Kira Scheerman

Older adults account for a large proportion of all hospital admissions and this will further rise. A hospital admission is a critical event for older adults. Hospitalized older adults are vulnerable making them prone for negative health outcomes after hospitalization, like loss of functional abilities. In response, comprehensive “senior-friendly hospital” (SFH)-programs aiming to improve hospital care were developed, however, it is unclear how effective these programs are. Sarcopenia or poor muscle status, in this thesis defined as low muscle strength and muscle mass, is highly prevalent in hospitalized older adults and associated with negative health outcomes, like readmissions. It is unknown if muscle strength and mass further deteriorate during and after hospitalization. Physical inactivity is an important determinant of sarcopenia. Routines of activities of daily living (ADL) and physical activity levels are disrupted during hospitalization resulting in hospitalized older adults being physically inactive, spending approximately 80% of the day in bed. Physical activity in hospitalized older adults is not routinely promoted by health care professionals and is challenging since it requires knowledge, and attitude and behavioral changes in patients and health care professionals. The aim of this thesis was to evaluate how care for hospitalized older adults can be improved focusing on 1) SFH-programs, their elements and effectiveness in improving care, 2) associations between poor muscle status and higher risks for negative health outcomes, and 3) aspects of physical activity promotion in older adults during hospitalization.

In chapter 2, an overview was provided of ten SFH-programs which were defined as a hospital-wide, i.e., applicable to all hospital wards, multilevel, i.e., affecting various levels in the organization, and multi-element approach, and were introduced in various countries between 1990-2017. Common mutual elements of SFH-programs were: ‘organizational support’, ‘social climate and services’, ‘processes of care’ and ‘physical environment’. Elements of SFH-programs, like comprehensive geriatric assessment, interdisciplinary care, and clinical standards for common geriatric conditions, may improve care for hospitalized older adults, however, little was published on the effect of such programs on quality of care and patient satisfaction.

Poor muscle status in hospitalized older adults is associated with negative health outcome. Probable sarcopenia and sarcopenia according to the EWGSOP-II definition were highly prevalent in an observational, prospective, longitudinal inception cohort study of hospitalized older adults aged 70 years and older (EMPOWER cohort), and predicted long-term mortality during a follow-up of 3.4-4.1 years (chapter 3). Low muscle strength and muscle mass in hospitalized older adults at admission were associated with being at risk of a higher cumulative number of geriatric conditions, i.e., delirium, falls, malnutrition, and ADL-dependency (chapter 4). Our systematic review and meta-analysis showed that muscle strength and muscle mass decreased significantly in electively admitted older adults during hospitalization, but not in acutely admitted older adults (chapter 5). This was also seen in the EMPOWER study where no negative impact on muscle strength and mass was observed during hospitalization in a cohort of mainly acutely hospitalized older adults (chapter 4).

Our systematic review showed that evidence for the effect of physical interventions during hospitalization, for instance exercise programs, on lower risks for negative health outcome is inconclusive (chapter 6). However, considering the detrimental effects of physical inactivity in older adults during hospitalization, it remains important to pay attention to increasing general levels of physical activity during hospital stay. Important aspects to promote physical activity during hospitalization identified in this thesis are that 1) it takes a multidisciplinary approach, including nurses, physicians, physiotherapist, patients, and carers, with clear description of roles and responsibilities, and 2) barriers and enablers influencing physical activity promotion should be acknowledged to facilitate hospital staff and patients (chapter 7 and 8). In a mixed method sequential explanatory study, nurses stated to be influenced mostly by low patient motivation, priority shifts due to high workload and the role of physicians (chapter 7). In our mixed method study in hospitalized older adults aged 70 years and older (chapter 8) was shown that focus on physical barriers and motivational enablers for hospitalized older adults might help to increase physical activity during hospitalization, and that encouragement by health care professionals should also encompass physically independent patients.

The high use of hospital care by older adults and the higher risks for negative health outcomes emphasize the need for “senior-friendly” hospital care. In general, increased awareness is necessary of the needs of hospitalized older adults, and the negative effects of sarcopenia and physical inactivity, in hospital management, health care professionals and patients. Thereby, the general approach needs to change away from ‘lying in the hospital’ being the standard, towards physical activity being routinely promoted and older adults being physically active on a regular basis. Hospitalized older adults are a heterogeneous group of patients with, for example, varying admission diagnoses, conditions, and capabilities regarding physical activity, which means that the ‘one size fits all’ principle might not suffice and also a more tailored approach is required to improve care for this patient population. In addition, the hospital admission is part of a care trajectory, and is relatively short. This underlines the need for identifying patients at risk for negative health outcomes followed by tailored interventions in collaboration with other health care services.

In conclusion, improving care for hospitalized older adults requires an integrated approach. Next to a general approach to increase awareness and physical activity promotion within the hospital, it is of importance to focus on a more tailored approach in implementing “senior-friendly” care which requires effort in identifying the right patients for the right interventions at the right time.