The Atlanta Journal-Constitution
Illness is bad; hospital stays may be worse
Ress from hospitalizations may be underlying reason for high rate of readmissions in older patients.
When she moved from Michigan to be near her daughter in Cary, North Carolina, Bernadine Lewandowski insisted on renting an apartment five minutes away.
Her daughter ,D ona Jones, would have welcomed her mother into her own home, but “she’s always been very independent,” Jones said.
Like most people in their 80s, Lewandowski contended with several chronic illnesses and took medication for osteoporosis, heart failure and pulmonary disease. Increasingly forgetful, she had been diagnosed with mild cognitive impairment. She used a cane for support as she walked around her apartment complex.
Still, “she was trucking along just fine,” said her geriatrician, Dr. Maureen Dale. “Minor health issues here and there, but she was taking good care of herself.”
But last September, Lewandowski entered a hospital after a compression fracture of her vertebra caused pain too intense to be managed at home. Over four days, she used nasal oxygen to help her breathe and received intravenous morphine for pain relief, later graduating to oxycodone tablets.
Even aft er her d ischarge, the stress and disruptions of hospitalization — interrupted sleep, weight loss, mild delirium, deconditioning caused by days in bed — left her disoriented and weakened, a vulnerable state some researchers call “post-hospital syndrome.”
They believe it underlies the stubbornly high rate of hospital readmissions among older patients. In 2016, about 18 percent of discharged Medicare beneficiaries returned to the hospital within 30 days, according to the federal Centers for Medicare and Medicaid Services.
Lewandowski, for example, was back within three weeks. She had developed a pulmonary embolism, a blood clot in her lungs, probably resulting from inactivity. The clot exacerbated her heart failure, causing fluid buildup in her lungs and increased swell- ing in her legs. She also suffered another compression fracture.
“These hospitalizations can lead to big life changes,” Dale said. Having grown too frail to live alone, Lewandowski, now 84,movedinw ith her daughter.
Dr. Harlan Krumholz, a cardiologist at Yale University, coined the phrase “post-hospital syndrome” in a New England Journal of Medicine article in 2013.
As Med icarebeganpen alizing hospitals for 30-day readmissions under the Affordable Care Act, he looked at the national data and noticed that most readmissions involved conditions seemingly unrelated to the initial diagnoses.
Patients came in with heart failure or pneumonia, were treated and discharged, then returned with internal bleeding or injuries from a fall.
“Our general approach in a hospital is, all hands on deck to deal with the problem people come in with,” Krumholz said. “All the other discomforts are seen as a minor inconvenience.”
He has argued instead that discharge marks the start of a 60to 90-day period of increased vulnerability to a range of other health problems, stemming from the stress of hospitalization itself.
“This is more than inconvenience,” he said. “This is toxic. It’s detrimental to people’s recovery.”
Any hospital patient, or hovering family member, knows those stresses: Disrupted sleep, as staff draw blood and take vital signs at 4a .m. A distorted sense of day and n ight.U nappetizing meals often
served at inopportune times.
Reduced muscle mass and poor balance following even a few days in bed. New prescriptions with unpredictable consequences. Shared rooms. Delirium. Pain.
“It affects your hormones, your metabolism, your immune system,” Krumholz said. “All these things have widespread effects,” leaving people depleted and less able to stave off other health threats.
The ripple effects vary considerably.
Researchers at Yale followed discharged Medicare patients after hospitalizations for heart failure, heart attacks and pneumonia.
Readmissions for gastrointestinal bleeding and anemia, they found, peaked four to 10 days after discharge. The risk of trauma from falls or other accidents, on the other hand, remained elevated for three to five weeks.
While post-hospital syndrome remains a hypothesis for now, research on several fronts may help establish its validity.
Making hospitals less destabilizing, more conducive to healing, seems an achievable goal. Hospitals do it for children, Krumholz has pointed out.
They could enable older patients, too, to wear their own clothes, get out of bed for walks (even with IV poles), eat enough to maintain their weight. They could assess how many lab tests patients actually need, and whether blood needs to be drawn before dawn.
“We should never wake a sleeping patient unless there’s a compelling reason, and that reason shouldn’t be our own convenience,” Krumholz said.
But while we’re waiting for hospitals to adopt such policies, we could try a DIY approach.
Families can bring in favorite foods and help their relatives eat. They can ensure that patients have their hearing aids, dentures, eyeglasses, and walkers or canes to help them stay oriented and mobile.
With a physician’s OK, they can accompany relatives on short strolls down the corridor to ward off deconditioning, and ask about curtailing wee-hour tests and readings.
“It’s unfair to put families in this position,” Krumholz said. “It should come from the institution.” But cultural change takes time.
Some hospitals already offer less stressful environments for older patients, including specialized geriatric emergency rooms.
Among those moving in that direction is the University of North Carolina Hospitals Hillsborough Campus, where Bernadine Lewandowski had a private room, as all its geriatrics patients do. She was helped into a chair every day and encouraged to use a walker to reach her bathroom.
The aftereffects proved profound, nonetheless. Already thin, she lost 15 pounds over two months. After her second hospitalization, she began wandering at night, apparently because of a new pain medication, and fell twice in two days. In April, she developed pneumonia, necessitating a third hospital stay.
She’s doing better now, her daughter said. After physical therapy, Lewandowski can climb the stairs, with someone at her elbow, to her second-floor room. Her weight has stabilized. She enjoys spending time with her family and visiting the hair salon every other week.
But, Jones said, “we were hoping she’d be with us for a short period and then return to her apartment.” And that never happened.