A hospital can offer emergency care, diagnostic tests, treatments or intensive operations that require recording or not. Older use hospitals more than younger patients; they have more hospital admissions from the emergency room and more frequent and longer hospital stays, and they consume more resources while they are in the hospital. Care in the emergency room in 2011, had about 20% of those between 65 and 74 years and 27% of ? 75 years of age at least one visit to an emergency room. Elderly patients tend to be sicker. More than 40% of elderly patients in an emergency room were taken to the hospital; 6% are in intensive care. More than 50% are prescribed a new medication. Older people can use as a substitute for primary care to the emergency room, or they can come because they do not receive adequate attention from their family doctor. Visits to the emergency room are often caused by a gap in the social structure of a frail elderly patient, for. B. can cause an absence or illness of their caregiver to the fact that the people call an ambulance, instead she goes to the practice of their physician. However, the reasons in many cases are real emergencies. A stay in an emergency room may cause more stress for the elderly, because there is usually no special accommodations for them are (z. B. quiet rooms, deep beds, zusätzlliche pillows, indirect lighting). The assessment of older people take longer in general and requires more diagnostic tests, because many elderly patients do not present with clear or typical symptoms and signs of disease (unusual disease entities in the elderly). A myocardial infarction is manifested z. B. at <50% of patients> 80 years as chest pain. Instead, elderly patients may complain that they generally feel weak or just not good. Factors that are not obvious (eg. As polypharmacy, adverse drug reactions) can affect the performance of an older patient. A fall z can. be due as on elder abuse, an adverse drug reaction (z. B. oversedation), domestic dangers physical problems (eg. as poor vision), depression or chronic alcoholism. At least 5% of hospital admissions of older people account for adverse drug reactions. Approximately 30-40% of elderly patients who come to the emergency room are cognitively impaired, but do not have a diagnosis of dementia; in 10% of cases, cognitive impairment in accordance with a delirium remains undetected. When indicated (eg. As when an older patient has difficulty with orientation to person, place or time) should be a standardized cognitive assessment (to assess how the mental status is) are performed in the emergency room. However, a standardized cognitive assessment for each elderly patients is adequate who comes to the emergency room. Cognitive impairment affects the reliability of the history as well as in the diagnosis, increases the risk of delirium during a hospital stay and must be considered in the planning of the patient disposition. Knowing whether the cognitive impairment has recently begun helps in determining whether the impairment in the emergency department should be fully clarified. A recently occurred cognitive impairment may indicate sepsis, an occult Subduralblutung or adverse drug effect. Suicide risk, fall risk incontinence and nutritional and vaccination status should be collected in the emergency room, so that a follow-up can be arranged. Communication between health professionals Good communication between doctors and patients in the emergency room, nurses, family doctors and employees of long-term care facilities improves the outcome of elderly patients with complicated problems. Advance directives should be communicated to emergency medical immediately and clearly. Basic information the family doctor of the patient facilitate the assessment and planning in the emergency room. Reports to the family doctor of the patient should even simple injuries describe (z. B. ankle sprain, Colles fracture wrist) because such injuries können.Disposition significantly affect the functioning and independence The discharge planning can be complex, as an acute illness or injury can impair the functioning of the elderly more (eg. as a simple ankle sprain can be very disabling, when patients do not have good support at home). The discharge planning can be improved by nurses, social workers and family physicians are included. They should include: collection of functional status (anamnesis: Functional status) strategies for handling problems (eg, depression, alcoholism, impaired functional status.) That were identified in the assessment in the emergency room setting, whether the patient drugs as received and instructed to take and receive the necessary follow-up to assess the performance of the caregiver (eg. as is required if short-term care) Many elderly patients are admitted to a hospital in the evaluation in the emergency room. Occasionally, older patients are brought by a nurse in the emergency room who refuses to take them home, or she leaves the hospital. Hospitalization Nearly half of adults who occupy hospital beds are ? 65 years old; It is expected that this proportion increases to the extent that the age of the population increases. Hospital care costs Medicare> 100, which corresponds billion $ / year 30% of health spending on hospital care in the United States. Hospitalizations may increase age-related physiological changes and increase morbidity. Only seriously ill elderly patients who can not be adequately cared for elsewhere, should be admitted to a hospital. for elderly patients, hospitalization is some risk because it includes bed rest, immobility, diagnostic measures and treatments (in particular changes in the medication). For admission to one or discharge from a hospital drugs are often added or replaced, which may increase the risk of adverse reactions (drug-associated problems in the elderly: reasons for drug-associated problems). Hospital treatment may be dehumanizing and impersonal. The acute hospital care should only take until a successful transition to home care, a nursing home or an outpatient rehabilitation program is possible. The result of hospital stay seems to get worse with age, although the physiological age is a more important predictor of outcome than the chronological age. The result falls better for patients who were admitted to a hospital because of elective surgery (eg. As joint replacement) than for patients who because of serious difficulties (z. B. multi-organ failure) were admitted to a hospital. About 75% of functionally independent in receiving patients ? 75 years are no longer functional selbststandig at discharge; 15% of patients ? 75 years are released into nursing facilities. The trend towards acute shortened hospital stays followed Subakutpflege and rehabilitation in a nursing home may explain why these percentages are high. Even if a disease is treatable or appear straightforward, the patient can not return to functional status before hospitalization. Improvement of results The following strategies can help to reduce the functional decline in the elderly and improve their care: Interdisciplinary Geriatric Team: identifying and meeting the complex needs of older patients and compliance and avoid problems that are common in the elderly and which develop during hospitalization or worse (interdisciplinary geriatric teams) nurse for primary care (a nurse with round-the-clock responsibility for a particular patient): application of the team care plan, monitor response to nursing and medical care and instructing patients, staff and members of changes in the hospital environment, often due to nurses: shipments of disturbing patients near the nursing station or Austau sch of roommates a patient rooming-in programs for older: providing a better one-on-one care, relief from employees of some maintenance tasks, distraction of the patient’s fear (especially in patients with delirium or dementia) and possibility of a family member to participate actively in the patient’s recovery Good communication between healthcare professionals: preventing errors and redundancy of diagnostic procedures and treatments (especially drugs) documentation of the drug regimen: specification of indication for each new drug, performing a daily list of (documentation of patient choice regarding health care proxy and decisions to health care: prescription drugs and received, thus avoiding unnecessary medication and drug interactions wills. Advance directives) Early mobilization and participation in functional activity: the prevention of physical impairment due to decreased activity during an illness and a stay in hospital discharge planning: ensuring that adequate supplies will continue units for acute care of the elderly (ACE): provision of effective care for the elderly in hospital already prepared by using the above strategies most living wills should be referred urgently to the hospital. Doctors should reaffirm those decisions during the acute hospitalization. If no guidelines have been documented, doctors should endeavor to ascertain the wishes of the patient. In older people, common problems require special considerations during hospitalization, especially after surgery (post-operative follow-up); many can be reminded (ELDERSS: Important questions to elders in the hospital) using the acronym ELDERSS. At the hospital, elderly patients often experience confusion evening (Sundowning), fractures with no apparent trauma, falls, or they can not walk. Hospitalization may cause or aggravate malnutrition, pressure ulcers, urinary incontinence, fecal impaction and urinary retention. Such problems can prolong convalescence. ELDERSS: Important questions to elders in the hospital acronym edition D food (nutrition) L Clarity (mental status) D guidelines to limit the maintenance (eg no revival.) E excretion (incontinence) R Rehabilitation (required due to the effects of bed rest) S Skin care (to prevent and treat pressure ulcers) S Social Services (discharge planning) Adverse Drug Reactions The hospitalization rates by adverse drug reactions are four times higher in older (ca. 17%) than in younger patients (4%). Reasons for these effects are polypharmacy Age-related changes in the pharmacokinetics and pharmacodynamics (Intentional and unintentional) changes of medicines; dumplings during hospitalization and at discharge (drug-associated problems in the elderly). Clinical Calculator: estimate of creatinine clearance with Sanaka Formula (in elderly patients with low muscle mass) Clinical Calculator: estimate of the creatinine clearance using the Cockcroft-Gault equation (SI units) Prevention Keeping a daily list of prescribed and medicines obtained can help prevent adverse drug reactions and drug interactions. Because distribution, metabolism and Elinimation of drugs in the elderly vary widely, the following should be done: The drug doses should be carefully titrated. Creatinine clearance for renal excreted medications should be calculated at dose changes. Serum concentrations should be measured. The patient’s responses are observed. Clinical Calculator: creatinine clearance (measured) Clinical Calculator: estimate the glomerular filtration rate according to the equation of the MDRD study certain drugs or drug categories should be avoided in the elderly (see table: Potentially inappropriate drug in the elderly (after American Geriatrics Society 2012 Beers Criteria update)). The use of hypnotics should be minimized because tachyphylaxis can occur and the risk is increased for falls and delirium; a measurement to improve sleep hygiene should be tried before the drugs (see Table: Sleep Hygiene). If medication is needed short-acting benzodiazepines are the best choice in general. Antihistamines have anticholinergic effects and should not be used for sedation werden.Auswirkungen of bed rest Prolonged bed rest, such as occurs during a hospital stay, causes deconditioning and is rarely justified. The resulting inactivity affects as follows: For complete inactivity muscle strength decreases by 5% per day, with the risk of falling increases. Muscles shorten and periarticular and cartilaginous joint structures are changing (the fastest in the legs), which causes restricted movement and contributes to the development of contractures. The aerobic capacity decreases significantly, substantially reduces the maximum O2 uptake. Bone loss (demineralization) is accelerated. The risk of deep venous thrombosis is increased. After a few days of bed rest elderly patients whose physiological reserves are reduced to that are independently functional but still lose this ability. Even if the losses are reversible, rehabilitation requires extensive, expensive and relatively long intervention. In elderly patients, bed rest can cause a 50 times faster disappearance of the vertebrae than in younger patients. The losses caused by 10 days of bed rest, require four months to Wiederherstellung.Prävention If it is not forbidden for a reason, activity should (especially walking) are encouraged. We need help in walking, therapists can offer these at specified times. However, doctors, nurses and family members should also help patients throughout the day while walking. Hospital procedures should the need to be active, stress. If immobilization is required or the result of a long illness, procedures are recommended to prevent deep vein thrombosis, if they are not contraindicated. Frequently rehabilitation is required. Realistic goals for rehabilitation at home can from the activity of the patient werden.Stürze dissipated before hospitalization and the current needs of the age-related changes (eg. As insensitivity of the baroreceptors, reduced total body water and plasma volume) lead to a tendency to develop orthostatic hypotension. These changes increase and the effects of bed rest and the use of sedatives and certain antihypertensives the risk of falling (and syncope). > 60% of falls of hospitalized elderly patients occur in the bathroom; often, patients abut against hard objects. Some patients fall when rising from hospital beds. The patients are in a strange bed, and in a strange environment and are easily irritable. Although bed railings can help remind elderly patients from asking for help before getting up, bed railings can entice even patients to over and around them to climb around and so to falls of patients beitragen.Prävention should normally the bed railings removed or left down become. The best alternatives to the use of physical or chemical restraints are to identify risk factors for falls (incl. Agitation), carefully analyze and modify or correct and monitor risk patients closely. The use of low beds and keep clear of paths in rooms and corridors of the risk of falling can verringern.Inkontinenz urinary or fecal incontinence develops in> 40% of hospital patients ? 65 years, often within a day of recording. This is due to an unfamiliar environment a confusing way to the toilet disorders that impair ambulation Too high bed bed rail Hindering equipment such as intravenous access, oxygen tubes in his nose, heart monitors, and catheters psychotropic drugs, which reduce the perception of the need for emptying inhibit the bladder or bowel function or impair the ability to walk medications that can lead to urinary incontinence (eg, anticholinergic drugs and opioids, which cause overflow incontinence;. diuretics, urge incontinence cause) bedpans can be uncomfortable, especially for post-operative patients or patients with chronic Arthritis. Patients with dementia or a neurological disorder may not be to ring in a position to request help with toileting. Fecal impaction, infections in the gastrointestinal tract (eg., By Clostridium difficile-induced colitis), adverse drug reactions and liquid supplements can cause uncontrollable diarrhea. With appropriate diagnosis and treatment continence can be restored werden.Änderungen in mental status Elderly patients may appear confused, because they have dementia, delirium, depression or a combination thereof. However, health professionals must always remember that confusion may have other causes, and their presence requires a thorough assessment. Confusion may be due to a specific disorder (see Table: Causes of delirium). However, they may also develop or worsen, because the conditions exacerbate the effects of an acute disease and age-related changes in cognition in the hospital. Older patients who z. B. do not have their eyeglasses and hearing aids, can be disoriented in a quiet, dimly lit room in the hospital. Patients may become confused by hospital procedures, schedules (eg. As frequent waking up in strange situations and rooms), the effects of psychotropic drugs and the stress during surgery or illness. An intensive care unit, the constant light and noise to agitation, paranoid ideation and mental and physical exhaustion führen.Prävention members may be asked to bring missing eyeglasses and hearing aids. Attaching a wall clock, a calendar, and family photos in the room can help patients with orientation. The room should be well lit, that the patient can see what and where who is in her room. Where appropriate, the staff and family members should remind the patient regularly in time and place. Measures should be discussed before and during their implementation. The use of physical restraints is not recommended. In agitated patients always increase fixations the agitation level. The identification and modification of risk factors for agitation and the close monitoring of patients can help to prevent agitation or minimize. Invasive and non-invasive device to the patient (. Eg pulse oximeters, urinary catheters, iv access) can also cause restlessness; the risk-benefit ratio of these measures should be considered werden.Druckulzera pressure ulcers develop because of age-related skin lesions common in older patients in the hospital. Direct pressure which is greater than the capillary perfusion pressure of 32 mmHg, can cause skin necrosis in only 2 hours. During a typical visit to the emergency room the development of pressure ulcers can begin, while older patients waiting for a hard deck on their investigation. After brief Immobilisierungszeiträumen the sacral pressure 70 mmHg, and the pressure under an unsupported heel reaches 45 mmHg in average. Shear forces arise when patients sit or propped up in bed in a wheelchair to slide down. Incontinence, poor nutrition and chronic diseases can to the development of pressure ulcers beitragen.Prävention A protocol to prevent and treat pressure ulcers should be started immediately when recording (decubitus ulcers: prevention). It should be implemented daily by the caregivers of the patient and are regularly reviewed by an interdisciplinary team. Pressure ulcers can be the only reason, released from the patient in a nursing home and not return to the community werden.Mangelernährung At the hospital, elderly patients can quickly suffer from malnutrition, or they may be malnourished during recording. Longer hospital stays exacerbate pre-existing problems and often lead to significant nutritional losses. Malnutrition is particularly serious for hospitalized patients because they are thus less able to fight off infection, to keep the skin intact and to participate in rehabilitation; and surgical wounds can not heal. Hospitelisierung contributes in many ways contribute to malnutrition: Rigid Esens plans, use of medicines and changes in the environment can affect appetite and food intake. Hospital food and therapeutic diets (eg. As a low salt diet) are not familiar and often not appetizing. In a hospital bed to eat on a tray is difficult, particularly when bed rail and fixations limit mobility. Elderly patients may need help with eating; it may take until the help arrives, so the food is cold and even less taste. It may be that older people do not drink enough water, because their perception of thirst decreases and / or the water is difficult to achieve; it may be a severe dehydration develop (sometimes leading to stupor and confusion). Dentures may have been left at home or relocated, so chewing is difficult; to characterize the denture helps to prevent it from lost or taken away with the food tray. Prevention Patients with preexisting nutritional abnormalities should be identified in the recording and treated accordingly. Doctors and staff should expect malnutrition in the elderly. The following measures can help: tailor earliest possible lifting of restrictive dietary monitoring daily food intake discussing the food preferences of patients and relatives and try a sensible diet specific to each patient suggestion to the members to make the patient when eating society because people with other eat Make sure that the patient always appropriate food is supplied (z. B. Make sure that meals stay in place when patients are out of their room during meal time to investigation or treatment) pull Temporary parenteral or tube feeding for patients considered, the too ill to swallowing are preset drinking explicit rules (z. B. providing a fresh and easily accessible water bottle od he other beverages at the bedside, as long as no water restriction exists; Advice to family members, friends and co-workers to offer the patient regularly drink) discharge planning and laying Early and effective discharge planning has many advantages. Shortening of hospitalization reduce the likelihood of a resumption identification favorable care alternatives installation of utilities (eg hospital bed, O2) in the patient’s home increase patient satisfaction may prevent placement in a nursing home early as the admission of a patient to start all members of the interdisciplinary team with discharge planning. A social worker or discharge planning coordinator judges the needs of the patient within 24 h after ingestion. Nurses help doctors to determine when the dismissal is safe and which setting is best eignet.Nach home patients being discharged home, need detailed instructions for aftercare, and it may be that relatives or other caregivers for care need a briefing. If the patient and family members not taught how to give the medication to implement treatments and the recovery progress must be monitored, this makes negative results and a recovery more likely. write down further appointments and medication schedules, can be helpful for patients and relatives. At discharge, the patient or family members should be given a copy of a brief medical letter if they have questions regarding the care before the family doctor erhält.An the official discharge report another medical facility When a patient is discharged to a nursing home or to another facility should a written summary will be given to him, and a complete copy should be sent electronically to the receiving institution. The summary must be complete and accurate information on the following points included: Mental and functional status of the patient time when the patient was receiving medication list of currently occupied medication and dosage known drug allergies advance directives, including resuscitation status marital contacts and support status further appointments and tests. names and phone numbers of a nurse and a doctor who can provide additional information the patient should it have a written copy of his medical and social history in his transfer; it can be sent electronically to the receiving institution to ensure that there are no gaps in information. Effective communication between the staff of the institution helps to ensure continuity of care. The supervising nurse of the patient such can. B. die aufnehmende Institution anrufen, um die Informationen kurz zu besprechen, bevor der Patient verlegt wird, und mit der Krankenschwester telefonieren, die sich nach der Entlassung um den Patienten kümmert.