the ACE unit, a geriatrician, a geriatrics nurse practitioner, a physical therapist, a pharmacist and a social worker consulted on his care every day, discussing not only his medical problems but also how to minimize the stress and dangers of his hospitalization. The team eliminated drugs that made him drowsy and carefully calibrated doses of others to account for his diminished ability to metabolize them. Staff members helped White walk to maintain muscle strength. While other patients worked on adult coloring books, did puzzles or played cards with volunteers to keep their minds active, White, a jazz aficionado, listened to music his nurses found for him.
More than one-third of hospitalized patients in the United States today are 65 and older, and the cost of their care accounts for roughly 42% of the nation’s total hospital bill. Older people will be filling even more hospital beds as the population ages. But most hospitals don’t cater to the unique needs of their most frequent patients or acknowledge, in substantive ways, that a 75-year-old is different from a 35-year-old.
Older hospitalized adults are typically sicker than younger patients, with multiple chronic diseases and fewer physical and mental reserves to withstand the stresses of being both acutely ill and hospitalized. “Many older adults live on the brink between independence and functional dependence, so even a small decline during hospitalization can tip them into not being able to live on their own at home,” says Melissa Mattison, chief of hospital medicine at Massachusetts General Hospital. Studies suggest that approximately four out of 10 older adults will lose some ability to function independently during a hospitalization, and a third of those who are affected will still be impaired a year after leaving the hospital.
To address such problems, an estimated 100 to 200 U.S. hospitals now have ACE units, and many have created geriatric emergency departments designed to be less disorienting and more comfortable for elderly patients, with the goal of getting them home again while dealing with whatever injury or illness brought them to the emergency department. Other hospitals train volunteers to visit older patients and help them avoid slipping into a delirium that may take weeks or even months to recover from. Meanwhile, geriatricians and hospitalists are creating virtual or mobile ACE units to improve outcomes for all older patients.
Still, most older hospitalized patients don’t receive specialized care that focuses on both quality of life and medical outcomes. “It’s shocking,” says Ethan Cumbler, professor of medicine and president of the medical staff at University of Colorado Hospital and director of the hospital’s 21-bed ACE unit. “If I told you there was a drug that reduced your chance of ending up in a nursing home by 22%, would you go to a hospital that didn’t have that drug?”
SINCE LONG BEFORE 1990, when the first ACE unit was started at University Hospitals of Cleveland by Robert Palmer and C. Seth Landefeld, it has been broadly understood that hospitals can be toxic to elderly patients. “Care in the hospital can be actively pernicious to older people,” says Edgar Pierluissi, medical director of the ACE unit at San Francisco General Hospital and professor of clinical medicine at University of California, San Francisco. Older patients are more vulnerable to hospital-acquired infections, such as from urinary catheters, and to experiencing adverse reactions to medications. A significant percentage of older adults are malnourished when they are admitted to a hospital, and unfamiliar hospital food or lack of assistance can cause them to stop eating while they’re there, leading to functional decline, longer stays, pressure ulcers and a stint in a nursing home. Aging brains are also more prone to develop delirium: the sudden onset of one or several symptoms that may include fluctuating confusion, withdrawal, agitation and hallucinations.
Older patients in the hospital are often unsteady on their feet and subject to falls—and that’s one big reason they spend almost all of their hospital stay in bed, according to research by Cynthia J. Brown, director of the division of gerontology, geriatrics, and palliative care at the University of Alabama, Birmingham. Falls are a risk—particularly to the hospital. A fall in the hospital is considered a “never event” by Medicare, meaning there’s no reimbursement for any diagnosis or treatment that follows.
Immobility, however, is associated with a higher risk of pressure ulcers, pneumonia, blood clots and delirium. And keeping patients in bed can create a vicious cycle, says Brown, who notes that the No. 1 reason for falls is muscle weakness, which staying in bed exacerbates. “We put people in the hospital for five days, don’t let them walk because we’re afraid they’ll fall and we’ll get in trouble, we wheel them out to their car when they leave—and two weeks later, they’re back in the hospital after falling at home,” she says. And while she acknowledges that encouraging elderly patients to walk will result in some falls, “we need to move away from a zero-falls mindset to one of trying to keep people as safe as possible when they get out of bed.”
JUGGLING THOSE PRIORITIES IS what Kellie Flood, Brown’s colleague—a geriatric quality officer and assistant chief medical officer for care transitions at UAB Hospital—tries to do at the 26-bed ACE unit she created in 2008. Flood had been the medical director of the nation’s first oncology ACE unit, at Washington University in St. Louis, and when she arrived at the UAB hospital, she brought a wish list she had compiled during 10 years of visiting other ACE units and running her own.
The rooms in the UAB unit have matte wood-grain flooring, not the shiny, highly reflective waxed floors that can be hard on older eyes. Doorjambs are painted a different color than the walls so that entrances and exits are highly visible. Lighting is low glare, and the furniture is comfortable for spouses and other family members who might spend the night and could themselves be elderly. Gait belts hang in every room, at the ready for nurses or aides to assist a patient in walking. Move and Groove, an exercise program set to music, is held twice a week to get patients out of their rooms.
Other ACE units have additional innovations—ice cream bars, pianos and karaoke machines to encourage patients to socialize and stay mentally engaged. San Francisco General’s ACE unit, built in part with private funds, is especially enviable. The unit is on the top floor, with a dining room in a solarium and a rooftop garden to break the isolation of a hospital stay.
When a patient is admitted to the ACE unit at UAB, nurses screen for cognitive impairment and the ability to perform daily tasks. “Being in the hospital is a stressful situation, and mild memory problems that may have gone undetected during an office visit or with the family can show up here,” says Brown. And discharge planning comes early. If the patient appears to have had trouble managing at home, a social worker and case manager immediately get to work lining up community resources, such as Meals on Wheels, in-home caregiving help, or referrals to adult day programs that help patients who have cognitive impairments or who are living alone to socialize and get exercise.
The real hallmark of ACE is an interdisciplinary team, which might include a geriatrician or hospitalist, plus a geriatric nurse specialist, pharmacist, geriatric social worker, case manager, nutritionist and physical therapist. Typically, the team will meet at least five times a week to discuss a care plan for each patient. A geriatric nurse may start with a rapid-fire rundown of who still has a urinary catheter, which patients are having bowel or bladder problems, who is not eating, and who seems excessively sleepy or confused. A pharmacist will chime in about paring down the number of a patient’s medications, reducing doses, or avoiding sedatives and hypnotic drugs for a patient who can’t sleep or is anxious. Controlling pain generally starts with ice or heat packs, massages, or topical agents; only when these aren’t effective will pain medicine be judiciously prescribed. Oxygen, cardiac monitoring or urinary catheters—tethers that can keep patients from getting out of bed—will be used only when clearly indicated. And patients normally won’t have their night’s sleep interrupted.
“It’s hard to overstate both how unusual and how powerful it is to have all of these disciplines talking face-to-face about the patient every day,” says Cumbler. The normal mode is for specialists to see patients independently and then page each other to talk about problems, or simply to leave written notes on the patients’ charts—a process that can lead to delays in preventing an infection or addressing the adverse effect of a medication. “When every medical discipline has an opportunity to be heard, it pays dividends to the patient,” says Cumbler.
ACE also reduces hospital costs. In a 2010 study, Flood and Brown demonstrated that ACE care resulted in savings of $371 per patient across the 25 most common diagnostic groups. “That may not sound like a lot, but when you multiply it by 1,500 patients a year, this 26-bed unit can save several hundred thousand dollars while delivering better care,” says Flood. In the same study, fewer ACE patients were readmitted within a month of discharge—7.9% versus 12.8% of the control group.
An analysis of 13 trials that compared care on ACE units to usual care of nearly 7,000 patients with an average age of 81 found that ACE patients had fewer falls, less frequent delirium, a 13% lower risk of functional decline during hospitalization, shorter stays, fewer discharges to a nursing home and lower costs.
THERE ARE MANY REASONS for a hospital not to create an ACE unit, including lack of space, the cost of physical modifications and the difficulty of holding space in reserve for older patients when the emergency department is full of people waiting for an open bed. Indeed, because many hospitals operate at full capacity, it’s not unusual to find younger patients in ACE. Geography also matters; most ACE units are in urban teaching hospitals, because that’s where geriatricians tend to work.
Yet those limitations haven’t stopped geriatricians and hospitalists from taking another tack, creating virtual or mobile ACEs. Fifteen years ago, Aurora Health Care, a 14-hospital system in Wisconsin, had ACE units at two of its hospitals but couldn’t afford to build more. And most of Aurora’s dozen geriatricians worked in its teaching hospital in Milwaukee, far from the rural hospital outposts that tended to have older patient populations. So Michael Malone, clinical adjunct professor at the University of Wisconsin School of Medicine and Public Health and medical director of Aurora Senior Services, developed an approach that lets patients in remote locations benefit from many of the protocols of a physical ACE unit.
At the heart of Aurora’s mobile ACE is the ACE Tracker, a computerized checklist that harvests information from each patient’s electronic medical record to identify those who are at risk for functional decline and poor outcomes. The hospital system already had an ACE-friendly infrastructure, with interdisciplinary teams of nurses, therapists and pharmacists who reviewed the care of at-risk elderly patients every day. “We just had to add geriatricians and the electronic health record tools, and then train and support our workforce,” says Malone. With ACE Tracker, the teams receive a one-page daily report for every patient 65 and older that focuses on the risks—of too many medications, for example, or problems with pressure ulcers—that any ACE team would monitor. And twice a week, an Aurora geriatrician joins each team’s rounds via teleconference. “We’re using technology to bring ACE concepts to older patients all over Wisconsin,” says Malone, who notes that 10 health systems in eight other states and in Canada have licensed ACE Tracker for their older patients.
Kellie Flood has taken a similar approach in seeking to provide ACE-like care to all frail patients on the 52 units of the 1,157-bed University of Alabama hospital—a quest that could extend many of the benefits of the small ACE unit, if not its physical characteristics. “We’re going from unit to unit and training staff to function as a mini-ACE to help any patients with mobility problems, cognitive issues or pain that makes them vulnerable, whether it’s a 55-year-old with a stroke or an 85-year-old with dementia,” says Flood.
Mount Sinai Hospital in New York, which closed its ACE unit after 10 years because of an overall shortage of beds at the hospital, now deploys a mobile ACE team consisting of a geriatrician, social worker, clinical nurse specialist and pharmacist to consult on complex geriatric patients, according to Martine Sanon, director of inpatient geriatric medicine clinical services. And in 2012, the hospital opened a 20-bed geriatric emergency department, one of approximately 150 in the country.
The goal in this and other geriatric emergency departments is to help keep patients from sliding downhill when they’re confronted with the disorienting chaos that prevails at most emergency departments. Older patients who arrive at the hospital may be directed to the geriatric section of the department. Instead of zeroing in only on a patient’s acute problem, a team of geriatric specialists also looks at the bigger picture. A pharmacist certified in geriatric pharmacy considers whether medications may be contributing to symptoms and guides emergency department physicians on prescribing appropriate drugs and doses. “Older adults are more sensitive to medications, so we start low and go slow,” says Sanon. A physical therapist assesses whether the patient can go home safely. And a geriatric social worker may step in to help make sure prescriptions are filled and doctors’ instructions followed, as well as to line up home health services to assist with preparing meals or arranging transportation for a patient’s follow-up appointments.
WHILE THERE’S LITTLE DISAGREEMENT that geriatric emergency departments and “acute care for elders” units can help protect vulnerable older patients, financial and other issues have so far prevented these and similar models from proliferating. But the John A. Hartford Foundation recently made a $3.19 million grant to the Institute for Healthcare Improvement and the American Hospital Association to establish what it calls Age-Friendly Health Systems at a fifth of U.S. hospitals and health systems by 2020. That system focuses on getting medications right, maintaining mobility, preventing or improving the treatment of cognitive problems (depression, dementia and delirium), and paying more attention to patients’ preferences. “A hospital doesn’t necessarily need an ACE unit if it implements all of these practices,” says Terry Fulmer, president of the foundation.
There’s also a need to figure out how to bolster older patients’ cognitive and physical functioning once they leave the hospital so they aren’t quickly readmitted. “One of the most dangerous points in a hospitalization is the day a patient goes home,” says Cumbler, whose current research examines the home therapy that older adults receive after a hospitalization. He says hospitals also need to do a better job of communicating with family members, whose support of an elderly patient is crucial to a successful recovery at home. “Families often feel out of the loop during a hospitalization but then are called upon to help the patient at home without preparation,” says Cumbler.
ACE pioneer Robert Palmer, director of the Glennan Center for Geriatrics and Gerontology at Eastern Virginia Medical School, in Norfolk, hopes that hospitals will soon stop thinking of geriatric patient-centered care as something extra but rather as a necessity—as excellent care. “Anyone hospitalized today is very sick,” he says, and so is at great risk of developing complications during hospitalization. “You can argue that ACE principles will benefit all acutely ill adult patients. That’s the idea that keeps us going.”
“Comparison of Posthospitalization Function and Community Mobility in Hospital Mobility Program and Usual Care Patients,” by Cynthia J. Brown et al., JAMA Internal Medicine, May 2016. This randomized trial confirms the importance of keeping hospitalized elderly patients ambulatory.
“Effectiveness of Acute Geriatric Unit Care Using Acute Care for Elders Components,” by Mary T. Fox et al., Journal of the American Geriatrics Society, December 2012. This meta-analysis of 13 trials and nearly 7,000 patients demonstrates the significant benefits of ACE care.
“Effect of a Modified Hospital Elder Life Program on Delirium and Length of Hospital Stay in Patients Undergoing Abdominal Surgery,” by Cheryl Chia-Hui Chen et al., JAMA Surgery, May 2017. This clinical trial demonstrates that a modified hospital elder life program may benefit older patients by reducing delirium incidence and length of hospital stay.
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