Making healthcare environments safer for seniors

It's an inevitable part of aging. By age 75, our eyes respond more slowly to the glaring lights of a hospital. We perceive the shiny, well-buffed floors as slippery, causing missteps and falls.

Our skin is thinner, making us more vulnerable to pressure sores from rock-hard mattresses. We chill more easily. The noise from monitors and other gadgets in an acute-care room or emergency department can interfere with our ability to communicate with medical staff.

As a result, older patients may find they are navigating a minefield in hospitals and other medical facilities that have been designed to be friendly to healthcare workers but not seniors.

“The hospital can be a hazardous place for anyone, but particularly for the elderly,” said Dr. Diana Anderson, a trained architect who is completing her internal medicine residency at New York-Presbyterian Hospital. “Hospitalization is one of the major risk factors for older people. We can end up seeing irreversible decline in their functional status after they're admitted. This decline cannot always be attributed to a progression of their presenting medical problem.”

Anderson, who plans to enter a geriatrics fellowship this year, has coined and trademarked the term “dochitect,” for the type of medicine she hopes to practice. She is the rare person who combines medical knowledge with know-how about how to design health facilities. She sees a need to use this combination of expertise to make healthcare environments safer and more comfortable for the elderly.

The U.S. Census Bureau has estimated that the population over age 65 will increase 75% from today's levels by 2029, when the last of the 76 million baby boomers reach retirement age. Medical facilities, from hospitals to medical offices, are gradually beginning to respond to the needs of this growing population.

Nurses Improving Care for Healthsystem Elders (NICHE), a project that promotes better care for older adult patients by improving nursing practice, has recognized more than 500 senior-friendly hospitals and 100 skilled-nursing facilities for their senior-friendly programs and physical environments. Geriatric nurse Linda Bub, director of education and program development for NICHE at New York University College of Nursing, said the number of participating facilities has doubled in the past three years.

More than 100 hospitals have acute care for the elderly (ACE) units, featuring such adaptations as slip-free flooring, large-face clocks to help patients remain oriented, thick mattresses, soundproofing and indirect lighting.

A new trend is geriatric emergency departments, although questions are being raised about whether it is an efficient use of scarce capital (See sidebar).

The first of these EDs, with features similar to ACE units, opened at 425-bed Holy Cross Hospital in Silver Spring, Md., in 2008 in a repurposed express-care unit at a cost of $150,000. Since then, about 200 geriatric EDs have opened or are being planned across the country, according to ECRI Institute.

The ED is a major portal to care for seniors: Only infants go to the emergency department at a higher rate than people over 75, according to federal researchers.

Holy Cross CEO Kevin Sexton's family experience led to the formation of the hospital's eight-bed Seniors Emergency Center.

In 2004, his mother, Katherine “Kay” Sexton, was under observation in a hospital emergency department on the Jersey shore. The medical staff was discussing whether she should be admitted.

Katherine Sexton, in her late 80s, was nauseated and upset. She had undergone a series of tests over many hours. Doctors feared she might have an underlying condition that could deteriorate. They were reluctant to discharge her because she lived alone.

A relative put an emergency physician in touch with her son.

Over the phone, Sexton picked up on the normal hubbub in the ED, with pagers going off, loud background conversations and machines pinging. He could tell his mother was “as much hungry and tired as she was sick.” Doctors agreed to send her home with the understanding that she would have a caretaker.

Kevin Sexton said: “When I got off the phone, I basically said to myself, 'You know, that's us.' ” Sexton envisioned a “kindler, gentler” unit than the traditional ED. He consulted with geriatricians, geriatric nurses and other experts to create such a unit.

One of the consultants, Dr. William Thomas, an Ithaca, N.Y.-based elder-care reformer and geriatrician, said the literature from environmental gerontology clearly defines seniors' needs.

“We looked at the five human senses, and then we walked into the space and said, 'How would a person, just for example, in their mid-80s with a fever, experience this space?' And you look at sound, and you look at sight, and you look at lighting levels and glare and illumination and nonglare surfaces. And we installed a blanket warmer, so as soon as somebody comes in, there's a blanket, a warm blanket goes over them. We looked at the mattress pads, which were hilariously pathetic 1-inch pieces of foam, and actually installed comfortable mattress pads on the structures,” he said.

The hospital triages patients 65 and older. Those with possible strokes and myocardial infarctions are sent to the regular ED for evaluation. But seniors being checked out for possible fractures from falls, flu, dehydration and more routine issues are examined in the geriatric ED.

The unit features:

• Bays separated by walls, not curtains, for added privacy and quiet
• Thick mattresses and heated blankets
• Handrails, softer lighting and nonslip floors
• Pillow speakers to let patients listen to music or watch TV
• Golden brown-colored walls with white contrast to help seniors find boundaries between rooms
• Telephones and remote controls with larger buttons
• Space for family consultations

While changes to the physical environment were important, even more important were changes in work roles and the culture of the emergency department. “Everything needs to fit together,” Thomas said.

Bub said the principles are applicable everywhere in health facilities. She said the elderly represent two-thirds of the population in many health facilities, while they may be only 13% to 20% of the community. “If the majority of your hospital population is geriatric, it behooves a facility to prepare the environment and staff for the care of this vulnerable population. This improves quality of care and satisfaction of care for both the patient/family as well as the staff,” she said.

Architects specializing in healthcare are applying research about changes in the bodies and cognition in the elderly to their designs.

Washington-based senior living architect and designer Daniel Cinelli, principal and executive director of the Perkins Eastman architecture and design firm, said the Americans With Disabilities Act is just the starting point. “You have to dive into the nuances of an elder-care population,” he said.

Cinelli's team designed the $12 million Center for Healthy Living at Moorings Park, a high-end continuing-care retirement community in Naples, Fla. The facility has offices for four geriatricians, a spa, a rehab center, and cardio and strength programming geared toward seniors, as well as cognitive and memory training. On average, incoming residents at Moorings Park are 80 years old.

Dr. Michael Gloth, a geriatrician and chief medical officer at the center who has been at the Moorings for three years, said interior designers installed handrails throughout the facility to provide support. “They're easy for residents to use and provide very strong support while blending into the hallway decor,” he said.

The tables in seven exam rooms are high-tech and pricey, costing about $5,000 each.

Southwest Florida may be warm outdoors, but it often is cold indoors with the air conditioner blasting. These tables can heat up to keep patients warm.

The rooms have indirect overhead lighting and natural light through blinds.

Paper gowns are not used at the Center for Healthy Living. Instead, patients don plush spa-style robes.

Elder care typically can be posh in a cost-constrained environment. Dr. Mark Rosenberg, chief of the geriatric emergency department at St. Joseph's Regional Medical Center in Paterson, N.J., outside New York City, retrofitted 24 beds in his ED for geriatric care for about $500 per room. “We went to Lowe's (home improvement) and bought insulation to dampen sound and switched out fluorescent lights to dimmable bulbs,” he said.

He also hired strolling harpists to play calming music in the ED. “Any emergency department can do this,” he said.

Thomas said many hospital leaders seem oblivious to the fact that more than 40% of their inpatients already are seniors. Beyond the ACE units and geriatric EDs, hospitals are filled with elderly patients, and their proportion is growing.

“Sometimes I do grand rounds for hospitals, and I say, “People, you do realize who's in the hospital, right? You do realize that if you were really being fair about it, you'd be running a geriatric hospital with a side wing for adults, pediatrics and obstetrics,” he said. “It's time to make the healthcare environment safe and friendly for seniors.”

Howard Wolinsky is a Chicago-based freelance writer.