Booming demographic: caring for the growing population of older adults
Interviews with three health-care professionals
Click here to read the interviews below with:
- Laurie Gould, Chief Clinical & Transformation Officer at LHSC
- Dr. Monidipa Dasgupta, Geriatrician at LHSC
- Laurie McKellar, Nurse Practitioner, Acute Care of the Elderly Unit at LHSC
Like many countries around the globe, Canada has an aging population with more Canadians living longer. The first wave of baby boomers turned 65 in 2011, representing about 15 per cent of the population. When the last of the baby boomers reach 65 by 2031 they’ll make up close to 25 per cent of Canadians. Putting that into numbers, the population of seniors will double between 2009 and 2036 from about 5 million to more than 10 million.
One of the most pressing imperatives of our time is the growing health-care needs of Canada’s older adults. With the rising demographic of older adults there is an ever increasing need for care both in the community and in health-care facilities. The demand for home care and for long-term care will increase. Seniors need access to coordinated, integrated, and affordable care.
So what does this mean to acute care hospitals such as London Health Sciences Centre? How are hospitals preparing for the aging of Canadians? Learn more as we speak to a geriatrician, a nurse practitioner who specializes in geriatric care, and a senior vice president of clinical care.
Q: What are the challenges facing hospitals with the growing demographic of seniors?
The reality for older patients who no longer need acute care is that they are better served outside the hospital setting. The longer older adults stay in hospital, the more vulnerable they become to hospital acquired infection due to a weakened immune system, to depression and delirium, and to issues related to reduced mobility such as falls while in hospital.
One of the biggest challenges facing acute care hospitals such as LHSC is the inability to discharge patients who no longer need acute care in a timely manner. Often this is because the required next level of care is not available at that time.
So the impact to patients who need an alternative level of care is significant. For hospitals this also impacts our ability to admit patients in need of acute care.
Q: What systems issues are emerging?
In addition to what I’ve mentioned above, there are gaps in community based care such as long-term care for example, which also impact hospitals. Such is the case of older adults with dementia who have severe behavioural issues. Long-term-care homes do not always have the appropriate level of staffing to care for these adults and so they are referred to hospital where they will experience long waits until an appropriate level of care is available in the community.
While the patients do not have acute care needs, there is not enough capacity in the current health system to care for them. Whereas the patient, despite behavioural issues, would benefit from the long-term care environment because of the recreational and social aspects of the care provided.
In acute care we want to ensure that patients are safe and are receiving the right care, in the most appropriate setting. This means that LHSC works proactively to identify patients at risk for falls, or those who may need alternative levels of care. LHSC will often assess patients in the emergency department for their care needs and work with community providers such as home care to prevent an admission to the hospital. This does not occur with every patient and more could be done from a systems perspective to ensure that patients receive the best care in the right setting, at the right time.
Q: What are some of the solutions being explored by LHSC and system wide?
LHSC works with its partners in the region and across the health-care system on a number of initiatives. In Ontario there is the Home First program, where the focus is on discharging elderly patients home from hospital and not looking to a long-term-care home as the only option. The goal of Home First is to provide patients with an appropriate level of care in their own home with services such as nursing and personal support through the community care access centres, community support such as adult day programs, and convalescent care beds. However, we need more of these innovative service models given the growing, aging population in London and surrounding areas.
Another is the Senior Friendly Hospital Strategy, a province-wide initiative being rolled out by the Local Health Integration Networks (LHINs). The Senior Friendly Hospital initiative is aimed at frail older adults, with a goal to maintain optimal health and function while they are in hospital so they can successfully transition home or to a more appropriate facility. Here at LHSC we are in the beginning stages of assessing and implementing the framework for this initiative.
LHSC specific solutions that we have implemented include a specialized Acute Care for the Elderly (ACE) unit. The ACE unit team cares for older patients who have, in addition to their complex medical needs, delirium, depression or dementia.
We also have a number of services geared specifically to the emotional and physical needs of older adults. These include putting together a behavioural response team in geriatric mental health and, in the case of physically vulnerable patients, a program to keep patients mobile and active, which is an important component of hospital care.
One thing is certain, this is a complex issue. With the rising demographic of older adults, and the corresponding increase in health care required, aging patients are in need of coordinated, integrated care. This is everyone’s challenge within health care.
Q: What are the unique challenges of providing care to aging adults?
There are a number of challenges to providing care to older adults. Aging adults don’t necessarily bounce back quickly after treatment of an acute illness and take longer to recover. The hospital environment however is meant for treating acute illnesses, and is ill-equipped to manage the longer recovery phase of an illness.
Older people are very sensitive to the adverse effects of being in bed. They may have poor mobility to start with and being in bed for any extended period of time can be even more detrimental to their health. Other disabilities are also prevalent that can make the hospital environment challenging. For example, communication can be difficult because of hearing impairment, and visual impairment can result in disorientation and an inability to maneuver within the environment. Cognitive problems become increasingly prevalent with aging, and this too can make the hospital environment particularly difficult.
Even without these factors, older people may have certain routines that are different from expectations in hospital. For example, the hospital caregiver may request the patient has assistance while they walk in order to prevent a fall. However, the patient has traditionally been comfortable walking on their own and does not place as much importance on having assistance for walking. Alternatively, for a patient who has already struggled with walking and perhaps has fallen at home, the fear of falling may result in a reluctance to walk.
Q: With more people living longer, are you seeing any changes in how patients are aging?
As I provide care in an acute care hospital, the patients I see are very ill; as such, I may have a biased view of seniors. People are living longer and this is accompanied by increasing co-morbidity, which is another way of saying they are more likely to have more than one disease at the same time. This is evident in the hospital environment, where multiple illnesses are more often the norm. In addition, geriatric syndromes such as immobility, confusion, pressure sores and functional decline, are becoming increasingly prevalent as people live longer.
Q: What are the greatest changes in the care requirements for older patients in an acute care setting?
Older adults may have certain routines which can help guide them when they are in their home setting. The acute care setting disrupts these routines. Whereas a visually impaired older adult or one with cognitive impairment can adjust to his/her own familiar home environment, this becomes increasingly difficult in the acute care setting. The acute care setting in many ways can promote dependence on others. Seniors who struggle in their own home come to depend on the extra assistance provided in hospital. In addition, older patients do have an increased risk of losing their functional abilities – for example, walking or having difficulties tending to personal hygiene. In fact, hospitalization is one of the biggest risk factors for losing functional abilities in seniors who live in their own homes. What can happen is a senior discharged from hospital is less able to care for themselves than they were two weeks prior to hospitalization, thereby needing increased care. Mobility impairments and increased falls risk are especially prevalent immediately after a hospital stay.
Q: What is the single most important change we can make?
Thinking about the functional and psychosocial needs from the moment patients are admitted, and thinking about how to optimize these aspects of health from the beginning may be beneficial. Long after the acute medical condition is treated, the hospitalized senior may still not be able to return home, and this may reflect the non-medical aspects of care. Therefore there should be greater focus on these aspects of health.
Q: What are the unique challenges of providing care to aging adults?
Caring for an older adult can be complex because the patient often has several health issues and is on multiple medications. The acute illness for which the patient is in hospital may be a symptom of other health issues that also need to be addressed for the person to recover.
For example, a man comes to hospital with a broken hip after a fall. The fall occurred because he forgot to use his walker and to take his medications. He has a delirium (acute confusion) due to a urine infection which developed because of urine retention caused by constipation. The constipation developed because he forgot to take his bowel medications as he has an undiagnosed dementia. So, the root cause of the acute medical issue that brought him to hospital can be challenging to determine because all the information may not be readily available.
Perhaps the greatest challenge in providing care for older adults in hospital is preventing physical decline and delirium while the older patient is recovering from their acute illness. This is important as delirium and functional decline can increase the length of stay in hospital and decrease the patient’s ability to return to the previous level of independence prior to becoming ill.
Q: What are some of the best programs/initiatives for older patients here at LHSC?
There are several. I will mention a few of them. The MOVE-ON initiative, being done on several inpatient units, is about keeping elderly patients moving in order to maintain their mobility so that they can be as independent as possible at discharge. Initiatives for delirium are in place on several inpatient units to optimize assessment and management of delirium.
A Geriatric Emergency Medicine (GEM) nurse in the Emergency Departments (ED) follows up on those older people identified as high risk for admission to hospital, admission to nursing home, or revisiting the ED.
The Geriatric Consult-Liaison team (geriatricians, psychiatrists, nurse practitioners and medical residents) makes recommendations about geriatric medical and/or psychiatric issues of inpatients when requested by the attending physician.
The Geriatric Mental Health Program has two teams for the elderly - the Mental Health Team provides care in a clinic or at home for people with mental health issues and the Behavioural Response Team provides crisis intervention to families and long-term care facilities to manage behavior.
Q: What can we do to prepare for the increasing number of older adults in an acute care hospital setting?
From my perspective, we need to build on all the excellent elder care initiatives that are already occurring at LHSC to create and implement an interprofessional, multifaceted, comprehensive and sustainable corporate strategic plan to ensure that LHSC is an elder-friendly hospital for older inpatients, outpatients, their families and visitors.
I believe that the creation of an interprofessional team of people with geriatric expertise at LHSC is important to develop and implement corporate processes to consistently enhance elder care with a focus on both prevention and intervention strategies for common geriatric issues.
Hospital and community health-care providers need to encourage older adults and their significant others to discuss their wishes about future health and personal care choices (Advance Care Planning). These discussions will greatly help prepare for and guide decision making whenever the older person is not able to make decisions about health or personal care.