When Jan Ives, 87, was hospitalized with irritability and confusion after a fall in 2015, she was admitted to the Acute Care for the Elderly (ACE) unit at a local hospital, where she was diagnosed with broken spinal bones. When stabilized, the Houston resident was discharged to a skilled nursing facility because she lived alone and needed physical therapy. Feeling disoriented and confused at the new facility, and with minimal clinician oversight over the weekend, Ives hardly ate or slept, became dehydrated, and didn’t receive pain medication, recalls Beatrice Selwyn, Sc.D., her at-home caregiver, who is also an associate professor of epidemiology at The University of Texas Health Science Center at Houston (UTHealth) School of Public Health. Consequently, Ives was readmitted to a hospital.
Once hospitalized, Ives was diagnosed with hyponatremia — low sodium levels in her blood. When stabilized with treatment, she was discharged and received in-home care, physical therapy, and occupational therapy, and fully recovered, says Nahid J. Rianon, MBBS, DrPH, associate professor in the Division of Geriatric and Palliative Medicine at McGovern Medical School at UTHealth, geriatrician with UT Physicians Center for Healthy Aging, and Ives’ primary care physician.
Sometimes, as a result of a hospital stay, a patient may develop new medical conditions and end up returning to the hospital. Such was the case with Ives, not once, but twice. Coined “post-hospital syndrome” by Harlan Krumholz, MD, in his New England Medicine of Journal article in 2013 about this newly identified condition, the term refers to a period of vulnerability within 30 days after hospital discharge for developing new health problems that result in being readmitted. Patients may experience physiological and behavioral changes when hospitalized, which can contribute to post-hospital syndrome.
Ives’ second bout with post-hospital syndrome occurred in 2017. She was initially hospitalized after vomiting and having a seizure. Once again, she had hyponatremia, Selwyn recalls. When her sodium level was stabilized with treatment, she was discharged home, but felt dizzy and tired, and had frequent urination and constipation. When she experienced back and neck pain as well as vomiting, Ives was readmitted to the hospital.
“Most likely post-hospital syndrome occurred because she was discharged too soon,” Rianon says. “She still had constipation and didn’t have proper home health care set up.”
Ives was diagnosed with a urinary tract infection, very low sodium, and constipation. When the infection was treated, her sodium level normalized and her bowel cleared. She was discharged and received care at home.
Rianon provides a closer look at what changes can occur in the hospital, which can lead to post-hospital syndrome.
Decreased muscle strength and bone loss. When bedridden, patients age 65 and older can lose up to 5 percent of their muscle strength each day. This can lead to decreased mobility, increasing the risk for falls.
Poorer lung function. Respiratory muscles can weaken when a patient doesn’t move much and lies flat in bed for a time, lowering oxygen levels and causing shortness of breath.
Reduced appetite. Hospitalized patients typically don’t finish more than half of their food, due to the food’s taste, their medical condition or medication, dietary restrictions, having to fast for an upcoming test or procedure, or feeling depressed. Nutrition is important for healing; poor nutrition can cause decreased muscle strength and low sugar levels, resulting in falls and poor cognitive function.
Difficulty swallowing. Decreased muscle strength and cognitive function can result in challenges with swallowing. Dementia patients are at an even greater risk. Consequently, these patients may need a liquid or soft diet, which usually isn’t appetizing, or may need tube feeding.
Confusion. When a patient is in a dark room and sleeps throughout the day, they can lose track of what is going on in the outside world. They may forget what time and day it is. Having pain and being in a strange place with lots of new faces adds to confusion.
Constipation and urinary incontinence. This can result from immobility, poor nutrition, additional medications, and becoming disoriented.
Post-hospital syndrome is more common in patients who are 65 and older, have dementia, or are frail, because they are most susceptible to having their abilities decline when hospitalized. Individuals who take at least five medications are also at greater risk, due to drug interactions and medication side effects.
Because the number of Americans age 65 and older is increasing, more patients are experiencing this syndrome. Due to a rise in incidents, more physicians, such as hospitalists —doctors who oversee a patient’s care when hospitalized, and geriatricians — doctors who care for older patients — are becoming more aware of it, are researching it, and are discussing ways to prevent and deal with it. “We need to find a way to prevent this syndrome by addressing the factors that cause it,” Rianon says.
Preventing post-hospital syndrome
Hospital staffs are taking steps to decrease incidents of this condition. Rianon says elderly patients, if possible, should seek treatment at hospitals with an ACE unit, where patients are usually managed by geriatricians with inputs from an interdisciplinary team. In an ACE unit, she says patients’ rooms are equipped with a large clock in front of the bed and a white board containing information to help keep them oriented such as the name of their physician and nurse, and contact information for family members. All rooms have large windows; blinds are opened during the day to orient patients to day and night.
Interdisciplinary team meetings run by geriatricians include nurses, caseworkers, home health workers, social workers, pharmacists, occupational therapists, physical therapists, and nutritionists who coordinate patient care. “We come together to discuss each patient on the floor, what each of us is doing for the patient, what should be done, what can be prevented, and what risks we can address related to discharge or post-discharge,” Rianon says. “Then, we address them accordingly.”
When a patient is first admitted, discussions with the patient and caregivers about where the patient will go after discharge already begin. “It’s important to plan for a good transition of care and try to prevent factors from happening while they’re in hospital, so there’s less risk of post-hospital syndrome,” Rianon says. “We assess whether a change in living conditions might be warranted.”
In the ACE unit, nurses check in with patients every one to two hours to see if they would like to get up or use the restroom, to help them maintain mobility. Patients can improve their muscle strength and mobility with physical and occupational therapy.
A nutritionist discusses each case with the geriatrician to determine a patient’s nutritional needs, and informs patients and their caregivers of what’s needed.
How caregivers can help
Educating caregivers about post-hospital syndrome, including why it occurs and how to prevent it, are key steps to avoiding it. “We tell caregivers what to expect based on a patient’s diagnosis, expected length of stay, and possible hazards during hospitalization,” Rianon says. “A caregiver can help determine if a patient can go home afterward, or go to another facility such as a nursing home, skilled nursing facility, or long-term acute care.”
Care team members will also teach loved ones how to care for a patient after discharge. For example, if a patient will need tube feeding at home, a nurse or nutritionist will teach the caregiver how to do that. If a patient has an infection and is taking antibiotics, a caregiver should be taught to recognize signs that the infection is worsening, such as getting a fever. If a patient is taking a new medication, caregivers should know what side effects might occur. “Caregivers should look for signs that something might be wrong with a discharged patient, such as the patient is falling, not following directions, is unable to communicate, or not eating, and inform their primary care physician,” Rianon says.
Ideally, a patient’s hospitalist will provide a discharge summary to the patient’s primary care physician after they leave the hospital about the patient’s condition and discharge plan. A patient or caregiver can request that the hospitalist call or write to the primary care doctor. Patients should follow-up with their primary care physician after leaving the hospital. “This can help to prevent gaps in care,” Rianon explains.
If a patient ends up being readmitted, it’s helpful for caregivers to provide care team members with details on what led to the patient’s decline. “Part of my job is to find out what went wrong,” Rianon says. “Caregivers should be open about the patient’s home situation and ask for help as needed.”