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Disease and treatment

New practices could prevent seniors from being unnecessarily hospitalized

Frail older people who are admitted to hospitals for acute care are often sent home again without being adequately assessed because their symptoms are unclear. This benefits neither seniors nor the public finances as a whole. New research shows that older people are five times more likely to be readmitted to hospital within 1 month and that they are hospitalized 13 times as long. Researchers suggest that new practices are needed.

If you are admitted acutely, a hospital assesses how rapidly you will be treated and by whom. Even an older person arriving at a hospital with an acute condition is often given lower priority based on severity. A new Danish study has shown that taking seniors more seriously is a very good idea.

“The current system neglects a very specific group of especially frail older people. Most have very non-specific symptoms. However, closer examination revealed that they average six types of prescribed medication, with one fifth taking an average of 12 types of medication,” explains Elizabeth Rosted, a nurse and the lead author of the study.

Six simple questions are enough

The researchers carried out their research in 2013 at Amager University Hospital in Copenhagen. For 14 days, they examined all the seniors admitted to the general medical ward or attending the Emergency Department. Every person older than 65 years was asked to complete an Identification of Seniors at Risk (ISAR) screening form with six simple questions to rate their health.

“ISAR is an internationally recognized screening tool that effectively determines whether an older person is frail. Our research showed that high ISAR scores were clearly associated with the risk of being readmitted to hospital within 1 month.”

This effect was especially clear for the seniors with both high ISAR scores and prescriptions for five or more medications. These people were five times more likely to be readmitted into hospital within 1 month and eight times more likely within 3 months.

“Since these frail seniors are 13 times more likely to be readmitted than other seniors, merely discharging them and sending them home place a severe and unnecessary burden on both the seniors and the finances of the healthcare system.”

New practices needed

Elizabeth Rosted believes that part of the problem is the massive work burden in emergency departments plus the current triage system: the tool personnel use to sort and set priorities among people presenting with acute illness based on assessing how serious their illness is.

Triage: A nurse or a doctor carries out triage on all patients arriving in the Emergency Department. Based on measurements and observations, this system determines how quickly an individual patient should be treated; what type of doctor should carry out treatment; and which initial examinations should be performed.

“This massive work burden means that the resources are not available to thoroughly assess seniors with non-specific symptoms and multiple health conditions. Older people are typically treated for the condition for which they were admitted, but this is the tip of the iceberg. The current triage system places gives low priority to frail seniors because their many and varied problems present a blurred picture with many non-specific symptoms.”

This new research therefore indicates that health personnel should examine the medicine taken when seniors present for acute care. If this is substantial, then ISAR should be used to determine whether a senior is at high risk.

“Older people at high risk should be thoroughly assessed to create a long-term treatment and medication plan for them. This should include follow-up by a geriatric team across specialties and collaboration with the patients’ general practitioners and possibly home care nursing with the goal of avoiding repeated readmissions and assessing whether their overall combination of medicine is necessary and appropriate. This will benefit both seniors and the healthcare system enormously,” concludes Elizabeth Rosted.

“Frailty and polypharmacy in elderly patients are associated with a high readmission risk” was published in the Danish Medical Journal. In 2014, the Novo Nordisk Foundation awarded Elizabeth Rosted a grant for clinical nursing research.

The Identification of Seniors at Risk (ISAR) method was developed in 1999 to identify especially frail seniors. The screening asks the following six questions.

1. Before the illness or injury that brought you to the emergency department, did you need someone to help you on a regular basis?

2. Since the illness or injury that brought you to the emergency department, have you needed more help than usual to take care of yourself?

3. Have you been hospitalized for one or more nights during the past 6 months (excluding a stay in the emergency department)?

4. In general, do you see well?

5. In general, do you have serious problems with your memory?

6. Do you take more than three different medications every day?

Elizabeth Emilie Rosted
Sygeplejerske, Postdoc