The hospital as hell

Taureef Mohammed

IT MAY sound crazy, but it is the reality for many older adults who get admitted to the hospital. Of course, the hospital is a paradise for nobody – it is a place of life crises. For an older patient, though, the hospital seems like a different kind of trial.

An older man, months after he was discharged from a hospital, could no longer sleep on a bed following his hospital admission – he opted for the couch. Sleeping on a bed, his family suggested, reminded him of his hospital stay: being strapped down to a bed at five points – two wrists, two ankles and the waist – in a delirious state.

I remember another older patient who I first saw in hospital. Six months after he was discharged, I saw him again at home. The contrast was compelling: the patient in the hospital and the person at home were different people. He described his hospital stay – which included a course of delirium – vividly. I got the title of this column from his description.

But the patient who stands out the most in my memory was a man whose death I had read about in the newspaper. My memory of the patient – a horrible one of a delirious, frail, old man strapped to a hospital bed – was incongruent with the newspaper story of the accomplished man. He was well-known in society. He had left a legacy. The newspaper story restored my patient’s humanity.

Why was his humanity lost in the first place? Was it a problem with how I practised medicine? Was it the nature of acute medicine? Was it a problem with the hospital itself, the environment, the system?

Over the last year, since starting geriatric medicine, I have found myself more often in this conundrum. Older people were the ones who, not uncommonly, ended up in such undignified situations. It was a sad reality.

The adult hospital, in its most basic form, was never designed to treat older people. Historically, patients – who were usually young – were admitted for an acute problem, treated and discharged. The hospital in its most basic form was meant to operate like a conveyor belt. Perhaps, in the mid 1900s, when life expectancy was less than 60 years old, this was a reasonable design. Younger patients were more likely to have single-system diseases, and, if an effective treatment was available, more likely to keep up with the conveyor belt.

But people are now living longer. In 2021, life expectancy in the Americas was 74.2 years, according to Our World in Data. As people age, their risk of getting multiple co-morbidities that negatively impact physical and cognitive health increases. Therefore, when an older person gets an acute illness, say pneumonia, his/her trajectory is different from an otherwise healthy 40-year-old with pneumonia. However, in many hospitals, they end up on the same conveyor belt.

In any adult hospital, older people account for a large proportion of the patient population. In a typical acute medical ward, the majority of patients are usually older, defined in most places as more than 65 years old. In Ontario, 43 to 73 per cent of inpatient days are accounted for by older patients. (An inpatient day is a unit of measurement used to quantify the usage of acute hospital beds.)

Many studies have shown how poorly older patients do in a hospital setting. Compared to younger adult patients, older patients had higher rates of delirium, falls, pressure ulcers, malnutrition, functional decline, longer hospital stays, and were more likely to require institutionalisation or supported living following discharge.

But forget the statistics and research. One simply has to spend some time on an adult hospital ward to see that something is not right.

Anxious families worry that their older relatives are being discharged too early.

Why are you all pushing him out?

We are not. It’s the system. The conveyor belt!

The patient census is always through the roof. An older man gets admitted for pneumonia. Before you know it, owing to excessive bed rest and decreased mobility, the patient loses physical function. The pneumonia is cured, but the patient is now functionally worse. He remains in hospital for a prolonged period of time. And repeat. The hospital becomes gridlocked; healthcare workers face burnout.

And the older patients? What you will see, not infrequently, on an acute hospital ward are people stripped of their humanity.

The model is broken and needs fixing – STAT.

Taureef Mohammed is a graduate of UWI and a geriatric medicine fellow at Western University, Canada