Isn't it time for age and planet friendly hospitals?

Around the world, hospitals are used more by older people than any other demographic, but hospitals are often as bad for the health and function of older people as they are for the planet. We nurses know well that hospitals are laden with risks to older people's health and function. What we know less well is that hospitals' outsized greenhouse gas emissions and waste streams harm the planet, significantly contributing to the triple planetary health crisis. The triple planetary crisis (https://unfccc.int/blog/what-is-the-triple-planetary-crisis) is comprised of climate, air pollution, and biodiversity crises and is fundamentally a health crisis. Abbasi and colleagues (2023) make the magnitude of this global health crisis abundantly clear. For us as gerontological nurses, this global planetary health crisis threatens healthy ageing for every one of every age around the world. While hospitals sit at the centre of the healthcare system in most societies, they are not friendly to ageing, older people, or the planet.

Despite known harms and risks for older people and for healthy ageing, hospitals respond sluggishly to the need to reduce these concerns. In this way, health care is unlike in other industries, where targeting ways to better meet the needs of a major user group are typically viewed as a priority. For example, uptake of the well-established Age Friendly Health Systems (https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx) and Practice Greenhealth (https://practicegreenhealth.org) initiatives here in the United States where I live are inconsistent at best. Both programmes remain far from becoming national requirements for healthcare delivery, and participation is the exception and not the rule. The same lag in achieving age friendly and planet friendly hospitals is true elsewhere, too, despite widespread assumptions that hospitals effectively care for older people and will promote health rather than harming it through damage to the planet.

In most societies around the world, the default approach to addressing care for hospitalized older people is piecemeal, using a culture of performance improvement. Most performance improvement projects targeting older patients focus on focal concerns like fall rates, delirium screening, or hospital length of stay. These endeavours target deleterious events and outcomes older people commonly endure in hospitals but without getting at the underlying factors that link them together. At best, such projects promote age friendly working. More commonly, though, they inadvertently promote functional loss, overuse of long-term care facilities, and caregiving burdens, all while not considering planetary sustainability. Inequitable outcomes for older people and those who love them are thus the more common result.

Social discrimination renders older people invisible such that their health equity is rarely considered. In health care and beyond, we expect the outcomes of their health care to be less than optimal. Structural ageism, healthism, and ableism lie at the heart of both this invisibility and health inequity. In health care, we unwittingly contribute to negative experiences and poor outcomes that make hospitals and most health care unfriendly for older people. To be fair, structural ageism prompts older people and the public, along with news media and entertainment, to play their roles. They too may also believe that decline, dysfunction, and dependence are foregone conclusions when an older person is admitted to an inpatient ward or unit.

Modern hospitals and nurses within them are stuck in a maladaptive cycle that begins with identifying older patients as a problematic population. Older patients are seen as being at substantial risk for complications, protracted length of stay, blocking beds for some vaguely defined preferred population, and somehow intentionally overusing healthcare resources. Too often that decline is associated with an ageist and ableist insinuation that they are also somehow responsible for their decline. Problematizing older people and health in later life is emblematic of the structural ageism that makes hospital care inequitable for older people. Seeing ageing as high-risk or problematic creates incorrect expectations that older people are universally vulnerable, leading to inpatient events and subsequent decline in physical and mental function.

Take the ubiquitous identification of falls among older people as a key problem in hospital performance. Around the world, nurses and others caring for these older people during hospitalization learn to expect that older patients will fall and that they, as nurses, must do everything possible up to and including using physical restraints to prevent those falls. The lack of evidence to support the use of physical restraints and much data to argue against their use are too often overlooked. Instead, fall risk is assessed countless times, generating a cascade of fall prevention interventions. Measures to limit movement and repeated messages to the patient and family about not moving without assistance are the bedrock of fall prevention interventions. To be sure, recent developments in fall prevention stress assessing and improving mobility. But most fall prevention efforts do anything but improve mobility and frequently end in permanently diminished capacity to move independently.

Delirium presents a similar predicament. Older people are simply expected to endure declines in mental capacity. Healthcare slang, at least in the many forms of English used around the world, for describing cognitive decline still lives richly in the labels ignominiously applied to older patients experiencing cognitive changes. Persistent everyday use of such slang conveys the strength of a shared expectation of older people as mentally incapable. As a result, actual changes in memory, executive function, and attention among other specific capacities are often missed or neglected in clinical assessments. Despite robust science to support it, routine assessment of delirium remains an exception rather than the rule in many hospitals around the world. Intervention in delirium is even more inconsistently applied despite additional evidence to backing it.

Focal and global functional decline is common after both falls and delirium. Such functional decline then generally thwarts any plans for the older person to return home with in-home support and resources. Like falling and losing mental acuity, losing functional independence is a firm expectation of older patients held by healthcare professionals. This expectation of functional decline is difficult to fully understand unless seen in the reverse. Think of how often we nurses, physicians and other colleagues marvel at an older person who lives alone and cares for themselves and even for others who live elsewhere. The strong and resilient older person who is living their life becomes the jaw-dropping exception to our rule of inevitable decline.

Fundamentally, the expectation of ubiquitous functional decline completes the cycle that casts older people as vulnerable. Belief in vulnerability growing across later life is deeply set in our professional thinking. Consider that instruments to measure the extent of vulnerability are routinely used in our specialty, despite growing science in frailty. Consequently, we come to understand vulnerability as a characteristic trait and not a time-limited state in later life. We ignore the reality that vulnerability describes a state in which any person at any age may find themselves. The planetary crisis, for example, makes people of all ages vulnerable to the direct and indirect effects of the climate, air pollution and biodiversity crises on health. In this situation, pregnant individuals, infants and children are frequently among those at greatest risk in different manifestations of the triple planetary crisis. Despite examples to the contrary, ‘vulnerable elder’ serves now as a catch phrase used across health care delivery and research. It represents the fixed trait, generated by structural ageism, which older people should presume to possess. Being vulnerable is portrayed as a physiological determinant of health rather than as a social determinant emerging from structural discrimination. Vulnerability is a label that captures just how poorly healthcare and sociocultural understandings misrepresent ageing and later life.

With a fixed belief in vulnerability and expectations of suboptimal outcomes, we consign older patients to age and planet unfriendly health care by viewing our ageing populations as a problem. Health care that results from this ageing problem is the foundation on which commonplace poor experiences and avoidable negative outcomes become possible. Confirming this notion of the ageing problem is easy. Just look at research published in most journals that report investigations addressing older populations. You will certainly find the declaration of ageing and older populations as a problem or, in more colourfully negative terms, an avalanche or tsunami. Beginning with belief in the ageing problem, our perspective, expectations, and understandings set a standard of care for hospitalized older adults and simultaneously create the expectancy of their reliance on that hospital care. The result is a downward spiral of over-reliance on high carbon hospital care, worsening the planetary crisis and structuring acute care that generates more difficulties for older patients than it resolves. Viewing ageing as a problem then prophecies health care that is as unfriendly to older people as it is to the planet.

The ageing problem—and with it the ageist, healthist, and ableist beliefs that undergird it—shapes a narrative that knowledge and evidence cannot penetrate. Data support assessing and improving mobility to support health in later life holds no sway over reactions to risk of falls that promote immobility. Robust evidence on preventing, assessing, and intervening in delirium matters little in the face of labels like ‘pleasantly confused’ and risky measures to exert control over the agitated behaviours of delirium. Discharge to a nursing facility is rarely viewed as avoidable and is more held as inevitable, no matter the distress it might cause to the older person and those whom they love. Unquestioning acceptance of immobility, cognitive impairment, and institutionalization, among other phenomena, is emblematic of the primary inequities that ageism creates in hospitals and across health care.

Overcoming the limitations of hospitals for older people means making hospitals and all healthcare both age and planet friendly. Age and planet friendly hospitals begin, as with sustainable hospitals providing lower carbon care, outside the institution itself and before hospitalization. Ageism balloons in the same way that carbon and greenhouse gas emissions are inflated across the acute care sector. For age friendly—and more planet friendly—hospitals, health care must be transformed. Across the healthcare industry, we nurses must help remake all sectors, services and processes to support health and function as means to limit over- and misuse of hospitals while promoting a focus on both age and planetary equity.

Our nursing focus on health and wellbeing easily combines with a functional perspective from the rehabilitative disciplines. Health, function, and wellbeing help shift the balance of structural ageism and emphasize the planet as our broader environment. Truly remaking hospitals consequently requires significant transformation across the rest of health care. Transformation must recast the function of hospitals and their place in healthcare systems just as it must replace ageism, healthism and ableism with age friendliness. Hospitals cannot exist sustainably as the centre of health care while we are all contending with a triple planetary crisis. Home and community-based settings for public, primary and function-focused care are the core of sustainable and age friendly health care.

Now is time to gather our allies, accrue our evidence, and marshal our resources to create age and planet friendly hospitals and healthcare systems. Just as our planet cannot wait, neither should those who endure ageist, healthist and ableist expectations and age unfriendly care within or outside hospitals. Every person hopes to age healthfully and we, as human beings and as nurses, both share and must support that hope. With that in mind, please take time to read the editorial proffered by Abbasi and colleagues (2023) that we, the International Journal of Older People Nursing, are publishing with many other journals across disciplines and around the world. Share it widely with colleagues, students and others across your networks.

The International Journal of Older People Nursing welcomes manuscripts reporting on initiatives to replace ageism and other damaging forces with age friendly and planet friendly care in hospitals and other settings. We welcome reports of investigations into replacing hospital over- and misuse with age and planet friendly community-based and in-home programmes. We are particularly interested in hospital and community partnerships and projects engaging older people, their families, friends, and neighbours in age and planet friendly healthcare transformation in culturally congruent ways in countries around the world. We invite those not yet ready to publish their experiences with age and planet friendly transformation to share their insights via social media on X (formerly Twitter) tagging our handle @IntJnlOPN and on Facebook at https://www.facebook.com/IJOPN/—just remember to include the hashtags #AgeFriendly #Greenhealth #GreenHealthcare and #GeroNurses with every post.

The author has no conflicts of interest to declare.