The patient must have the capacity for medical decision-making in order to fully engage in a discussion about goals, values, and preferences. Since approximately 1/4 of hospitalized elders lack decision-making capacity, all hospitalists must be skilled in assessing decision-making capacity and must routinely determine this capacity in older patients—not just when prompted by a patient’s unusual behavior or denial of a recommended treatment [15]. Importantly, a patient with dementia may still maintain decisional capacity. The assessment of a patient’s medical decisional capacity involves his or her ability to understand the consequences of a decision. Four elements of a decision-making capacity assessment include: (1) communicating a choice, (2) understanding the question asked, (3) appreciating the situation, and (4) demonstrating reasoning. Capacity is determined in relation to a specific question or situation and must be reassessed as the clinical picture changes [16]. Several tools are available to help structure the assessment including the Aid to Capacity Evaluation tool [17]. Specialty consultants, including psychiatrists, may be brought in when there is evidence for depression or psychosis complicating the discussion. Chapters 4 and 6 also provide information on determining decision-making capacity.

Establishing the patient’s goals, values, and preferences is a very early step in GA. Specific treatment decisions follow this understanding and it should drive the hospital management plan. Determine if the patient has any advance care planning in place (e.g., durable medical power of attorney for health care, living will, etc.) and follow the patient’s desired wishes as best as possible. A helpful framework in discussion with patients with multi-morbidity includes attention to treatment-related risks, burdens, and benefits, including their anticipated life expectancy, functional impairments, and quality of life [6, 18].

To develop a plan of care in alignment with patient/family goals, preferences, and values, engage in a discussion following these guidelines. Before beginning the discussion, be as prepared as you can be with the facts of the case and share this information with the patient and family to ensure understanding. Ask open-ended questions and be prepared to listen and respond to the patient’s questions and concerns. Examples of how to start the conversation include: “What would you like to see happen?”, “What would you like to avoid?”, “What fears or worries do you have about your illness or medical care?”, and “What are you hoping for now?”, and “What is important to you?” Specific issues to discuss (in addition to resuscitation orders and code status) may include (as appropriate) ICU care, dialysis, nutritional support, future hospitalizations, and the role of comfort measures. Confirm understanding of the patient’s wishes at the end of discussion.

With a structured approach and practice, the discussion can be completed within a short time. The benefit to patient, family, consultants, and all involved hospital personnel is invaluable in focusing on the goals of care. In many cases, managing patient and family expectations is a key part of the initial and follow-up discussions.

At times, these expectations may be overly optimistic, failing to appreciate an extremely poor prognosis. Other times, the expectations may be based on age-related stereotypes that unreasonably deny the opportunity for an elder to recover from their acute illness. For example, a family may misunderstand the clinical picture of delirium and acute onset of urinary incontinence (two common adverse effects in the hospital setting) and come to the conclusion that their loved one suffers from dementia and chronic urinary incontinence. They may then believe that they can no longer care for the patient at home. These inappropriate diagnoses, if unchallenged by the hospital team, impact further care. The family may decide that a transfer to a more supervised setting is in their loved one’s best interests, and the family’s lowered expectations for recovery often solidify cognitive and functional losses.

The traditional history and physical includes past medical history, medication review, social history, review of systems, and physical exam. Within these domains, several assessments should be systematically incorporated to elicit important geriatric issues. For example, in addition to gathering the list of medications, directly ask the patient and/or caregiver to describe the strategies they use to ensure medication adherence and carefully consider whether the medications (or lack thereof) could be contributing to the patient’s acute illness. In addition to usual social history questions, ask the patient about any help they require from others to meet their Activities of Daily Living (ADLs) or Instrumental Activities of Daily Living (IADL) needs, or if they feel safe at home. In the review of systems, ask about vision and hearing problems or weight loss in the prior 6 months. For the physical examination, checks of orthostatic blood pressure and gait are very informative. Utilize the hospital team (e.g., nurses, social workers, pharmacists, dietitians, and therapists) to broaden and deepen the assessment in a time-efficient manner (Table 7.2).

It is essential to maintain a high degree of skepticism and carefully re-evaluate the initial diagnosis of older patients admitted through the emergency department. Signs and symptoms due to adverse medication effects are often incorrectly ascribed to a medical or psychiatric problem. Up to 30 % of hospitalizations in the older population involve an adverse medication effect [19]. Although chest pain is the most common presenting symptom of acute coronary syndrome (ACS) in all ages, elderly patients often present with non-typical symptoms, including dyspnea, delirium, GERD, or fatigue [20]. In addition, ACS can be precipitated by other stresses, such as infection or dehydration, further delaying clinical recognition when the symptoms are non-classical. Older adults often have severe infection without fever or other typical signs and symptoms. Even in the setting of pneumonia or sepsis, fever is absent in 30–50 % of elderly patients [21]. Clinically, these infections present as non-specific symptoms of functional decline (abrupt change in self-care ability), a new geriatric syndrome (falls or delirium)—or exacerbation of an underlying chronic condition. There is often a recognized pattern to this common “atypical” presentation of acute illness, whereby the elder’s symptoms are reflective of the system with the least physiologic reserve (termed the “weakest-link principle”) [22].

In addition, the presence of clinically significant chronic kidney disease is often missed (and medications incorrectly dosed) because of pseudo-normalization of the serum creatinine in older adults with low muscle mass and diminished renal function. To avoid this, renal function must be assessed by estimated glomerular filtration rate or creatinine clearance, rather than the MDRD that often appears in lab reports. Dementia or the new onset of acute confusion (delirium) interferes with obtaining a history and assessing symptoms. See Chap. 2 for a discussion of diagnosis and prevention of delirium. Lastly, the negative impact of ageism, combined with the absence of a reliable history, results in the inaccurate assumption of a terminal illness or advanced dementia in a malnourished, confused elderly patient who is suffering from an acute illness.

Finally, a common conundrum for hospitalists: is the excessive information from imaging and laboratory assessments typically developed in a patient admitted through the emergency department. Seniors have many comorbidities and incidental findings. Therefore, often there are data that are irrelevant to the patient’s acute problem. Reviewing these data carefully and deciding what is important or irrelevant requires judgment and thoughtful communication with the patient and family but is important in developing a wise care plan and avoiding iatrogenic complications.

Care transitions (often termed “handoffs,” “discharges,” or “transfers”) can be complicated and costly for older adults with complex needs, and planning for a safe and effective transition of care should begin on the day of admission. Care transitions occur between providers, between levels of care (e.g., from intensive care unit to the floor), or across healthcare settings (e.g., from hospital to a skilled-nursing facility, or hospital to home) and require several, well-orchestrated steps that address patient and family/caregiver, physician/healthcare provider, and health system factors [23]. While making every attempt to respect the patient’s autonomy and privacy, an important first step involves including caregivers and family members in the process.

Elements of transition include care coordination, discharge planning, and disease management and hospitalists are responsible for the patient’s care from admission until the transition of care is complete. Hospitalists are encouraged by the National Transition of Care Coalition to adopt the concept of “transfer with continuous management” [24]. Unless a team-based, structured approach is utilized, key elements can get lost in the transition, resulting in highly fragmented and poor quality care. The transition plan should include a complete and clear medication list (reconciled with preadmission medication list), assessment of cognitive and functional level, lists of diagnoses, pending tests and appointments (and attention to logistical needs), assessment of caregiver needs and resources, and advance care directives. It should also include specific education regarding self-management, warning symptoms or signs (“red flags”) of their disease condition and who to call and what to do when these arise, instructions as to what to expect (including other clinical disciplines that may be involved in care, such as nursing or physical therapy), and how to navigate the next site of care (Table 7.3). At the time of any transition, a brief phone call between the current and receiving provider is very helpful.

Suboptimal care transitions are hazardous to older adults and it impacts safety, costs, functional outcomes, morbidity, and mortality. Current high hospital readmission rates in part are a sobering reflection of our failures in transitional care, and a focus of national scrutiny. Nearly 20 % of Medicare beneficiaries are re-admitted within 30 days, and 30 % are readmitted within 90 days [25]. Risk for poor transitions in older adults include: living alone, limited self-care abilities, poor health literacy, low income, prior hospitalization, five or more comorbidities, functional impairments and limited resources or caregiver support, or transition to home with home-care services (because of the challenges involved in coordinating care at home for patients with complex needs). Specific diagnoses, including depression, heart disease, diabetes, and cancer, also predict poor transitions [26].

Many problems occur if the hospitalists are not familiar with the capabilities of various settings , which include: home with family support, home with home-health care, custodial care (e.g., assisted living), skilled nursing facilities (SNF), acute rehabilitation hospital, long-term acute care (LTAC), and hospice care (home support or inpatient). Unless the hospitalist is familiar with resources at care settings, such as the availability of on-site medical care, specific medications, imaging or lab tests at SNF, the discharge plan may be unrealistic and unsustainable. It would be wise for hospitalists to briefly visit the most common community institutions used in his or her discharges to gain firsthand knowledge of their unique resources and limitations. Table 7.4 provides a synopsis of post-acute care services and institutions. For a planned discharge to home, access to ongoing medical care, cognitive or functional capabilities of the patient, availability of a caregiver, financial resources to pay for care, and the availability of community resources are especially important to consider. Ultimately, the choice of the discharge site of care should be the best match between the patient’s needs and the resources and services available at the location.