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The Acute Care Hospital and the Elderly. Introcluction Jeremiah A. Barondess . The entire effort of this forum addresses a real life spectrum, not only of degrees of illness and degrees of dependency, but also of social locus and sites of care. As you are ad aware, a number of forces are changing the fulcrum of that balance from the acute care hospital to the community and the venous sites of care In the community. For most sick people, and perhaps especially for the sick elderly, there is an ongoing, potential flux between the acute care hospital and the variety of sites of care in me community. Technologies are singularly important causes and energizers of that flux. The overall issues here are how to harness and rationalize me insertion or the withdrawal of those technologies and how to make them less dependent on the site of care. From the point of view of He acute care hospital, one could say that it is a locus in which medical technologies are concentrated; our interest is to maximize the effectiveness of the clinical use of those technologies. Subsumed in that term are, ~ would suggest, maximal appro- priateness in the selection and application of technologies in conical care, maximal coccal benefit, minimal risk, and appropriate cost. ~ would suggest furler that the algebraic sum of aU of that is optional patient outcomes with acceptable costs in time, patient discomfort, risk, doBars, social disruption, and so on. Of particular interest for purposes of the second part of this forum are the potential negative effects on health status, costs, and persistence of the acute care paradigm that all clinically applied technologies carry; our further interest is to examine the question of whether elderly patients are at particular risk of adverse effects in the acute care hospital and what can be done to define those and to minimize or obviate them. 77

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78 ]~1~ A. BAROND~S The literature in this area is surprisingly thin concerning the risks of hospitalization in general and conceiving the risks relative to old people in particular. Most of what we know relates to rawer global assessments of We risk of specific clinical procedures the risk of having a hernia repaired or a general anesthetic or getting a pulmonary embolus under a variety of circumstancesor of the administration of drugs. There are essentially no studies on Me negative effects of hospital rou- t~ne~putting people to bed or interrupting their fluid intake or regiment- ing their sleep-wake cycles at the convenience of hospital routine or sedating them for one or another purpose or restraining them low tech, one might say, but so broadly applied across such a large population that the net mass becomes very considerable in size and the aggregate risk potentially very large. Very few studies on hospital risks have been stratified by age, and even fewer have suggested procedural alterations that might be useful with special reference to older patients. A few things, however, have been examined. C3inical studies have shown, for example, that elderly patients are at increased risk of hospital-acquired kidney failure and, in particular, the risk of aminoglycoside-induced kidney injury increases very sharply with age Alp. Over studies have shown a heightened risk among older people of drug-induced illness leading to hospitalization and, further, that a significant portion of those admissions are related to or triggered by the use of over-the-counter drugs that are used more by old patients than by others; among those drugs especially aspirin, laxatives, and antacids have appeared as the chief inducers of drug-reaction-induced hospitalization (2~. The risks of intensive care units are also higher in old people, with a higher proportion requiring major interventions like mechanical ventila- tion and pulmonary artery catheters, and with higher death rates and higher cumulative mortality rates at the end of one year follow-up (31. In addition to expressions like theseof physiologic frailty, or, one might say, clinical frailty in the elderly, the importance of today's discussion is pointed out by Me fact that old people use acute care hospitals much more than anyone else, as everyone here knows. I-ooking for numbers, I found the following figures. In 1979, for acute care hospital days per year per 1,000 population, the rate was 1,224 days for all ages; for those age 65 to 74, 3,124 days per year per 1,000; and for those age 75 or older, 6,062 days per year per 1,000. Overall in- hospital mortality among old patients in one community hospital was 15 percent, and, perhaps more important, no elderly patient had, as a result of

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ACUTE CARE AND THE It nERLY: INTRODUCI7ON 79 an acute care hospitalization, an improvement in his or her prehospital level of care nee~no one (4~. In the second half of this forum, we want to focus on these and over impacts of acute care hospitalization on the elderly, considering technologies very broadly, and we want particularly to trier to isolate issues needing furler investigation, policy development, or clinical revision. REFERENCES I. Shusterman, N., Strom, B.~., Murray, T.G., et al. Risk factors and outcome of hospital-acquired acute renal failure. American loumal of Medicine 83:65, 1987. 2. Caranasos, Go., Stewart, R.B., and Cluff, L.E. Drug-induced illness leading to hospitalization. Joumal of Me American Medical Associa- lion 228:713, 1974. 3. Campion, E.W., Mulley, A.G., Goldstein, R.L., et al. Medical inten- sive care for the elderly. Joumal of the American Medical Associa- tion 246:2052, 1981. 4. Lamont, C.T., Sampson, S., Matthias, R., and Kane, R. The outcome of hospitalization for acute illness In the elderly. Journal of the American Geriatrics Society 31:282, 1983.