The nearly 25% of adults 65 years and older who are hospitalized each year represents a higher proportion than for any other age group. Many of these older adults experience protracted or permanent functional decline and worsening health after their acute hospital stay. Although people 65 years and older comprise only about 12% of the U.S. population, they account for one-third of acute hospital admissions and about 46% of the national costs for acute hospital care.

National data show that older hospitalized patients have a more complex hospital course than younger hospitalized patients (Table 17-1). In 2003, the length of stay for patients 65 years and older was 1.7 days longer than for those under 65 years old, although the length of stay for the major discharge diagnoses has dropped since 1997. The mean total hospital costs were 46% higher for the 65 years and older group compared with the younger group. Hospital costs for older patients have increased over 25% since 1997. Although hospital deaths are decreasing, people 65 years and older have nearly five times the in-hospital mortality as younger hospitalized patients.

While many principles of acute hospital care are the same for all age groups, the elderly patient population is at increased risk of collecting comorbidities and accompanying medications, functional decline, cognitive impairment, and dwindling social supports. Therefore, there are several issues related to the hospital admission, hospital 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 this often medically complex and potentially vulnerable population.

Reasons for Admission for Geriatric Patients

The major diagnoses for which older adults are hospitalized are related to chronic diseases and respiratory conditions. The 15 most common conditions, accounting for 48% of the hospital admission diagnoses, are listed in Table 17-2. 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 maybe admitted with an atypical presentation of another condition, such as when change in mental status is due to underlying fluid and electrolyte disorder or urinary tract infection (UTI). 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. While many of the 15 most frequent conditions reported as causes for hospitalizations among older adults represent acute exacerbations of chronic diseases, the reasons why a stable older adult with heart failure suddenly decompensates or a 90-year-old assisted living resident is admitted with a broken hip, often relate as much to the physical and/or social vulnerability of many older adults as to their complex health status.

In addition to the primary problems that led to the admission, the effect of comorbid chronic diseases must be considered. Over 60% of Medicare patients have two or more major chronic diseases and 24% have four or more. In 2004, people 65 years and older admitted to the hospital had an average of 2.3 comorbid conditions. Comorbid chronic diseases have several consequences for the hospitalized elder and for the clinician. Multiple diseases often mean multiple outpatient physicians, complicating communication between inpatient and outpatient providers. Multiple diseases lead to the use of multiple medications. Multiple medications, even if indicated, can result in confusion about medications, difficulty with medication reconciliation and drug adherence, and adverse drug events (ADEs) including amplified side effects, drug–drug or drug–disease interactions, and errors in drug administration. A high burden of chronic disease can lead to self-care difficulties, patient and caregiver frustration and burnout, and physiological instability for the patient.

In older patients, 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 hospital admissions. For example, 2004 data from the Health and Retirement Survey (HRS), a nationally representative health interview survey sponsored by the National Institute on Aging demonstrate that the geriatric conditions of falls and incontinence are common in older adults with heart failure, coronary heart diseases, and diabetes (Table 17-3).

Conditions commonly seen in older patients often labeled as “geriatric” conditions can contribute to the need for the acute admission, and substantially influence the hospital course and discharge plans. Cognitive impairment, one such geriatric condition, is a major risk for delirium. At admission, it may be impossible to distinguish between delirium and dementia or to determine a patient’s baseline cognitive performance. Delirium is associated with longer hospital length of stay, greater functional disability, and increased mortality following hospitalization. Several prospective studies have documented that hospital mortality is related to nutritional status, cognitive dysfunction, and functional disability. These factors independently predict mortality even when the comorbid diseases and diseases leading to hospitalization are considered.

Often physicians caring for an acutely ill, unstable or unsafe older adult who requires acute hospitalization are advised to identify or “screen” for frailty. There is as yet no universally accepted definition or measure of frailty. The term “frail” tends to be used to refer to an older adult who is physiologically or socially vulnerable. Recently, researchers have tried to develop empiric definitions of frailty, which, while promising, may not yet be clinically applicable. The idea of a vulnerable or at-risk elderly person may be clinically more helpful. The presence of comorbid conditions, functional decline, cognitive impairment, or inadequate or abusive social situations suggests vulnerability. Since functional decline and cognitive impairments increase with age, the advanced age of a patient (e.g., >75 years) may strongly factor into a clinician’s decision to “screen” for risk of frailty and perform screens of memory, functional status, hearing, and sight, and take an in-depth social history during the hospitalization. These issues require attention from the admission process through discharge planning and postacute care transitions.

Geriatric conditions can be the reason for admission. Examples include falls or “failure to thrive,” defined as poor nutrition and weight loss associated with diseases, dementia, functional disability, and sometimes inadequate caregiving. Assessment of comorbidities and geriatric conditions (e.g., falls, failure to thrive, dementia, urinary incontinence) upon admission and during the hospitalization with simple screening questions and physical evaluation will help the clinician operationalize the ideas of “vulnerable” and frail, and provide targets for therapy such as increased nutrition, physical therapy, glasses, and hearing aids. Social issues, such as inability to buy medications, inadequate caregiving and/or insufficient help at home, elder neglect and abuse, and elder self-neglect are unfortunately relatively common. They can be missed if they are not specifically considered and investigated.

Admission Screening

At the time of admission, much of the focus is on evaluation and management of a disease-specific, perhaps life-threatening illness. However, the admission also provides an opportune time to screen for issues of importance in the care of elderly patients, particularly issues likely to affect the course, treatment, and prognosis of the illness that precipitated the hospitalization. Important components of the admission screen are described.

Communication with Family and Primary Care Providers

While many patients can provide accurate descriptions of their home situations and presenting symptoms, every effort should be made to discuss these issues with family members who can often provide additional information about social issues that may have contributed to admission or who may describe symptoms or events that help clarify the admitting diagnosis. Older patients often present with complex symptoms and atypical presentations of disease requiring increased attention to the factors that led up to the admission. Similarly, the patient’s primary outpatient provider of care should be contacted. It is increasingly common for patients to be cared for by inpatient physicians, such as hospitalists, who do not care for patients in the outpatient setting. This means many elderly patients are being “handed-off” at admission. Studies have shown that most primary care providers want to be contacted at admission. Primary providers can help clarify the acute problem and can provide a more complete medical history including other comorbid conditions, previous diagnostic testing, and response to previous treatments. Depending on the reason for admission and the hospital course, communication with the patient’s specialist physicians may also be necessary.

Medication Reconciliation

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 (ADRs) are two important aspects of medication review. ADRs may lead to hospital admission and are more common as numbers of medications and comorbid illness increase. While age alone is not an independent predictor of ADRs, older patients are more likely to have multiple comorbid conditions and be on multiple medications. In addition, there are certain medications or classes of medications that have been identified by expert consensus panels as being at high risk for ADRs in elderly patients with relatively low clinical benefit and often a safer alternative medication exists. These high-risk medications should likewise be identified and discussed with the primary care physician. Careful attention should be paid to medications most likely to lead to ADRs including analgesics, sedatives, cardiovascular medications, and psychoactive drugs. Regulatory bodies, such as the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), are requiring that all institutions have a process in place to reconcile, or review, medication lists for high-risk or unnecessary medications. This process needs to happen throughout the hospitalization, but is especially important at admission. Medication reconciliation is a time-consuming, but important process involving a rigorous review of each medication for appropriateness in conjunction with comorbidities and the other medications the patient is taking and requires discussion with the primary care physician and, often, specialty physicians at the point of discharge for continuity of care, best drug choices, and safety. Aspects of medication reconciliation can be aided by computerized physician order entry systems and clinical pharmacists.

Identify Frailty

While precise definitions of frailty are elusive, studies have shown that patients of advanced age (e.g., >80 years) or with functional impairments are the most vulnerable and should be considered “frail.” At least one survey of a general medicine service in an urban medical center estimated 25% of elderly patients were frail or vulnerable, according to the Vulnerable Elderly Survey-13 tool that scores age, self-perceived health, and aspects of functional status to predict increased risk of morbidity and mortality. Frailty puts patients at risk for further functional and cognitive decline, delirium, prolonged hospitalization, increased costs, and mortality. Identification of frailty at admission should alert the hospital physician to the need to further evaluate for dementia and other geriatric conditions and can help frame discussions about prognosis. It also signals the need to start advanced discharge planning.

Functional Screen

Functional measures are stronger predictors of mortality and contribute more to prognosis in the hospitalized older patient than comorbid illness, disease severity, and diagnoses. Assessing activities of daily living (ADLs) and instrumental activities of daily living (IADLs) are well-known measures of functional impairment. The hospital physician should also be comfortable in performing routine assessments of mobility, such as the “Get Up and Go” test (see Chapter 115). Any documented mobility or ADL impairment should trigger physical therapy and/or occupational therapy assessments and should signal the need to institute early mobilization and early institution of discharge planning.

Dementia Screen

Screening for dementia is particularly important in the elderly patient who is losing weight, noncompliant with medications, admitted from a nursing home or readmitted to the hospital. Impaired judgment and insight can impact a patient’s ability to make health decisions, discuss end-of-life issues, and live independently after discharge. It also identifies patients at risk for the development of delirium in the hospital and readmission after discharge. While diagnosis of dementia is based on DSM-IV criteria, two common screening tools, the Mini-Mental Status Examination (MMSE) and the Mini-Cog (see Chapters 11 and 12), can be used to quickly identify patients at high risk for dementia. Both tests have similar sensitivities, but the MMSE is the only one to have been validated in the hospital setting, while the Mini-Cog is faster to perform. Impairments on either test should result in active planning for cognitive stimulation during the hospitalization, comprehensive discharge planning instituted at the beginning of the hospital stay, and family/caregiver involvement.

Hospitalization presents many hazards for older patients. While the outcome of hospitalization is dependent on the severity and type of acute illness and the patient’s baseline vulnerability, elderly patients 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. After discharge, they are at increased risk for needing institutionalization and hospital readmission. While the hospital may be considered “unsafe” for vulnerable elderly patients, hospitalization is often necessary to treat acute illness. Thus, considerable attention must be given to creating a systematic approach to preventing and treating common hospital complications in the geriatric population. This topic has appropriately generated considerable attention recently among researchers, payors, regulatory bodies such as JCAHO and the federal government, as well as patients and their families.

Common Problems in Hospitalized Elderly Patients

Delirium

The incidence of delirium in hospitalized older patients is as high as 50% and is associated with increased mortality, hospital length of stay, and need for placement in long-term care. Because delirium in elderly patients can present atypically (such as the hypoactive form), it often goes unrecognized by physicians and nurses. Understanding risk factors, making the diagnosis, and instituting strategies for prevention of delirium are critical for the hospital physician.

In a study group of patients >70 years old, risk factors for delirium included severe illness, cognitive impairment (MMSE<24), and BUN / Cr ratio ≥ 18. Precipitating factors for delirium were use of restraints or a bladder catheter, ≥ 3 medications added, an iatrogenic event, and malnutrition (see Chapter 53). Patients at risk for delirium should have targeted strategies to prevent its development. Many institutions have put formal delirium prevention programs into place. These programs are designed to prevent cognitive impairment, sleep deprivation, immobility, dehydration, as well as vision and hearing impairment. The Hospital Elder Life Program (HELP) uses an orientation board and a program of cognitive stimulation to reduce the rate of confusion from 26% to 8%. Even in the absence of a formal program, the hospital physician should have the patient’s family stay overnight if possible, remove unnecessary foley catheters, avoid restraints, eliminate unnecessary medications, order early mobilization and visual / hearing aids, and address dehydration. While attention to these issues by individual physicians is important, the case can also be made for a more systematic, interdisciplinary approach.

Over a 6-month period, a community hospital was able to demonstrate a 14% reduction in the rate of delirium and cost savings of over $600,000 for a 40-bed unit by implementing portions of the HELP program. The program showed sustained results including higher nursing and patient satisfaction. This program succeeded despite limited resources that required them to eliminate portions of the original HELP program.

Immobility and Falls

During an acute hospital stay, the older patient is at high-risk for falls. These inpatient falls are not only common, but carry significant risk of short- and long-term adverse effects for the frail elderly patient. Estimates for inpatient falls among all hospitalized patients range from two to seven falls per 1000 patient-days. However, not all hospitalized patients face the same risk. In a single urban academic center, rates for medical patients were significantly higher (6.2 falls/1000 patient days) as compared to surgical patients (2.18 falls/1000 patient days).

Inpatient falls are frequently associated with injury, with estimates of one-third to almost one-half of falls resulting in injuries. Most concerning is that an estimated 8% of falls result in moderate to severe injuries. These falls and injuries are associated with significant in-hospital adverse outcomes. Patients who suffer falls with injury have longer lengths of stay and higher costs than similar patients who do not suffer a fall. In addition to the in-hospital effects, a fall with injury may lead to serious long-term health outcomes as well. Falls among elderly patients with and without injuries are risk factors for increased use of health care resources in the future, functional decline, loss of independence, higher rates of discharge to extended care facilities, and even death.