Older adults are at disproportionate risk of becoming seriously ill and requiring hospital care, whether it is an emergency department, on a medical or surgical ward, or in a critical-care unit. Adults aged 60 and above account for 35% of acute-care hospital admissions and nearly 50% of hospital expenditure for all adults.1,2 While many principles of acute hospital care are the same for all age groups, the elderly patient population is at increased risk of comorbidities and accompanying medications, functional decline and cognitive impairment. Therefore, there are several issues related to the hospital admission, stay and discharge that deserve specific attention when considering the care of the geriatric population. The care of hospitalized elders requires a systematic approach to the evaluation and management of commonly seen geriatric conditions and perhaps implementation of structural changes specifically designed to address the needs of an often medically complex and potentially vulnerable population.3,4
Reason for Admission for Geriatric Patients
The major diagnoses for which older adults are hospitalized are related to chronic diseases, particularly cardiovascular and respiratory conditions. The five most common conditions, accounting for 24% of hospital admission diagnoses, are listed in Table 1. Also common and important to recognize, but less likely to be reported as the reason for admission, are conditions more likely to occur in older adults such as failure to thrive, falls, adverse drug effects, or change in mental status. In addition, older adults may be admitted with an atypical presentation of another condition, such as when change in mental status is due to urinary tract infection. Often the reported diagnosis for a hospitalized older patient may not fully capture the underlying reasons that necessitated the admission and does not explain the hospital course and subsequent health status of the patient. In addition to the primary problems that led to the admission, the effect of comorbid chronic diseases must be considered. Over 60% of elderly patients have two or more major chronic diseases. Comorbid chronic diseases have several consequences for the hospitalized elder and for the clinician. Multiple diseases often mean multiple outpatient physicians and multiple medications. Multiple medications, can result in confusion about medications, difficulty with medication reconciliation and drug adherence, and adverse drug events.5 In older adults, especially those 75 years and older, common conditions such as vision or hearing impairment, mobility impairment and fall risk, poor nutrition, incontinence, depression, cognitive impairment and functional impairment often occur in conjunction with the major chronic diseases that lead to the hospital admissions.
Conditions commonly seen in older patients are often labeled as ‘geriatric’ and can contribute to the need for acute admission, and will substantially influence the hospital course and discharge plans. Cognitive impairment, one such geriatric condition, is a major risk for delirium, which is associated with longer hospital length of stay, greater functional disability and increased mortality following hospitalization.3
At the time of admission, much of the focus is on evaluation and management of a disease-specific, perhaps life-threatening illness. However, elderly patients should be screened for issues of importance in the care, particularly issues that are likely to affect the course, treatment and prognosis of the illness that precipitated the hospitalization.6
Hospital admission is an important time for medication review. Clarification of the patient’s medications, often prescribed by multiple physicians, and identification of potential adverse drug reactions (ADR) are two important aspects of medication review. ADR lead to one-third of the hospital admission in the elderly. Aging is not the only predictor of ADRs: polypharmacy is also an important factor. There are certain medications or classes of medication that have been identified by expert consensus panels as being high risk for ADRs in elderly patients; Tables 2-6 list the Beers criteria. These high risk medications such as sedatives, psychoactive drugs and analgesics should be avoided if possible.7
There are not precise definitions of frailty; many studies have shown that patients of advanced age, 80 and above or with functional impairments are the most vulnerable and should be considered ‘frail’. Frailty puts patients at risk for further functional and cognitive decline, delirium and prolonged hospital stay, increased costs and mortality. Identification of frailty at admission should alert the physician to the need to further evaluate for dementia and other geriatric conditions.3
Functional measures are strong predictors of mortality and contribute more to prognosis in hospitalized older patients than comorbid illness, disease severity and diagnosis. Assessing activities of daily living (ADLs) and instrumental activities of daily living (IADLs) are well-known measures of functional impairment. Any documented mobility of ADL impairment should trigger physical therapy and /or occupational therapy assessment and should signal the need to institute early mobilization.8
Screening for dementia is particularly important in the elderly patient who is losing weight, noncompliant with mediations and readmitted to the hospital. Impaired judgment can impact a patient’s ability to make sensible health decisions. While diagnosis of dementia is based on DSM-IV criteria, two common screening tools are Mini-Mental Status Examination (Table 7) and the Mini-Cog Screening (Table 8). Impairments on either test should result in active planning for cognitive stimulation and comprehensive discharge planning.
Hospitalization presents many hazards for older patients. The elderly are at five times increased risk for iatrogenic complications during hospitalization. Older patients have an average 35% risk of functional decline during acute hospitalization. In addition, they are at increased risk for the development of delirium. Thus, considerable attention must be given to creating a systematic approach to preventing and treating common hospital complications in the geriatric population.
Delirium is an acute confusional state marked by inattention and a fluctuating course. The confusion assessment method is frequently used to diagnose delirium (Table 9).9 The incidence of delirium in hospitalized older patients is as high as 50% and is associated with increased mortality and hospital length of stay. Delirium in elderly patients can be present atypically, such as in the hypoactive form where it often goes unrecognized by physicians and nurses. Many aspects of hospitalization promote delirium for the older patient. The change in environment is disruptive to the patient’s daily routine. Pain, interruption of sleep patterns, and several classes of medications as listed in Beer’s criteria are important risk factors for delirium. Effective measures to prevent delirium include orientation protocols, environmental modification, early mobilization, use of visual and hearing aids, adequate pain treatment and reduction in polypharmacy.
Immobility and Falls
Older hospitalized adults are at greater risk of falling due to the effects of acute illness along with unfamiliar environment and side effects of treatment. While all elderly patients are at risk for falling, the risk of falls increases with age. Multiple factors that can identify patients at the highest risk (Table 10).10 Several strategies can help prevent falls in the hospital setting, such as avoiding medications that might increase the fall risk and close supervision with ambulation for patients who are at risk for fall. Time out of bed throughout the day should be encouraged in order to prevent orthostatic hypotension associated with prolonged immobility; intravenous lines and urinary catheters should be discontinued as early as possible.11
Older patients have an increasing rate of nocosomial infections due to underlying health conditions, poor nutritional status and severity of illness. Atypical presentations are quite common, hence fever may not be present in older adults with active infection. Commonly seen infections in older hospitalized patients include:
Pneumonia - Hospital-acquired pneumonia (HAP) is pneumonia that occurs 48 hours or more after admission. The most significant risk factor for HAP is mechanical ventilation. Patient with advanced dementia, severe Parkinson disease, or stroke, are also at high risk for aspiration pneumonia. Preventive measures include avoidance of acid-blocking medications, attention to oral hygiene, and feeding in an upright position.
Urinary Tract infections - Urinary tract infection associated with urinary catheters are the leading cause of secondary nocosomial bacteremia, which is associated with high mortality. The most effective strategies to reduce urinary infections are avoidance of unnecessary catheterization and catheter removal when this is no longer indicated.
Standard precautions are recommended in the care of all hospitalized patients to reduce the risk of infection transmission between patients and healthcare workers. Precautions include hand hygiene before and after every patient contact; use of gloves, gowns, and eye protection for situations in which there is exposure to body fluid.
Poor nutrition for older hospitalized patients may result from several factors such as impaired cognition, poor appetite, restriction of movement, difficulty in selffeeding and restricted diet orders. In-patient assessment by a nutritionist can identify nutritional deficiencies in older patients, and combined with subsequent nutritional follow-up following discharge, may decrease mortality. In malnourished geriatric patients, providing the liquid diet supplements may improve survival rates.12
Several host and environmental factors increase the risk of developing pressure ulcers during hospitalization in older patients, including poor nutritional status, incontinence, immobility and neurologic impairment. Optimizing nutritional status and limiting the time spent in one position can help prevent pressure ulcers. Patients who are bed-bound should be repositioned at least every two hours and pressure-reducing products for patients at increased risk of ulcers should also be used.
Although limitations in the physiologic reserve for older patients are largely not modifiable, there are several strategies that can improve outcomes for older adults when implemented on a hospital–wide basis.
Multidisciplinary team - Multidisciplinary teams strive to integrate all care providers into the daily assessment and plan of care for older patients. Including input from the attending physician, geriatrician, nursing staff, physical therapists and dietician, can enhance the quality of care provided to the complex, frail elderly patients. The benefits of multidisciplinary care have been demonstrated in shorter length of stays, lower rate of complications and reduced hospital cost.13-15
Since not all hospitals have the resources to provide specialized units for older patients, some programs have attempted to re-create the core elements of multidisciplinary care units for hospitalized older persons who are not located in a single unit. Some hospitals have combined hospitalist-directed care with mobile geriatric care teams to provide enhanced care to older patients throughout the hospital. In a trial comparing hospitalized patients age > 75 assigned to an intervention involving an interdisciplinary geriatric team or usual care, patients who were assigned the intervention were associated with a lower rate of adverse events, shorter hospital stays and better satisfaction.16,17
Checklists and order sets - Checklists can improve the quality of care for older patients by integrating reminders into everyday care to ensure practice standards are met. Checklists can be tailored to remind staff about specific geriatric issues such as daily patient mobilization, readdressing the need for catheters, and assessing for the presence of delirium.
Early mobilization programs - It is important to ensure that patients are mobilized early and often during their hospitalization. Mobilization can help prevent falls. Observational studies find that increased mobility in the hospital is associated with less functional decline during hospitalization and shorter lengths of stay.18-20
Older adults represent a large and growing segment of hospitalized patients and are at high risk of complications during hospitalization, including falls, delirium, adverse drug events, infections, and death. The assessment of older hospitalized adults should extend beyond the traditional history and physical to include: assessment of physical function and cognition; social support; living situation; as well as an evaluation for possible polypharmacy. Many adverse outcomes encountered by older adults during hospitalization can be prevented. Some hospital-wide strategies are associated with improved outcomes for older adults, including care involving multidisciplinary teams, checklists, and early mobilization programs.
Table 1: Most frequent conditions causing hospitalization among older patients, 2003.
Table 2: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
Table 3: 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Due to Drug-Disease or Drug-Syndrome Interactions That May Exacerbate the Disease or Syndrome.
Table 4: 2012 AGS Beers Criteria for Potentially Inappropriate Medications to Be Used with Caution in Older Adults.
Table 5: First- and Second-Generation Antipsychotics.
Table 6: Drugs with Strong Anticholinergic Properties.
Table 7: Mini-Mental State Examination.
Table 8: Mini-Cog screening.
Table 9: Confusion Assessment Method (CAM) screening.9
Table 10: Fall risk factors and associated relative risk.10