Mercedes Lupo, MD1, Eric Wong, MD, FRCPC2,3, Christina Reppas-Rindlisbacher, MD, FRCPC2,4, Justin Lee, MD, FRCPC, BSCPHM, ACPR, PhD1,5, Christopher Gabor, MSc, MHM6, Christopher Patterson, MD, FRCPC, FACP, FRCP(Glasg.)1,5
1Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton
2Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto
3Division of Geriatric Medicine, St. Michael’s Hospital, Unity Health Toronto, Toronto
4Division of General Internal Medicine and Geriatrics, Sinai Health System and the University Health Network, Toronto
5Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton
6Hamilton Health Sciences, Hamilton, ON, CanadaDOI: https://doi.org/10.5770/cgj.27.734
ABSTRACT
Background
Hospitalized older adults have unique physical, emotional, and psychosocial needs. We sought to understand older patients’ and care partners’ experiences with multicomponent interventions that support age-friendly care and identify areas for improvement.
Methods
We conducted a mixed methods study using surveys and interviews to explore older adult patients’ (65 years or older) and their care partners’ experiences with hospital-delivered multicomponent initiatives. We recruited participants from the Geriatric Rehabilitation (GRU) and Musculoskeletal (MSK) Rehabilitation units in a Canadian academic hospital from October 2021 to April 2022 until we reached data saturation and no new themes emerged.
Results
We recruited 18 participants, 10 patients (mean age 78 years, 80.0% female) and 8 care partners (mean age 61, 87.5% female). Surveys revealed overall positive experiences with multicomponent interventions. Interviews revealed five themes: 1) various forms of companionship for patients, 2) recreation and entertainment, 3) physical activity, 4) communication, and 5) pleasant physical environment. Having forms of companionship and proper communication with the care team were highlighted as areas of importance. Physical activity was highly valued, but participants expressed hesitation around safety of mobilizing without physiotherapists. Recreational activities helped distract from social isolation during a hospital stay and participants had diverse preferences for activities. Participants had strong memories of the physical environment, including the lack of natural light, institutionallike décor, and smells.
Conclusion
Companionship, recreation and entertainment, physical activity, communication, and the physical environment were important to hospitalized patients and their care partners. Hospital administrators and policy makers should consider these when targeting areas to improve care for the aging population.
Key words: hospitalized older adults, multicomponent interventions, delirium, functional decline, care partner experience
Older adults comprise a significant portion of hospitalized patients(1,2) and this population is expected to rise over the coming decade.(3) Hospital practices often overlook ways to support patient well-being, and this can worsen cognition and function. Bed rest(4,5) and the use of invasive devices and physical restraints(6–9) precipitate adverse outcomes such as delirium and immobility, leading to downstream cognitive and functional decline, reduced quality of life, and decreased likelihood of returning home after discharge.(4,6,7,10,11) Further, hospital infrastructure leads to a lack of privacy and sleep that contributes to hospitalization trauma and psychosocial distress.(12) This distress was worsened during the COVID-19 pandemic when restrictive visitor policies intensified social isolation.(13)
A variety of frameworks exist for older-adult care that considers their needs and values while serving to maintain cognition, function, and well-being.(1,14–16) These frameworks emphasize universal design of the physical environment for maintenance of function and independence, comprehensive services with a geriatric focus, and removing ageism at all levels of organization. For example, the Hospital Elder Life Program (HELP) is a multicomponent intervention which supports cognition, function, and well-being through volunteer-led therapeutic activities and socialization, promotion of sleep hygiene, and early mobilization.(17) HELP has demonstrated reduced cognitive and functional decline in older hospitalized adults, as well as reducing costs, while improving patient satisfaction with hospital admission.(17)
While the implementation of age-friendly care interventions such as HELP are being considered by hospitals, there is a pressing need to better understand older adults’ and care partners’ perspectives so as to inform patient-centered policies. This is especially relevant as global health-care systems work to address the system strains that have been amplified during the covid-19 pandemic.(18,19) The aim of this study was to explore patient and care partner perspectives on initiatives that support age-friendly care.
We conducted a mixed methods study utilizing surveys and semi-structured interviews. Approval was obtained from Hamilton Integrated Research Ethics Board (#13306). A narrative approach and constructivist paradigm was used through open-ended questions in the qualitative inquiry to allow interpretation of meaning from participants reflections on their hospital stay.(20) We adhered to the Standards for Reporting Qualitative Research Guidelines.(21) Personal reflexivity was maintained by regular reflection on the researcher’s role and potential biases as physicians caring for older adults through iterative data collection to maintain neutrality. Mixed methodology and simultaneous coding allowed for method and investigator triangulation.(22)
We recruited patients and their care partners from October 2021 to April 2022, throughout waves 4 and 5 of the COVID-19 pandemic, when policies enforcing isolation procedures and reduced visiting were present. Participants were recruited through purposive sampling(23) from two rehabilitation wards (Geriatric Rehabilitation Unit [GRU] and Musculoskeletal [MSK] Rehabilitation Unit) within Hamilton Health Sciences, Ontario, Canada. Recruitment continued until saturation of themes in qualitative data was achieved. Patients over the age of 65 who were admitted to acute care for more than three days before transfer to rehabilitation units were included. Care partners, defined as individuals most involved in the patient’s care, were invited to participate whenever available. Both units require Mini-Mental Status Examination (MMSE) scores above 16/30 for admission. Patients with documented dementia diagnoses were excluded due to the added complexity with the consent process and recall. Patients who could not communicate in English were also excluded.
Surveys included 42 questions designed by the research team to assess the helpfulness of current and proposed interventions, some of which had been previously studied, to support cognition, function, and well-being.(17) Paper and online formats with large print font and grade eight level language (Appendices A and B) were used. Participants ranked items on a 4-point Likert scale (strongly agree, agree, disagree, and strongly disagree). We followed best practices for presenting survey results.(24)
Semi-structured telephone and video interviews further probed ideas and were recorded with participants’ permission. The interview guide contained 11 questions for patients and 12 questions for care partners to explore how hospitals support them (Appendices C and D). The interview guide was developed in consultation with knowledge users (physicians, allied health, hospital administration, community members) with prior experience of hospital stays or working with older adults. Patients and care partners were interviewed separately, allowing free expression from both parties and to elicit differing ideas. Interviews were conducted by the primary researcher (ML) with a qualitative expert from the research team (CP) participating for the pilot process.
Surveys and interviews were conducted within the immediate weeks post-discharge to avoid recall bias, and interviews generally followed survey completion.
Surveys were analyzed using counts and percentages. Interview recordings were transcribed through an online transcription software, Sonix (Sonix Inc, San Francisco) and cleaned by the investigator using intelligent verbatim cleaning. The first transcript was coded independently by two members of the research team (CP, ML). Remaining transcripts were coded using Nvivo 12 software (QSR International Pty Ltd, USA) by the primary investigator through an inductive process, deriving meaning from the data itself. Qualitative description and subsequent thematic analysis were used.(25,26)
Of the 23 participants who consented to participate, 18 completed the study (patients n=10, care partners n=8) as outlined in Table 1. Figure 1 outlines study participation. Some potential participants could not complete the study due to early re-admission or time constraints during the discharge period.
TABLE 1 Participant characteristics
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FIGURE 1 Outline of study participation | ||
Most participants were satisfied with their hospital stay: 89.9% were satisfied with acute care and 100% with rehabilitation. Most patients strongly agreed that the following interventions were helpful: involving family or care partners in the circle of care (88.9%), information on how to stay physically active (88.9%), and how to improve vision/hearing, sleep, hydration, and nutrition (88.9%). Most care partners strongly agreed that having volunteers to guide patients around the hospital was most helpful (83.3%). Most patients disagreed that stamps and stationary sets for the purposes of writing loved ones would be helpful (55.6%). Survey results are summarized in Appendix E.
Thematic analysis of interviews revealed five main themes, summarized in Table 2, related to preserving cognition, function, and well-being: 1) companionship, 2) recreation and entertainment, 3) motivation to move, 4) communication, and 5) the physical environment.
Patients and care partners valued companionship from family and friends, staff, other patients, and families of patients in adjacent beds. One patient remarked, “I think that’s the most important thing—knowing that your family’s there.” (Patient 3)
“The girl that was in the bed next to me and her family were...I sort of got adopted into their family every night… They always brought me dessert and they brought her dessert, and they sort of spoiled us...it was a very social atmosphere.” (Patient 8)
Companionship offered social stimulation and distraction from being ill and away from home. As one care partner explained, “Sometimes when you’re not feeling well and somebody comes in to start to talk to you, you kind of forget about your illness a little bit and that perks you up for a while.” (Care partner 5).
COVID-19 pandemic infection control measures impacted companionship experiences. Restricted visitor numbers and ward lockdowns left patients feeling isolated and increased the emotional burden on individual care partners. As one care partner described:
“You’re only allowed two visitors. And she had me and my aunt, who’s actually older than her…so it was getting hard for her. It was all on me because I was the only other person that could go. So that kind of made things a little harder, too. I couldn’t share the burden.” (Care partner 6)
Virtual methods of companionship became important, such as video calls or social media, though this required comfort with technology. Care partners noted it would have been helpful for someone within the hospital to set these up for patients to increase opportunities for patients to initiate socialization.
To increase companionship opportunities, participants recommended social dining, where patients could eat meals in a common space.
“I think if she got to eat more with other people...because she was good buddies with the people that were in her room, but sometimes they would be sleeping and that’s not their fault. [It’s helpful] having someone to sit and eat with.” (Care partner 7)
Additionally, participants suggested ways to support care partners by expanding visiting hours beyond non-traditional work hours, reducing parking costs, and optimizing physical space for visiting.
Participants valued recreation and entertainment during the hospital stay. Table 3 outlines a full list of suggested activities. These distracted from illness, being away from home, and “boredom” (Care partner 2) experienced in hospital. Social activities, such as playing cards or bingo, offered opportunities to experience companionship. As one patient described, “As long as you’re busy or you’re occupied, you don’t have time to think about how...depressive...you are in the hospital” (Patient 8). While care partners brought in personal devices and materials for entertainment, the option of a hospital delivery service for supplementary items was viewed favorably.
TABLE 3 Examples of recreation and entertainment mentioned in interviews
Someone to assist with devices and adaptive devices was important, especially during the COVID-19 pandemic when care partners were less available.
“She’s also isolated anyway because of her vision issues, so it’s hard for her to do things to entertain herself” (Care partner 1)
“Would the staff have helped [set up her phone]? Possibly. We just didn’t want to bother them. But maybe knowing that, you know, there was somebody that she could have turned to say, ‘I need some help’, would have been actually a bit of a relief for her.” (Care partner 1)
Physical activity was highly valued, often described as the highlight of a patient’s day. However, apprehension around mobilization was a barrier to activity outside of formal physiotherapy. One patient explains “I found that there were times I’d try something, but I would think, ‘maybe I better not do that’” (Patient 1). Participants suggested having someone outside of the therapy team with knowledge about safely transferring and walking.
“[Older adults] don’t want to feel dependent on us, but they’re afraid to get up, they’re afraid to fall, right? And just to physically have someone there, it may be helpful…I think once a relationship is built then that trust is there, but just kind of having those little supports built-in.” (Care partner 3)
Suggestions to encourage mobilization included incorporating movement into social activities, inserting landmarks and motivational sayings into the physical space, designing hospital spaces to naturally encourage movement, or using incentives for achieving milestones.
“The one lady, she it brought back a nice childhood memory…The Rummoli chips...this nurse knew that if my mom did her walking, she would pick up a chip at each station and then she had to give it back to her. And my mum just felt like this was amazing because she collected all of her chips…very creative and getting them physically mobile.” (Care partner 3)
Participants valued consistent communication with the healthcare team, including medical updates, information on medication changes, and scheduling of tests, procedures, and therapy. From a patient perspective, this was important for well-being.
“That is a little bit of a concern when you don’t know what’s going on. And I think that raises his stress level, which he doesn’t need.” (Care partner 5)
One patient expressed that the most important part of the hospital stay was “being informed of the state of your health”. (Patient 7)
Information delivered to the appropriate person and through the appropriate medium was important. For example, while patients were acutely unwell, regular communication with care partners was important, as they may be in a better position to retain information. Written updates, including reports generated by electronic medical records, were recommended for older adult care partners.
“Written [communication], especially when you’re dealing with [older adults], it’s just that it’s black and white in front of them instead of us trying to tell them and have him remember.” (Care partner 1)
Informing care partners allowed them to better support patients as they were able to answer questions and reinforce care plans.
“If they communicate what’s going on, rather than you having to kind of observe and put two and two together, then we’d all be better off and we could all be a bit more goal-directed, and the outcome might be shorter hospital stays.” (Care partner 2).
Awareness of scheduling also helped care partners assign personal commitments. “Instead of coincidentally running into a medical person, we actually could have planned to be there. And we also were never sure if she was going to be gone for a test when we were coming in, if we get to her room and she wouldn’t be there.” (Care partner 1)
Participants described the hospital space as “dismal”, “institutional”, and “depressive”, referring to décor, window views, and smells. One patient recalled her bedroom window looking out to a jail and feeling like she was looking “from one institution to another” (Patient 8), comparing the atmosphere within the hospital to that of the jail outside. A care partner described the lingering unpleasantness of the physical environment: “I would come home, take my clothes off and put them in the wash because they smell of urine and poo, and it was horrible.” (Care partner 2). Those without windows described feeling claustrophobic and disoriented. As one patient explained, “You had no idea if it was day or night. You never knew what the weather was like” (Patient 8). Care partners brought in blankets for comfort and plants to improve the aesthetic.
Multi-patient rooms limited privacy and made patients conscious of their use of space. For example, patients were concerned that they would disrupt those in adjacent beds when using over-bed lights at night.
Participants recommended using physical space for social and recreational communal activities with other patients for additional companionship opportunities. However, limited and cluttered physical space hindered companionship opportunities. Care partners stood due to a lack of seating during visits. Further, infection control measures during the COVID-19 pandemic restricted movement outside of patient rooms.
“If they had a lounge area that was a little bit more conducive to sitting there or going there as a change of scenery from your room, then there would be more socializing going on and maybe people would get a card game going or something like that.” (Care partner 2)
Another care partner reflected on the role of the physical environment in serious illness: “Even for their family members that are visiting, it is the last time that they see their family member in a hospital. What’s that environment going to look like?” (Care partner 3)
Interviews revealed five key themes, supported by survey responses, that were important to older adults for preserving cognition, function, and well-being in hospital: companionship, recreation and entertainment, motivation for physical activity, optimal communication, and a pleasant physical environment. These themes align with those of various existing age-friendly frameworks.(1,14–16) Table 4 integrates key recommendations with values of various age-friendly practices and processes. These serve as potential areas for hospitals to focus resources to optimize patient-centered care for older adults. The WHO Age-Friendly recommendations emphasize the importance of learning about older adults’ needs from patients and their care partners, which this study offers.(27)
TABLE 4 Summary of recommendations
Companionship and recreation were two themes identified in this study. They distracted from one’s illness, provided social stimulation, and supported well-being. This aligns with previous literature demonstrating that social stimulation for older adults preserves cognition and function and supports illness recovery.(28–30)
Volunteer programs, which have been shown to reduce length of stays,(31) can increase companionship, improve access to devices for socialization and entertainment, and facilitate communal programming. Reduced visiting time and limited space due to COVID-19 restrictions negatively impacted companionship experiences, reflected in studies emerging since the start of the pandemic.(13) Increasing availability and accessibility of virtual forms of companionship telephone and video calls should be considered. The HELP-ME program(32) is a modified version of the HELP program developed to accommodate physical distancing during the COVID-19 pandemic with increased technology use, which could address this. Hospitals would do well to enhance support for in-person and adapted volunteer programs.
Participants highly valued physical activity but were apprehensive about mobilizing outside of physiotherapy. This has been connected to longstanding beliefs about the benefits of bed rest during illness, uncertainty around safe mobilization, and the bed-centric nature of hospital rooms.(33) As counter measures, hospitals could train care partners and volunteers on safe mobilization, incorporate mobilization into socialization and recreation, and design hospital spaces to promote transferring out of bed. Empowering care partners by way of health promotion education—such as how to safely mobilize—is a key element of age-friendly care that was also identified as important to participants in this study.(27)
Participants valued care partner participation and information adaptation to suit the needs of older adults. Written communication of medical updates, medication changes, and discharge information was preferred. When care partner presence is limited in hospital in the context of infection control measures, such as during the COVID-19 pandemic,(34) the need for optimizing written regular communication may be particularly valuable. Surveys highlighted interest in education around preventing complications such as dehydration, immobility, and delirium. Family empowerment and engagement are known to be successful parts of bundled interventions for delirium as well as age-friendly care, and further opportunities for care partner education need to be explored.(24–26)
Optimizing use of physical space can support independence and function, as well as create and maintain social networks.(2,35,36) Designing hospital spaces to support older adults is a key pillar of the WHO age-friendly framework to maintain function and independence.(14) Study participant narratives reflected the importance of designing spaces to encourage mobilization, recreation, and companionship. Moreover, design features such as wall color, harsh lighting, lack of windows, and lack of privacy negatively affected participants’ well-being, which offers another potential area of focus for hospitals.
Individuals with low levels of literacy, vision, or hearing were not fully represented because of difficulty completing surveys independently. We attempted to mitigate this as much as possible by using grade eight level English, large print, and video calls. Patients may have received assistance from care partners to set up video calls, which could have influenced interview answers if care partners were listening in on the call. Similarly, restricting our study to English-speaking participants may have limited the cultural and linguistic diversity we were able to capture. This study also excluded individuals with a diagnosis of dementia for consent and recall purposes; therefore, we did not capture the needs and values of patients with dementia in this study. The MSK rehabilitation unit admits patients typically after an orthopedic injury or surgery, as opposed to a general medicine issue which may lead to admission to the GRU, which may have influenced participants’ experiences, though this was not specifically captured. Though interviews were conducted in the immediate weeks post-discharge and as close to discharge as possible, interviews after discharge may have still led to recall bias.
We did not evaluate differences in characteristics between care partners who did and did not choose to participate, which may have influenced experiences and perspectives. We were also unaware if care partners influenced patients’ choice to consider study participation. Further, though patients and caregivers understood which interventions are generally provided on the units, it was not known exactly which interventions each patient personally experienced during their admissions.
The results of this study are limited to a small subset of hospitalized patients in a single setting in Hamilton, Ontario, which limits generalizability. However, our sample size is consistent with other qualitative studies.(37) Though participants were asked to answer as truthfully as possible, investigators were members of staff where patients were admitted, so it is possible that survey responses were skewed positively to avoid offense. There may have been selection bias towards more motivated older adults due to choosing individuals admitted to rehabilitation units, where engagement with health-care providers is inherent in the rehabilitation process (e.g., mobilization). Further research encompassing different settings such as acute care hospitals, psychiatric hospitals, and long-term care homes may yield different results. We did not report characteristics that were present in fewer than five participants to avoid identification and preserve anonymity. Future studies could look at the impact of education level, ethnicity, co-morbid health conditions, and physical and social frailty.
This study examined patient and care partner hospital experiences to understand their values with respect to age-friendly care and the multicomponent interventions to support this. Patients and their care partners wanted a greater focus on companionship, recreation and entertainment, motivation to move, communication, and a pleasant physical environment. These results can inform improvements in delivery of multicomponent interventions, resource allocation to areas important to patients, and optimal hospital design for older adults.
We acknowledge Kalpana Nair for her contribution to the qualitative analysis process, and our stakeholders’ group for their contribution to the development of the interview guide.
We have read and understood the Canadian Geriatrics Journal’s policy on conflicts of interest disclosure and declare we have no conflicts of interest.
Funding from The Department of Medicine, Division of Geriatric Medicine, McMaster University and St. Peter’s McMaster Chair of Aging supported educational sessions for the recruitment team.
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Title of Research Study: “How can we help you?” Older adults’ perspectives on improving care in hospital: A mixed methods study
To what extent do you agree with the following statement:
Place an [X] in the box that reflects your answer.
Place an [X] in the box that reflects your answer.
This question is about how you maintained physical strength while admitted to hospital. To what extent do you agree with the following statements:
Place an [X] in the box that reflects your answer. You may answer based on your experience with the initiative or answer according to how helpful you would find this initiative.
Maintaining normal brain function during a hospital stay helps to prevent delirium or confusion. To what extent do you agree with the following statements:
Place an [X] in the box that reflects your answer. You may answer based on your experience with the initiative or answer according to how helpful you would find this initiative.
With regards to existing initiatives to promote wellbeing, to what extent do you agree with the following statement.
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This question is related to how we can orient you to the hospital, your care team, and the plan of care. To what extent do you agree with the following statements:
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With regards to additional services and equipment to what extent do you agree with the following statement.
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Title of Research Study: “How can we help you?” Older adults’ perspectives on improving care in hospital: A mixed methods study
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This question is about maintaining physical strength while in hospital. To what extent do you agree with the following statements:
Place an [X] in the box that reflects your answer. You may answer based on your experience with the initiative or answer according to how helpful you would find this initiative.
Maintaining normal brain function during a hospital stay helps to prevent delirium or confusion. To what extent do you agree with the following statements:
Place an [X] in the box that reflects your answer. You may answer based on your experience with the initiative or answer according to how helpful you would find this initiative.
With regards to existing initiatives to promote wellbeing, to what extent do you agree with the following statements.
Place an [X] in the box that reflects your answer. You may answer based on your experience with the initiative or answer according to how helpful you would find this initiative.
This question is related to how we can orient you to the hospital, your care team, and the plan of care. To what extent do you agree to the following statements:
Place an [X] in the box that reflects your answer.
With regards to additional services and equipment to what extent do you agree with the following statements.
Place an [X] in the box that reflects your answer.
Regarding the overall experience and what matters most to patients:
Regarding comfort during a hospital stay:
Regarding the medical recovery process:
Regarding the overall experience and what matters most to patients:
Regarding comfort during a hospital stay:
Regarding the medical recovery process:
Correspondence to: Christopher Patterson, md, frcpc, facp, frcp (Glasg.), St. Peter’s Hospital, Hamilton Health Sciences, 88 Maplewood Ave, Hamilton, ON L8M 1W9, E-mail: pattec@hhsc.ca
COPYRIGHT
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No-Derivative license (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.
Canadian Geriatrics Journal, Vol. 27, No. 4, DECEMBER 2024