A key component of the CGA is a functional assessment. Functional assessment allows patient-centered goal setting and provides information for measuring progress and predicting prognosis. It also helps to understand the impact of disease and disability on the older person and the caregiver. The basic ADLs include self-care activities such as eating, toileting, bathing, dressing, transferring, and ambulation [31]. Instrumental ADLs are composed of those activities that foster independence in the community and encompass housekeeping, cooking, shopping, managing finances, using telephone, managing medications, and transportation [31]. In many cases, functional assessment relies on patients and/or family caregivers who are asked to report on ADLs. Where self-less reliable (e.g., in dementia patients), informant-based questionnaires, and direct observation by nurses and occupational therapists may be necessary. A number of validated tools are available for functional assessment of older persons, such as the Barthel Index [32], Functional Independence Measure (FIM) [33], Physical Self-Maintenance Scale [34], and Lawton Brody Instrumental Activities of Daily Living Scale [35]. As mobility is of central importance to accomplishing most functional activities, assessment of physical activity status, gait, and balance is also an important aspect of the functional assessment. The functional assessment is of diagnostic and therapeutic relevance in the management of hospitalized older person in several ways:

About 30% of the community-dwelling older persons fall each year [11]. Older persons are more likely to suffer serious injury than younger persons as a result of same-level falls [36]. More than 90% of hip fractures are associated with falls, and most occur in persons above the age of 70 years [37]. Falls contribute to functional decline, social isolation, depression, and need for permanent residential care [38]. In the acute setting, 3–20% of inpatients fall at least once during their hospital stay [39]. Falls in older people are multifactorial. Intrinsic risk factors for falls include age, previous history of falls, gait and balance disorders, cognitive impairment, visual impairment, ADL disabilities, and medication use [40, 41]. Extrinsic risk factors include cluttered environment, poor lighting, uneven floors, and use of restraints such as indwelling catheters and chest drains [41]. Acute illness and medication side effects are common precipitants of falls. Older persons who present to the hospital with a fall, give a history of recurrent falls in the past year, or have abnormalities of gait and/or balance should be offered a multifactorial fall-risk assessment [42]. A number of fall-risk assessment tools have been developed; however, only a few tools have been tested in more than one setting [43], and most tools discriminate poorly between fallers and non-fallers [44]. The STRATIFY tool [45] and fall-risk assessment tool [46] have been reported to have good positive- and negative-predictive value in the acute care setting [43]. Patients identified as at risk of falling should be considered for multifactorial intervention by multidisciplinary teams targeting risk factors [42]. Risk factors for falls in older persons are multivariate, and there is limited evidence to support any single intervention. On the other hand, multicomponent interventions targeting risk factors have been shown to reduce falls in various settings [47, 48]. Exercise is often a key component in successful multifactorial falls intervention programs. Group or individual exercise, balance training, and tai chi have been shown to reduce both risk and rate of falls [47] in the community setting. Additional interventions supported by evidence in this setting include home safety assessment and hazard reduction, gradual withdrawal of psychotropic medications, correction of vitamin D insufficiency, cardiac pacing for cardioinhibitory carotid sinus hypersensitivity in patients with unexplained falls, first cataract surgery for the appropriate eye, and restricted bifocal spectacle use [47]. Supervised exercise and vinyl flooring (as opposed to carpeting) have been shown to reduce falls in the acute hospital setting [48].

Osteoporosis treatment is an important component of the management of future fracture risk. Assessment should include a focused history to identify risk factors for low bone mineral density (BMD), falls, and resultant fracture [49]. Diagnosis of osteoporosis is by hip and lumbar vertebral BMD measurement using dual-energy X-ray absorptiometry. Non-pharmacologic management of osteoporosis includes lifestyle counseling with regard to smoking cessation, limiting alcohol intake, regular weight-bearing and muscle-strengthening exercise, and taking adequate calcium and vitamin D intake [50]. Vitamin D deficiency and hypocalcemia should be corrected before commencing antiresorptive treatment [51]. Oral or intravenous bisphosphonates and the human monoclonal antibody denosumab are approved for primary and secondary prevention of vertebral, non-vertebral, and hip fractures in men and postmenopausal women. Raloxifene is approved for secondary prevention of vertebral fracture in postmenopausal women. We reserve teriparatide for patients who do not respond or tolerate first-line treatments. BMD measurement should be repeated in 1-3 years after initiating treatment and thereafter at longer intervals if BMD is stable. The optimal duration of treatment is debatable, but in patients with moderate 10-year fracture risk, bisphosphonate treatment may be continued after 5 years [51]. Patients at high risk of fracture may be treated with bisphosphonates for up to 10 years before giving a drug holiday; alternatively they can be switched to bone formation therapy after 5–10 years [51].

Delirium is common in hospitalized patients, with reported prevalence of 10–31% among medical inpatients [52]. Incident delirium is particularly common in the postoperative period [53]. Delirium is associated with increased hospital-acquired complications, length of stay, mortality, and discharge to long-term residential care [52]. Recent evidence also suggests delirium may lead to permanent cognitive decline and dementia in some patients [54]. Vulnerability to delirium can be viewed as a marker of diminished cognitive reserve. Factors predisposing to delirium include dementia, previous episode of delirium, cerebrovascular disease, multiple comorbidities, functional impairment, sensory impairments, polypharmacy, depression, and alcohol abuse [55]. There are a number of tools available to screen hospitalized older persons for delirium. The Confusion Assessment Method (CAM) [56] diagnostic algorithm acute onset and fluctuating cognitive dysfunction, inattention, disorganized thinking, and altered sensorium. It can be completed at the bedside within minutes and can be used to both rule in and rule out delirium (positive likelihood ratio 9.6 and negative likelihood ratio −0.16) [57]. Multicomponent interventions that target risk factors implemented by skilled interdisciplinary teams are known to prevent delirium [58]. Such interventions include orientation, ensuring adequate hydration and nutrition, sleep hygiene, pain management, optimizing hearing and vision, reduced use of psychoactive medications, reducing restraints such as intravenous lines and indwelling urinary catheters, and early mobilization [59]. There is insufficient evidence at present for the use of pharmacological interventions such as antipsychotics or choline esterase inhibitors in primary prevention of delirium [59]. Management of delirium involves removal of precipitating factors, symptom management, preventing complications such as pressure injuries and falls, and providing education and support to the carers. Antipsychotics and sedatives do not improve prognosis and can paradoxically prolong delirium and worsen cognitive dysfunction. Therefore, these agents should be reserved for patients with severe agitation or having distressing psychotic symptoms.

Around 40% of the hospitalized older persons above the age of 65 years have dementia, although only about half of them have been previously diagnosed [60]. Hospitalized patients with dementia have higher mortality than others [60]. Identifying those with dementia is important to formulate an appropriate inpatient and discharge care plan, including follow-up. However, the diagnosis of dementia in hospital setting is complicated by the potential concurrence of delirium, and cognitive assessments undertaken in hospital may not accurately reflect premorbid cognitive functioning. There may be reasons other than dementia and delirium for hospitalized patients to perform poorly on cognitive screening, such as acute illness, poorly controlled pain, psychoactive medication, anxiety and depression, and poor engagement [61]. Therefore, results of single cognitive tests should be interpreted with caution, and progress should be assessed with further tests as indicated. A number of validated tools are available for cognitive assessment such as MMSE and MOCA; however, a recent systematic review showed lack of evidence to help clinicians to select a validated tool in the hospital setting; the mostly researched instrument was the AMTS, with a score of <7 predictive of dementia with a sensitivity of 81% and specificity of 84% [62].

Although depression is common among hospitalized older persons, with weighted prevalence estimated around 17%, it is often unrecognized [63]. Symptoms of depression in acutely unwell older adults can be difficult to separate from those of the physical illness. Concurrent depression adversely affects the outcome of a number of medical conditions, compliance with treatment, engagement with rehabilitation process, and in-hospital mortality [64]. Depression is a risk factor for Alzheimer’s disease and is a common psychological symptom of all disease stages of dementia [65]. Guidelines recommend that hospitalized older persons be screened for depression. The Geriatric Depression Scale (GDS) has been widely evaluated in the general hospital setting, and a cutoff of 5 or 6 out of 15 has a sensitivity of 79% and specificity of 77% for diagnosing depression [66]. The Cornell Scale for Depression in Dementia (CSDD) [67], which combines the patient interview, direct observation, and caregiver report, is more appropriate for screening dementia patients for depression.

Orthostatic hypotension (OH) is defined as a drop in systolic blood pressure by 20 mmHg or diastolic blood pressure by 10 mmHg, compared to supine blood pressure, within 3 min of standing [68]. The prevalence of OH is reported to be between 5% and 30% [69]. OH is a risk factor for syncope [70], falls [71], cognitive impairment [72], and hospitalization. OH is also an independent predictor of mortality in older persons [73]. OH is an important consideration in the treatment of hypertension in older persons, as cardiovascular drugs are a common cause of OH [74]. OH in older persons is often multifactorial; contributing causes may include volume depletion, anemia, prolonged bed rest, autonomic neuropathy (e.g., diabetes, amyloidosis), primary autonomic failure, Parkinson’s disease, stroke, cardiac disease, and endocrinopathies such as hypoadrenalism and pheochromocytoma [75]. Evaluation should begin by identifying reversible causes and underlying associated medical conditions. Blood pressure should be measured supine and 3 min after standing. Head-up tilt table testing should be considered where there is a high pretest probability of OH despite negative bedside evaluation and in patients who are unable to stand for blood pressure measurement [76]. Non-pharmacologic management includes discontinuing potential medications contributing to OH, ensuring adequate hydration and sodium intake, avoiding alcohol, exercise program to improve conditioning, teaching physical maneuvers (e.g., squatting, bending at waist), and abdominal and lower limb binders [75]. Patients with postprandial symptoms should be advised to avoid large carbohydrate meals [75]. In patients with persistent symptoms despite these measures, a trial of pharmacologic therapy is indicated. Fludrocortisone is often used as the first line. Other treatment options include midodrine and other alpha-adrenergic agents, desmopressin, octreotide, and erythropoietin [77].

Polypharmacy, or the concurrent use of multiple medications, is a common problem in older persons that can lead to reduced medication compliance, lack of efficacy, adverse drug reactions, drug interactions, and iatrogenic illness [78]. The appropriate management of medications is one of the most important areas in geriatric medicine. Medication review should therefore be a key component in geriatric assessment. This should start by taking an accurate medication history. Discrepancies between what the patient has been prescribed and what they are actually taking are common. Asking the patient or the caregiver to bring all prescribed and checking patient’s understanding about the indications, benefits, and potential adverse effects allow a more accurate picture of current medication use. Medication review should be viewed as an opportunity to identify any inappropriate medications (errors of commission) and potentially beneficial medications that may have been overlooked (errors of omission). Inappropriate prescribing can lead to increased healthcare utilization and adverse clinical outcomes [79]. On the other hand, in some patients, multiple medications are indicated for optimal management of comorbidities, and therefore undertreatment should be avoided [80]. There are published lists of potentially inappropriate medications for the older persons to guide treating physicians; examples include the Beers Criteria [81], Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP), and Screening Tool to Alert doctors to the Right Treatment (START) [82]. In the hospital setting, clinical pharmacists can provide assistance with medication review, reconciliation, and discharge counseling, which has been shown to improved clinical outcomes [83]. Older persons with multiple comorbid conditions are often excluded or underrepresented in clinical trials [84], and care should be taken when extrapolating evidence to frail older persons, as unintended adverse effects may overweigh potentially modest benefits. Prescribing considerations should include patient’s goals of care, remaining life expectancy, and age-associated physiological changes.

Pressure ulcers are the result of pressure and/or shear forces, usually over a bony prominence. These are associated with extended length of stay, increased incidence of hospital-acquired infections and other complications, and increased healthcare costs [85]. Risk factors include advanced age, low body mass index, hypoalbuminemia, malnutrition, immobility, cognitive impairment, urinary or fecal incontinence, and diabetes [86]. Pressure ulcers are a potentially preventable adverse event. About one third of emergently admitted hospital patients may acquire pressure ulcers soon after their admission [87]. Therefore, risk assessment and preventive interventions should start early during the hospital stay. Studies have not shown significant differences between nurses’ clinical judgment vs. various risk assessment tools such as the Waterlow, Braden, Cubbin and Jackson, and Norton scales in reducing pressure ulcer incidence [86]. Advanced static mattresses and overlays, and alternating-air mattresses or overlays have been shown to reduce the pressure ulcer incidence compared with standard hospital mattresses [86, 88]. It is not clear if powered surfaces are better than non-powered surfaces, and cost should be taken into consideration when deciding between them [88]. There is no clear evidence that nutritional supplementation, repositioning, heel supports and boots, wheel chair cushions, or various dressings prevent pressure ulcers [86]. Dry skin is a risk factor for pressure injury, and there is weak evidence that a skin cleanser other than soap, and a fatty acid containing cream, reduces risk of pressure ulcers [86].

Urinary incontinence is rarely the reason for hospitalization but can be a sign that the older person is experiencing other health problems. Around 35% of older adults are incontinent at some stage during acute hospital stay [89]. Incontinence in acute care setting is associated with urinary tract infection, immobility, and cognitive impairment [89]. A number of medications such as diuretics, hypnotics, narcotics, antipsychotics, and anticholinergics agents can affect the older person’s ability to toilet successfully by direct or indirect mechanisms [90]. Several types of incontinence may coexist due to the presence of multifactorial etiologies. Assessment should comprise, at least, a focused history, physical examination including the genitourinary and nervous systems, a stress test, urinalysis, and measurement of post void residual volumes. Management depends on the type of urinary incontinence and underlying causes identified. General measures include treating any urinary tract infection, avoiding constipation, stopping offending medications, attention to orientation, providing regular toilet assistance, and use of appropriate continence aids [91].

Older persons take longer to functionally recover than to medically recover. Once patient is medically stable, every effort must be made to prevent further decline and to help return to functional independence. Discharge planning should begin early during the hospitalization, and carers should be engaged in the discharge planning process as key members of the older person’s care team. Patients who are slow to progress and therefore need a coordinated multidisciplinary strategy of restorative care should be identified early. Some of these patients may benefit from referral to an inpatient geriatric rehabilitation unit or a day hospital. Short- and long-term goals toward achieving maximal functional independence should be set, and future medical, physical, psychological, and accommodation needs of the older person should be identified. Referral to appropriate home and community support services may be needed to provide additional support at least in the early post-discharge stage. It is crucial that the hospitalist liaise with patient’s family physician with regard to medication changes, services arranged, and post-discharge care plan prior to discharge.

Mrs. Smith was worked up for infection and turned out to have a lower urinary tract infection. The rest of the septic screen was negative. She had recurrent falls from the history given by her daughter. Her bone scan showed recent L4 fracture. She was found to have orthostatic hypotension. Medications were reviewed and indapamide was ceased; potential benefits vs. risks of warfarin and statins were discussed with her and the family. Her delirium resolved, and she was discharged home with social support to be followed up in geriatric outpatient clinic.