Geriatrics update 2018: Challenges in mental health, mobility, and postdischarge care
ABSTRACT
A review of articles on geriatric topics from 2017 and 2018 revealed evidence supporting exercise for the elderly, early mobility for hospitalized patients, and oral anticoagulant therapy for atrial fibrillation to support cognitive function, and evidence against antipsychotic drugs for dementia-associated behaviors. No silver bullet was found for Alzheimer prevention or therapy.
KEY POINTS
- Oral anticoagulant treatment for atrial fibrillation helps preserve cognitive function.
- Antipsychotics are not recommended as initial therapy for dementia-associated behavioral disturbances or for hospitalization-induced delirium.
- A multicomponent inpatient program can help prevent postoperative delirium in hospitalized patients.
- The US Preventive Services Task Force recommends exercise to prevent falls.
- Early mobility should be encouraged for hospitalized patients.
- Better continuity of care between hospitals and skilled nursing facilities can reduce hospital readmission rates.
EXERCISE, EXERCISE, EXERCISE
Exercise recommended, but not vitamin D, to prevent falls
In 2018, the US Preventive Services Task Force updated its recommendations for preventing falls in community-dwelling older adults.32 Based on the findings of several trials, the task force recommends exercise interventions for adults age 65 and older who are at increased risk for falls. Gait, balance, and functional training were studied in 17 trials, resistance training in 13, flexibility in 8, endurance training in 5, and tai chi in 3, with 5 studies including general physical activity. Exercise interventions most commonly took place for 3 sessions per week for 12 months (range 2–42 months).
The task force also recommends against vitamin D supplementation for fall prevention in community-dwelling adults age 65 or older who are not known to have osteoporosis or vitamin D deficiency.
Early mobilization helps inpatients
Hospitalized older adults usually spend most of their time in bed. Forty-five previously ambulatory patients (age ≥ 65 without dementia or delirium) in a Veterans Affairs hospital were monitored with wireless accelerometers and were found to spend, on average, 83% of the measured hospital stay in bed. Standing or walking time ranged from 0.2% to 21%, with a median of only 3% (43 minutes a day).33
Since falls with injury became a Centers for Medicare and Medicaid Services nonreimbursable hospital-acquired condition, tension has arisen between promoting mobility and preventing falls.34 Two studies evaluating the adoption of mobility-restricting approaches such as bed-alarms, “fall-alert” signs, supervision of patients in the bathroom, and ensuring patients’ walking aids are within reach, did not find a significant reduction in falls or fall-related injuries.35,36
A clinically significant loss of community mobility is common after hospitalization in older adults.37 Older adults who developed mobility impairment during hospitalization had a higher risk of death in a large, retrospective study.38 A large Canadian multisite intervention trial39 that promoted early mobilization in older patients who were admitted to general medical wards resulted in increased mobilization and significantly shorter hospital stays.
POSTHOSPITAL CARE NEEDS IMPROVEMENT
After hospitalization, older adults who have difficulty with activities of daily living or complex medical needs often require continued care.
About 20% of hospitalized Medicare beneficiaries in the United States are discharged to skilled nursing facilities.40 This is often a stressful transition, and most people have little guidance on selecting a facility and simply choose one based on its proximity to home.41
A program of frequent visits by hospital-employed physicians and advanced practice professionals at skilled nursing facilities resulted in a significantly lower 30-day readmission rate compared with nonparticipating skilled nursing facilities in the same geographic area.42
Home healthcare is recommended after hospital discharge at a rapidly increasing rate. Overall referral rates increased from 8.6% to 14.1% between 2001 and 2012, and from 14.3% to 24.0% for patients with heart failure.43 A qualitative study of home healthcare nurses found a need for improved care coordination between home healthcare agencies and discharging hospitals, including defining accountability for orders and enhancing communication.44
