Abington Hospital's Acute Care for Elders' unit offers 'prehab'

Mary Hofmann, chief of geriatric medicine at Abington Memorial, visits with Dorothy Gamble in the new unit designed for able people aged 70 and older. RON TARVER / Staff Photographer
Mary Hofmann, chief of geriatric medicine at Abington Memorial, visits with Dorothy Gamble in the new unit designed for able people aged 70 and older. RON TARVER / Staff Photographer
Posted: July 03, 2012

Kim Shields, a nurse, and Mary Hofmann, a doctor, like to think of Abington Memorial Hospital's new Older Adult Specialty Unit as "prehab."

The 21-bed unit, which opened in mid-June, is meant to prevent complications that often befall the elderly when they are hospitalized.

"What we're doing is promoting wellness in the midst of their illness," Shields, who is clinical director of the geriatric service line at Abington, said during a tour of the unit.

Too often, hospitals can cure an older woman's pneumonia, for example, but she goes home weaker and is never the same again.

"We don't want to hear that," said Hofmann, the hospital's chief of geriatric medicine.

While other hospitals have created special programs for their frailest elderly patients, Hofmann said Abington's approach is unusual. It focuses on people 70 and older who can still walk and are in pretty good mental shape, with the goal of keeping them that way.

So that they don't get weaker, more confused, or depressed, patients are expected to walk in the halls three times a day and will be strongly encouraged to participate in group recreational activities and meals. "The medical literature will say that there is almost no reason for bed rest," Hofmann explained.

To prevent falls, the physical design compensates for failing eyesight and spatial skills.

The floors are purposely less shiny because older people find glare disorienting. While most of the hospital is decorated in blues and greens, the palette in the new unit is from the yellow end of the spectrum. Older eyes see those colors better. Letters on signs are twice the usual size. Trim along the floor and door frames is dark gray to make boundaries easy to see.

The primary goal is to keep patients healthy and independent longer. And word-of-mouth from happy patients and families could attract more patients, Hofmann said.

But, in an age when insurers demand efficiency and penalize hospitals if patients get certain infections or bedsores, this approach could also have financial benefits. New Medicare rules, cutting hospital pay when patients need to be readmitted, are coming.

University Hospitals Case Medical Center in Cleveland pioneered the idea of a special unit focused on maintaining functional abilities of elderly patients in the early 1990s. Such Acute Care for Elders, or ACE units, have since spread to about 200 hospitals. Among those are Penn Presbyterian and Crozer-Chester medical centers.

Many hospitals, including Abington, also participate in other programs designed to improve the care of elderly patients.

"The new thing to have is a geriatric-sensitive emergency room," said Denise Kresevic, a geriatric clinical nurse specialist who helped found the first ACE unit in Cleveland.

At Abington, patients 65 and older make up 41 percent of admissions and, because they stay longer than younger patients, are half of the patients on any given day.

Lying in a hospital bed can be terrible for older people. It takes three days for them to regain the strength they lose spending one day in bed, Hofmann said. It's easy for doctors to focus on treating whatever brought the patient in — maybe pneumonia or heart failure — and forget that they also need to maintain physical functioning. That's why all the patients on the new unit are expected to walk every day and eat sitting up.

It's also important to maintain mental equilibrium. Older people who seem fine in their familiar environment can get unhinged when their routines are disrupted.

Seventy-five to 80 percent of people over age 70 suffer from delirium in the Intensive Care Unit, Kresevic said. It affects 50 to 60 percent of older orthopedic patients and 20 to 30 percent of older patients overall.

Some hospitals have now started screening all older patients for delirium. To prevent or mitigate it, they steer away from some pain drugs and let older patients sleep through the night. Nurses make sure patients are wearing their glasses and hearing aids.

Delirium causes the body to release chemicals that can be dangerous. "It can be a medical emergency," Hofmann said.

Abington's unit has social activities to keep patients more mentally engaged and prevent depression. Patients are encouraged to eat lunch together in a sunny open space and participate in quiet games twice a day.

During a recent visit, a 90-year-old patient got 50 points for remembering the first words of the Gettysburg Address. Her fellow patient Norman Lies, 72, of Hatboro remembered that Camp David was named after Dwight Eisenhower's grandson. Everybody had trouble remembering the presidents who came before the younger George Bush. Later, they and some volunteers and staffers listed words they could make from the letters in the word grandparents.

Dorothy T. Gamble, 83, of Rydal Park was in for breathing trouble. She praised the unit, but said she wasn't up for activities or a group lunch. She'd been through a stressful period at home and wanted quiet. She'd been transferred from another unit where she had not been out of bed for several days. She'd walked from her bed in the new unit to the nurses station that morning.

Hofmann said most ACE units cater to frail patients with dementia, but the recreational activities and communal meals Abington offers are not typically included.

Peter DeGolia, a physician who directs the geriatric medicine program at University Hospitals, said doctors there now have a mobile ACE team. Demand for rooms is too great, he said, to hold beds open for patients who meet certain criteria, such as the ambulatory elderly. He wondered whether healthier older people would stay in the hospital long enough to benefit from the recreation and social meals that some ACE units offer.

John Bruza, medical director of Penn Presbyterian's ACE unit, said some hospitals had closed their units for elderly patients. "It's a complicated issue," he said. "As much as there's a big need for them, they're expensive to kind of maintain, and hospitals have competing programs."

Contact Stacey Burling at 215-854-4944 or sburling@phillynews.com.

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