Version July 2025
INTRODUCTION —
Patients aged 65 years and older represent a large proportion of hospitalized patients. They tend to have more comorbid chronic illnesses and disability, and require age-appropriate management to lessen the risk of adverse events during hospitalization.
This topic will discuss common issues related to the management of older hospitalized patients. The medical care of older adults in the outpatient setting and in nursing homes is discussed in detail separately. (See "Geriatric health maintenance" and "Medical care in skilled nursing facilities (SNFs) in the United States".)
SCOPE OF THE ISSUE —
Older adults are more than twice as likely to require hospitalization compared with adults in middle age, with nearly 17 percent of Americans aged 65 years and older hospitalized at least once during the year, while only 8 percent of adults aged 45 to 64 years required hospitalization [1]. The leading diagnoses for medical admissions among older patients include sepsis and cardiovascular disease [2]. Older adults have a similar average length of stay (five days) when compared with adults aged 45 to 64 years [3], yet older adults require more support after discharge, perhaps because of medical complexity and functional disability. Adults aged 65 years and older require postacute care such as home health or skilled nursing facility (SNF) care nearly 70 percent of the time at discharge, compared with middle-aged (45 to 64 years old) adults who receive postacute care only 23 percent of the time [4].
Despite the aging of the population, the number of formally trained physicians in geriatrics is inadequate to meet the need [5]. Therefore, geriatrics leaders have advocated for enhancing the education of all clinicians to attain competency in caring for older adults [6]. Launched in 2017 and widely championed in the United States and Canada, the 5Ms (Mobility, Mind, Medications, Multicomplexity, and what Matters most) framework has been proposed as a useful mechanism to train core concepts of geriatrics to clinicians and interprofessional trainees [7,8]. In addition, the Institute for Healthcare Improvement, in partnership with the John A. Hartford Foundation, has worked to develop, support, and sustain age-friendly health systems using the 4Ms (what Matters, Medication, Mentation, and Mobility) across the care continuum [9].
GENERAL APPROACH —
Certain strategies are appropriate for all older adults in the hospital.
Recognize increased vulnerability — Older adults have greater vulnerability to acute stress than younger individuals due to age-related diminution of physiologic reserves. This vulnerability is compounded by the greater prevalence of chronic disease (eg, hypertension, chronic kidney disease, and heart failure) in older adults.
At baseline, the older adult lives in a state in which organ systems, while functioning with some compromise, are able to sustain life in relative harmony (homeostasis). The term homeostenosis refers to decreasing reserves with aging such that the individual is less able to respond to a stressor (eg, inability to maintain homeostasis) (figure 1) [10]. An acute insult or stressor may push one or more organ systems "over the brink," resulting in organ failure. When one organ system fails, others often follow. Thus, when an older adult with several chronic medical conditions develops an acute illness, those organ systems that are seemingly unrelated to the presenting problem may lack the reserve to withstand the stresses of the acute illness [11]. The resulting failure of the heart, lungs, kidneys, and/or brain (delirium) appears apart from the original complaint for which the patient was hospitalized [11]. It is best to avoid additional insults (eg, sleep deprivation, untreated pain) and assess for organ dysfunction by monitoring the patient's status.
Engage a multidisciplinary team — Multidisciplinary hospital teams strive to integrate all care providers into the daily assessment and plan of care for older patients. Including input from the attending physician, geriatrics specialist, nursing staff, physical/occupational/speech therapists, nutritionists, outpatient providers, social worker, and discharge staff, combined with input from the patient and family, can enhance the quality of care provided to the complex, older, hospitalized patient.
Components of effective multidisciplinary teams include localization of clinicians, daily goals of care forms and checklists, and interdisciplinary rounds [12]. The benefits of multidisciplinary care have been demonstrated in patients hospitalized for hip fractures, in particular, where patients who received multidisciplinary care with involvement of geriatric medical experts experienced shorter length of stays and lower rates of complications, including delirium [13-15].
One model for multidisciplinary care involves dedicated staff in a designated geriatric unit within the hospital (see 'Geriatric units' below). However, since not all hospitals have the resources to provide specialized units for older patients, some programs have attempted to recreate the core elements of multidisciplinary care units for hospitalized older persons who are not located on a single unit [16]. Other hospitals have combined hospitalist-directed care with geriatric care teams to provide enhanced care throughout the hospital [17]. In a trial comparing hospitalized patients aged >70 years assigned to an intervention involving an interdisciplinary geriatric team or usual care, patients who were assigned the intervention were more likely to have "do not resuscitate" orders and more likely to be recognized with cognitive and/or functional status impairments, but there was no difference in outcomes such as length of stay or readmission rates, or in falls, use of restraints, or sleeping medications [18]. Bundled interventions leveraging embedded decision support in the electronic medical record targeted to older patients can improve safer medication prescribing and possibly result in less need for extended care after discharge [19].
The Hospital Elder Life Program (HELP) demonstrated that skilled staff and volunteers could implement targeted, practical interventions including reorientation, cognitive stimulation, and nonpharmacologic sleep protocols [20].This program improves patient outcomes and lowers costs by integrating best practice standards of care for older adults into routine nursing and medical care. It continues to successfully function at hospitals nationwide and is now a part of the American Geriatrics Society (AGS) educational portfolio, termed AGS CoCare: HELP Program [21].
PATIENT ASSESSMENT ON ADMISSION —
Age may not always correlate with physiologic age. Thus, it is important to perform a thorough initial patient assessment to understand the patient's physiologic status and functional abilities. This assessment should include physical function, cognition, social resources and supports, living situation, and advance directives (table 1).
Functional assessment — It is increasingly recognized that a person's functional status on admission correlates to their risk of adverse events including death and readmission [22]. Functional assessment upon admission is appropriate for all older adults. We use instruments for the assessment of physical activities of daily living ([ADLs] the Katz index for ADL) and instrumental activities of daily living ([IADLs] the Lawton scale for IADL) as shown in tables (table 2 and table 3).
Hospital-associated disability (the loss of one or more of the basic ADLs needed to live independently) is common, seen in up to one-third of patients aged >70 years [23-27]. Specific risk factors for hospital-associated disability include age ≥80 years, dependence in three or more criteria in the assessment of IADL two weeks before admission, poor mobility at baseline, severe cognitive impairment, metastatic cancer, and albumin less than 3 g/dL [28]. Risk factors that predict functional decline in patients admitted with cardiovascular complications include impairments in mobility or cognition, loss of appetite, depressive symptoms, or use of restraints at the time of admission [29].
Frailty — Frailty, the geriatric syndrome whereby a person has increased vulnerability to stress, provides a framework for understanding a patient's risk of adverse events. There are a number of tools available to assess frailty [30].We use the Clinical Frailty Scale [31,32].
Cognitive function — It is important to assess a patient's cognition at the time of admission and regularly throughout their hospitalization. A patient's baseline cognitive status prior to their acute illness is critical to understanding any cognitive changes noted during hospitalization, and patients with dementia are at increased risk for developing delirium. The MiniCog is frequently used to assess for dementia. The Ultrabrief Confusion Assessment Method (UB-CAM) and the Three-Minute Diagnostic Confusion Assessment Method (3D-CAM) represent two relatively short and useful tools [33,34]. Formal assessment of cognitive function is described in detail elsewhere. (See "Evaluation of cognitive impairment and dementia".)
Pain — Pain is a common symptom for many older patients [35,36] and can impact daily functioning. Untreated pain can cause delirium, suffering, and inability to participate in prescribed medical therapies. A patient's own report of pain is the best way to determine degree of pain. Understanding whether a patient with advanced cognitive impairment is experiencing pain can be challenging, but there are validated tools to aid in this assessment (table 4) [37]. The American Geriatrics Society (AGS) has developed guidelines to aid clinicians in assessing and treating older adults with pain [38].
Medication review
Reconciliation — Up to 30 percent of hospital admissions are the result of adverse drug events [39,40]. Since older patients often take multiple medications and are more vulnerable to adverse drug events, it is particularly important to ensure that a complete and accurate list of medications is obtained at each transition within the hospital setting: on admission, during transfers between hospital wards, and at discharge. Some drugs may be nonprescription, and patients should be asked about use of over-the-counter medications, including complementary or herbal medications. Be aware that patients who see many outpatient specialists may have several different medication lists. Hospital pharmacists can be helpful as a resource for medication reconciliation (see "Prevention of adverse drug events in hospitals", section on 'Medication reconciliation'). In addition, it is important to understand whether the patient has been taking the medications as prescribed or not.
Appropriateness — Evaluating the appropriateness and clinical utility of each medication and its potential for side effects or drug interactions is critical to caring for patients' acute needs and preventing adverse drug events (see "Drug prescribing for older adults"). Medications that are not appropriate may be targets for discontinuation, with appropriate communication with the patient's primary care team. (See "Deprescribing".)
Potentially inappropriate medication (PIM) use (as defined by the Beers [41] and the Screening Tool of Older Persons' Prescriptions [STOPP] criteria [42]) in hospitalized older adults is common [43] and associated with functional decline and adverse drug reactions. Successful strategies to limit exposure to PIM include computerized-embedded decision support [19] and interruptive alerts [44]. Leveraging pharmacist expertise with medication review and reconciliation improves accuracy, decreases mortality, and improves transitions of care. Some states (eg, California) have mandated pharmacy involvement in medication reconciliation at the time of admission [45].
Standardized order sets have been shown to improve adherence to other best-practice guidelines and may be applied to the hospitalized older adult population as well [46,47].
Advance directives and goals of care — A patient's goals, values, and preferences regarding treatment decisions are particularly relevant during an acute hospitalization, especially in older patients given a larger burden of illness. Inpatient clinicians should know who has been identified as the patient's surrogate decision maker (health care proxy) and complete appropriate paperwork with patients to ensure proxies are documented in the medical record. The patient's desired intensity of care, including goals, values, and preferences regarding treatments, resuscitation, and artificial respiration, must be clarified with the patient, when possible, or with the health care proxy if the patient is not capable of understanding or communicating this information. It is important to discuss existing advance directives with a patient when they are hospitalized, as a retrospective study of hospitalized patients in one United States health care system found that patients modified their preferences for life-sustaining treatments after hospitalization and that patients 65 years and older were more likely to add limitations than younger patients [48].
Surrogate decision makers — As with all patients unable to participate in treatment decisions, it is important for older patients to find a surrogate decision maker for when the patient is unable to make their own decisions to help guide the patient's goals of care. For example, in the United States, if a patient has not created a health care power of attorney, the spouse or other first-degree relative typically is the default surrogate decision maker, though this is governed by state, not federal, statute and therefore it is necessary to understand the law in your state. If no surrogate is designated and next-of-kin is not available, guardianship may be obtained. Guardianship is a legal proceeding whereby the court appoints a surrogate decision maker. (See "Advance care planning and advance directives" and "Legal aspects in palliative and end-of-life care in the United States", section on 'Surrogate decision makers'.)
Social support and living situation — An important component of the admission assessment for older patients is inquiry about the patient's home situation and social support. Multiple aspects of the living situation can impact the health of the older patient (eg, living with family or friends, having part- or full-time help, being in a home versus an assisted living facility, the presence of stairs, access to mealtime support, social isolation). Questionnaires to assess social resources for patients admitted from the community or a nursing home, adapted from the Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire, are shown in tables (table 5 and table 6) [49].
A safe transition at discharge is dependent on an understanding of how the patient manages when not in the hospital. Planning for discharge must begin early in the course of the hospitalization to address all relevant factors and allow ample time to mitigate identified obstacles, thus avoiding unnecessarily prolonged hospitalization. Hospital-based social workers and discharge planners can help address concerns related to medication adherence, home safety, and access to community support after discharge. (See "Hospital discharge and readmission".)
Vaccinations — Hospitalization provides an important opportunity to address vaccination status, particularly for pneumococcal, influenza, and coronavirus disease 2019 (COVID-19) vaccination. The Centers for Disease Control and Prevention (CDC) recommends ensuring vaccination during hospitalization or at the time of discharge [50]. For patients who are felt to be moderately or severely ill during the hospitalization, it is recommended that vaccination occur at the earliest opportunity when the patient has improved clinically. There are some precautions related to vaccination; for instance, live vaccines should not be given to immunocompromised or suppressed persons. It's best to consult the CDC guidelines on vaccine administration if your patient falls into a high-risk category [51].
PREVENTING SPECIFIC ADVERSE OUTCOMES —
Hospitalization for the older adult patient can result in unintended adverse consequences from interventions meant to be therapeutic. Bed rest, polypharmacy, tethering devices (eg, intravenous lines, urinary catheters, telemetry, restraints), sensory deprivation, disruption of usual sleep patterns, and lack of proper nutrition all contribute to functional, physical, and cognitive decline [52]. Since many older adults live at a balance point between independence and functional dependence, even a small decline in function during hospitalization can place them in a position of newly acquired dependence.
Some decline may be unavoidable due to the effects of the acute illness. However, many of the harmful effects of hospitalization can be avoided or minimized by addressing specific risks that predispose to a poor clinical outcome.
Embedded checklists have been shown to be successful at reminding staff about specific geriatric issues such as daily patient mobilization, readdressing the need for tethers, and assessing for the presence of delirium [19], improving outcomes. Defined admission order sets have also been shown to improve outcomes such as adherence with venous thromboembolism prophylaxis and may be used to address some of the most common concerns affecting older patients, including diet, medications, and advance directives [53].
Functional decline — Bed rest and lack of mobility combine to hasten physical deconditioning and muscle weakness [54]. Immobility is associated with an increased risk of falls, delirium, skin breakdown, and venous thromboembolic disease [55,56]. Improved mobility during hospitalization has been linked to shorter length of stay, greater functional capacity at discharge, and decreased mortality at two years [57-63] Evidence suggests that even ventilated patients in the intensive care unit (ICU) can benefit from early mobilization programs [64].
Although a few conditions require absolute bedrest (eg, unstable fractures and certain critical illnesses), most medical conditions do not necessitate immobility. While mobility is not commonly tracked during hospitalization, older adults spend most of their hospitalization in bed [65]. Activity orders for bed rest should be avoided unless absolutely medically required. Staff should attempt to get patients out of bed to a chair with meals (which also decreases risk of aspiration [66]) and, when possible, encourage patients to walk several times daily. The Johns Hopkins Highest Level of Mobility Scale is one tool that can be incorporated into daily assessments of patients and guide daily mobilization goals [67]. Promoting and measuring mobility is best practice and enhanced mobility protocols may reduce length of stay [68,69].
Patients who have difficulty ambulating on their own or who pose a significant fall risk may need supervision by trained staff (eg, physical therapy) or referral to a specialized mobility program. Increased activity during hospitalization can mitigate functional decline so that patients can transition optimally outside the hospital setting [70].
Falls — Older hospitalized adults are at great risk of falling during hospitalization due to the effects of the acute illness compounded by an unfamiliar environment and side effects of treatments. Falls, when they do occur, are often multifactorial (figure 2). Many of the interventions needed to address the acute illness can increase the risk of falling. As an example, interventions to treat an older adult in heart failure (eg, antihypertensive medications, diuretics, telemetry, and an indwelling urinary catheter) all combine to increase the patient's propensity to fall. (See "Falls in older persons: Risk factors and patient evaluation".)
Several strategies can help prevent falls in the hospital setting. (See "Falls: Prevention in nursing care facilities and the hospital setting".)
●Weigh the risks and benefits of medications with significant psychotropic and anticholinergic effects (eg, opioid analgesics, diphenhydramine).
●Monitor patients who are prescribed drugs that might increase the risk of falls (eg, when diuretics are prescribed, blood pressure and volume status should be monitored closely to avoid orthostatic hypotension).
●Assess whether patients at higher fall risk need supervision with ambulation.
●Encourage time out of bed throughout the day, whether walking or sitting in a chair, to prevent orthostatic hypotension associated with prolonged immobility [71].
●Discontinue intravenous lines, continuous cardiac telemetry, pulse oximetry lines, and urinary catheters as early as possible. (See 'Tethers' below.)
●Avoid use of restraints, either physical or pharmacologic (eg, antipsychotics, benzodiazepines), as these may increase the risk of falling. Restraints are associated with harm and have been found to be used disproportionately in Black patients [72].
In the United States, Medicare does not reimburse hospitals for complications or extended length of stay related to falls that occur during hospitalization. Institutions should promote mobility and not adopt potentially deleterious practices such as increased use of bed rest, restraints, or restraint-like chairs or other devices in an effort to decrease their revenue losses [73]. Lack of mobilization can increase length of stay and fall risk; early and frequent mobilization can reduce length of stay, help maintain functional capacity during illness, reduce the need for short-term rehabilitation on discharge, and reduce readmissions [74,75].
Fall prevention strategies vary. In 2022, the world guidelines for fall prevention for older adults recommended all patients aged 65 years and older be screened for fall risk at the time of hospitalization [76]. Personalized fall prevention strategies based on risk factors are strongly recommended by the guideline, although specific strategies to mitigate fall risk are not specified. Some commonly used strategies include providing ambulating assistance, consulting physical therapy specialists, providing assistance with exiting the bed, frequently checking on the patient, and providing reorientation. Many hospitals rely upon safety devices to monitor patients for falls, including alarms integrated into patient beds and chairs to notify nursing staff when a patient attempts to rise unassisted, but we do not use them. These alarms have not been shown to prevent falls or improve overall care of patients; moreover, they may contribute to alarm fatigue, be distressing to patients, and provide a false sense of security [77]. (See "Falls: Prevention in nursing care facilities and the hospital setting", section on 'Restraints and alarms'.)
Beds positioned lower to the ground or at floor level have been used to lessen the potential height that a patient may fall when they rise from bed. Although "low beds" theoretically may limit the risk of severe injury, they have also not been shown to limit injury or improve safety and may make it more challenging to mobilize the patient [78].
Delirium — Delirium is acute brain failure characterized by inattention and a fluctuating course. The Confusion Assessment Method (CAM) is frequently used to diagnose delirium (table 7) [79-81]. The CAM-ICU instrument has been developed and validated for identification of delirium in the ICU [82]. An altered level of consciousness and/or disorganized thinking are usual components of delirium. Early recognition of delirium is important in ensuring prompt delivery of appropriate care. (See "Diagnosis of delirium and confusional states", section on 'Evaluation'.)
Many aspects of hospitalization inherently promote delirium in the older patient. The change in environment from the comfort of home to a hospital room is disruptive to the patient's daily routine. An older patient, particularly someone with preexisting cognitive impairment, is prone to developing delirium [83]. Pain, interruption in sleep patterns, and several classes of medications are also risk factors for delirium (table 8) [84,85]. Confusional states can be worsened when sensory input is affected, such as when a patient lacks access to eyeglasses or hearing aids.
Many hospitals now require CAM screening every 8 to 12 hours by frontline nursing staff for all patients. Clinicians should be attentive to their patient's CAM scores and conduct brief assessments of cognition daily. The Ultrabrief Confusion Assessment Method (UB-CAM) and the Three-Minute Diagnostic Confusion Assessment Method (3D-CAM) represent two relatively short and useful tools [33,34].
Effective measures to prevent and manage delirium include orientation protocols, environmental modification, nonpharmacologic sleep aids (eg, warm milk or herbal tea offered at bedtime, relaxing music, soft lighting, massage), early and frequent mobilization, minimizing use of physical restraints, use of visual and hearing aids (eg, pocket talkers), adequate pain treatment, and reduction in polypharmacy (particularly psychoactive drugs) [79,80,86]. A systemic review and meta-analysis found that there is no evidence to prescribe antipsychotic medication for the prevention or treatment of delirium [87]. Guidelines from the American Geriatrics Society (AGS) and the American College of Surgeons on the prevention and treatment of postoperative delirium similarly recommend against the use of antipsychotic medications in this population as well, unless there is concern for imminent harm to the patient or care team [88,89].
The management of patients with delirium is summarized in an algorithm (algorithm 1). (See "Delirium and acute confusional states: Prevention, treatment, and prognosis".)
Some hospitals have found that patients with delirium benefit from specialized care delivered in a dedicated room for disoriented patients. This room supports multidisciplinary care that avoids the use of restraints and reduces use of psychoactive drugs. These "delirium rooms" can offer a useful option for caring for delirious patients [90], using the T-A-DA method (Tolerate, Anticipate, and Don't Agitate) to guide the approach to caring for delirious patients [91].
Sleeplessness/sleep deprivation — Multiple factors contribute to sleep deprivation during hospitalization, including an unfamiliar sleep setting, conditions related to illness (eg, shortness of breath, pain), environmental factors (eg, noise, light), and the logistics of providing care (eg, phlebotomy, medication schedules). Inadequate sleep, whether it is too short in duration, of poor quality, or interrupted, may contribute to a host of complications, including increased risk for delirium [86]. (See "Insufficient sleep: Definition, epidemiology, and adverse outcomes", section on 'Effects of acute sleep deprivation'.)
Strategies such as bundling care at night (eg, vital sign monitoring, dispensing medications, toileting) and creating a conducive environment for sleep with low light and quiet surroundings may help achieve improved sleep for patients receiving care in the hospital and decrease the risk for adverse events. One study showed that electronic "nudges" prompting nurses to forgo vital sign checks overnight and medications improved patient sleep [92].
Tethers — Some tethering medical devices such as urinary catheters, intravascular lines, cardiac telemetry leads and pulse oximetry, oxygen tubing, drains, intermittent pneumatic compression devices, and restraints may be necessary to provide optimal care. However, tethering devices make it more difficult to mobilize patients safely and are associated with increased rates of delirium, infection, and falls [93-95], and the devices can contribute to sleepless nights and distress from ringing alarms. Tethers are commonly ordered when not absolutely indicated and, even when initially appropriate, may remain in place when no longer needed. Urinary catheter use has declined, perhaps due to federally mandated nursing home quality measures and other quality initiatives focused on reducing catheter-associated urinary tract infections, suggesting that coordinated efforts across the system to reduce the use of certain tethers can be effective [96].
Clinicians should weigh the risks and benefits of each tethering device and initiate use only when the likelihood of benefit is significant, keeping with the patient's preferred intensity of care, and there is no effective alternative. As an example, if a patient prefers not to be resuscitated in the event of a cardiac arrest, the benefit of continuous cardiac telemetry should be questioned.
There may be options to reduce the total tether burden, such as the use of fluid boluses rather than continuous intravenous fluids. In most cases, urinary catheters should not be used as a treatment for incontinence or as a substitute for getting the patient up to the bathroom. (See "Complications of urinary bladder catheters and preventive strategies", section on 'Prevention of complications'.)
Nosocomial infections — Underlying health conditions, poor nutritional status, and greater severity of illness contribute to increased rates of hospital-acquired (or nosocomial) infections in older patients. Heightened clinical suspicion is necessary to identify infection in older patients as they may demonstrate only atypical symptoms, including delirium. Fever may not be present in older patients with an active infection. (See "Approach to infection in the older adult".)
Infections commonly seen in older hospitalized patients include:
●Clostridioides difficile-associated diarrhea – C. difficile is the most frequent cause of nosocomial diarrhea and a significant cause of morbidity and mortality among hospitalized older patients [97].
Contact precautions help to prevent spread of C. difficile spores and should be used in patients who have suspected or proven C. difficile infection. (See "Clostridioides difficile infection: Prevention and control".)
●Pneumonia – Hospital-acquired pneumonia (HAP) is pneumonia that is not associated with mechanical ventilation and that develops 48 hours or more after admission.
Patients with advanced dementia, severe Parkinson disease, or other neurologic conditions are at high risk for aspiration pneumonia. Older patients treated with antipsychotics are also at increased risk for developing aspiration pneumonia [98,99].
HAP prevention measures include avoiding acid-blocking medications, attending to oral hygiene, and feeding only at times when the patient is alert and able to sit upright [100,101]. Patients who cough when swallowing may be showing signs of swallowing dysfunction and aspiration. Offering increased assistance with feeding, modified consistency of foods, and a formal swallowing assessment may be warranted. (See "Epidemiology, pathogenesis, microbiology, and diagnosis of hospital-acquired and ventilator-associated pneumonia in adults" and "Risk factors and prevention of hospital-acquired and ventilator-associated pneumonia in adults" and "Aspiration pneumonia in adults".)
●Urinary tract infections – Urinary tract infections associated with urinary catheters are the leading cause of secondary nosocomial bacteremia, which is associated with high mortality. Patients with indwelling catheters often do not experience typical signs of urinary tract infection. Blood and urine cultures should be obtained when patients develop fever or otherwise unexplained systemic manifestations compatible with infection (eg, altered mental status, fall in blood pressure, metabolic acidosis, and respiratory alkalosis).
The most effective strategies to reduce urinary infections are avoidance of unnecessary catheterization and catheter removal when the catheter is no longer indicated. (See "Catheter-associated urinary tract infection in adults" and "Complications of urinary bladder catheters and preventive strategies", section on 'Prevention of complications'.)
●Intravascular catheter-related infections – Intravascular catheter infections are an important cause of morbidity and mortality.
Several preventive measures such as wiping access sites with antiseptic and connecting only to sterile devices can markedly reduce the rate of intravascular catheter infections (table 9). (See "Routine care and maintenance of intravenous devices".)
Infection control programs aim to prevent and reduce rates of nosocomial infections. Major components of infection control are (table 10):
●Standard (universal) precautions
●Isolation precautions when appropriate, with recognition that isolation may increase the risk of delirium in older adults
●Environmental cleaning
●Surveillance
Standard precautions are recommended in the care of all hospitalized patients to reduce the risk of infection transmission between patients and health care workers, even when the presence of an infectious agent is not apparent. Precautions include hand hygiene before and after every patient contact (table 11); use of gloves, gowns, and eye protection for situations in which exposure to body fluids is possible; and safe disposal of sharp instruments in impervious containers (see "Infection prevention: Precautions for preventing transmission of infection" and "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Epidemiology", section on 'Health care-associated MRSA infection' and "Vancomycin-resistant enterococci: Epidemiology, prevention, and control"). Patients who require isolation precautions are at risk of less contact with their care team, depression and anxiety, and decreased satisfaction with care. The health care team should be attentive to these risks and seek to mitigate them as much as possible [102].
Malnutrition — Up to 30 percent of hospitalized patients will develop protein-calorie malnutrition. Older adults are at increased risk of malnutrition, even prior to hospital admission [103]. Poor nutritional status for older hospitalized patients is often underdiagnosed and undertreated. Exacerbating factors for older adults include:
●Impaired cognition or delirium
●Poor appetite, nausea, or constipation (due to underlying illness or as side effects of medications)
●Restriction of movement (see 'Tethers' above)
●No access to dentures/poor dentition
●Difficulty in self-feeding
●Severely restricted diet orders (eg, "nothing by mouth")
Evaluation for malnutrition includes a history of changes in weight, dietary intake, and physical examination, as well as select laboratory and radiologic studies. This is discussed in detail separately. (See "Geriatric nutrition: Nutritional issues in older adults".)
Simple interventions such as getting an older patient out of bed at mealtime and providing assistance with feeding can improve nutritional intake and prevent dehydration during hospitalization. Inpatient assessment by a nutritionist can identify nutritional deficiencies in older patients and, combined with subsequent nutritional follow-up in the community after discharge, may decrease mortality [104]. Sufficient protein intake is important for recovery from illness and associated with improved outcomes [103]. Patients should be allowed to eat unless medically required to be maintained "nothing by mouth." Generally, restricted diets are not required for older patients and when ordered may further limit the nutritional intake of older patients. Even patients with heart failure may be allowed access to an unrestricted diet without adverse impact during hospitalization [105]. A discussion of swallowing issues for older patients is presented separately. (See "Geriatric nutrition: Nutritional issues in older adults", section on 'Address inadequate food intake'.)
Nutritional repletion may be provided to restore the patient to a target weight, with recognition that weight correction in the older population f than in younger people. A meta-analysis of 15 studies in malnourished older adults (including some patients in hospital, as well as nursing home, settings) found a small survival advantage for patients provided with liquid diet supplements compared with no specific nutrition treatment [106]. (See "Geriatric nutrition: Nutritional issues in older adults", section on 'Treatment of weight loss' and "Nutrition support in critically ill adult patients: Initial evaluation and prescription".)
Pressure ulcers — Several host and environmental factors increase the risk of developing pressure ulcers during hospitalization in older patients, including (see "Epidemiology, pathogenesis, and risk assessment of pressure-induced skin and soft tissue injury"):
●Poor nutritional status
●Incontinence, causing a moist environment
●Immobility
●Neurologic impairment
Optimizing nutritional status and limiting time spent in one position can help prevent pressure ulcers. Patients who are bed-bound should be repositioned at least every two hours, with proper repositioning techniques to minimize shear forces. Pressure-reducing products for patients at increased risk of ulcers should also be used. Clinical risk assessment and preventive interventions are discussed in detail separately. (See "Prevention of pressure-induced skin and soft tissue injury".)
Venous thromboembolism — Hospitalization is a significant risk factor for developing venous thromboembolism [55]. The use of prophylaxis for venous thromboembolic disease, including pharmacologic or mechanical methods, depends on the individual risk of thrombosis and bleeding. Prophylactic anticoagulation is generally recommended for most patients >75 years of age who are hospitalized for an acute illness and who do not have risk factors for increased bleeding. However, data supporting prophylactic anticoagulation for this population are scant [107]. (See "Prevention of venous thromboembolic disease in acutely ill hospitalized medical adults".)
Adverse drug events — Serious adverse drug events include delirium, urinary retention, orthostasis, metabolic derangements, bleeding from anticoagulation, and hypoglycemia related to medications for diabetes. Gastrointestinal side effects, including nausea, anorexia, dysphagia, and constipation, are common. Adverse drug events increase the length of stay and costs of care.
Several high-risk drugs are commonly associated with adverse drug events in hospitalized patients (table 12). Multiple medications, often new to the patient during hospitalization, potentiate the risk of nutritional, functional, and cognitive decline in older adults during hospitalization [108], as well as increase the risk of overall mortality [109]. With physiologic decreases in liver and kidney function, older patients have a higher incidence of adverse drug events than younger patients. In addition, older adults may be especially vulnerable to the prescription cascade where one medication is prescribed to offset the side effects of another. (See "Drug prescribing for older adults" and "Prevention of adverse drug events in hospitals", section on 'High-risk populations'.)
Minimizing the use of nonessential medications can reduce the risk that an older patient will suffer from an adverse drug event. Avoiding potentially inappropriate medication (PIM) and starting with the smallest possible therapeutic dose can similarly help avoid adverse drug events. Older patients who have impaired renal or hepatic function should have their dose of medications (eg, antibiotics) adjusted appropriately. (See "Prevention of adverse drug events in hospitals", section on 'Interventions'.)
Prolonged stay in the emergency department — The majority of patients who are admitted to the hospital are initially evaluated in the emergency department (ED) where they are assessed, treated, and triaged to inpatient care. Increasingly, hospitals are challenged with too many patients and not enough inpatient beds, resulting in delays in transfer for the patients going from the ED to the inpatient care unit. The duration of time, termed "boarding," a person might wait in the ED before physically being moved to an inpatient unit varies but can range from a few hours to multiple days. It is increasingly understood that prolonged boarding in the ED is associated with adverse outcomes. In one study in France looking at patients aged 75 years and older, it was found that patients who spent an overnight in the ED waiting for an inpatient bed had higher rates of in-hospital mortality and adverse events, and an increased overall length of stay [110]. Another retrospective study suggests that longer boarding times are associated with increased risk for developing delirium or severe agitation during the admission [111]. Strategies to mitigate the harms of prolonged boarding include deploying dedicated teams separate from the ED clinicians who can advance the care of the patient while they are still physically in the ED, potentially limiting the effects of boarding on length of stay [112]. Other strategies might be borrowed from proven tactics to prevent delirium. For instance, directly addressing the environmental challenges of providing care in the ED (optimizing a quiet environment, normalizing day-night routine, ensuring adequate nutrition, hydration, and mobility) might help mitigate the adverse consequences of prolonged boarding.
SITES OF CARE
Intensive care in critical illness — Patients 65 years and older account for a large percentage of patients in the intensive care unit (ICU) [113,114]. Age alone does not predict survival from a critical medical illness, even in the most vulnerable older patients [115]. The most important factor in determining if the ICU is appropriate for an older patient is the consideration of whether or not intensive care is congruent with an individual patient's care wishes. Ambiguous advance directives can make this difficult, especially during the acute presentation, highlighting the importance of proactively addressing goals of care [116]. (See "Withholding and withdrawing ventilatory support in adults in the intensive care unit".)
If resuscitation and artificial respiration are acceptable, the clinician should keep in mind that the selection of medications for anesthesia and the approach to bag masking and intubation may vary in older adults. (See "Airway management in the geriatric patient for emergency medicine and critical care".)
Geriatric units — While not available at all hospitals, medical units dedicated specifically to the multidisciplinary care of older patients can improve functional status and reduce the frequency of discharge to long-term care facilities [117]. Several inpatient geriatric unit approaches have been developed in a variety of clinical settings [118]. Within the United States Department of Veterans Affairs hospitals, these were referred to as Geriatric Evaluation and Management Units. In academic and private sector hospitals, they are usually labeled Acute Care of the Elderly (ACE) units. ACE units initially included structural modifications to promote mobility and simulate living conditions at home in preparation for a return to independence. ACE units may be located on conventional hospital wards as designated geriatric units. (See "Comprehensive geriatric assessment", section on 'Acute geriatric care units'.)
One meta-analysis of 17 randomized trials evaluating geriatric rehabilitative units (within an acute care hospital or a rehabilitation hospital) found that inpatient multidisciplinary programs were associated with improvement in all outcomes at discharge, including better functional status (odds ratio [OR] 1.75, 95% CI 1.31-2.35), decreased nursing home admission (relative risk [RR] 0.64, 95% CI 0.51-0.81), and reduced mortality (RR 0.72, 95% CI 0.55-0.95) [119]. Another meta-analysis of 22 randomized trials found that hospitalized patients receiving comprehensive geriatric evaluation in a geriatric unit were more likely to be alive and in their homes during 6- and 12-month follow-ups [120]. This meta-analysis was limited by wide variability in interventions across trials.
These geriatric units rely upon team-based care as well as staffing and environmental modifications to the unit to address some of the difficulties older adults face during hospitalization. However, due to a longer length of stay (up to three months), such rehabilitative units are rarely available in the United States outside of the Department of Veterans Affairs hospitals.
Alternatives to hospital care — Hospitalization is disruptive for all individuals, but particularly so for medically complex older patients. Additionally, older patients are particularly vulnerable to medical errors that occur during transitions of care [121]. Avoiding hospitalization and providing care within the patient's home environment can sometimes meet the medical needs of the patient, as well as align with the patient's goals of care around intensity of treatment [122].
Only patients who require care that can be uniquely provided in the hospital should be admitted. For selected patients, home health services or care within nursing homes may provide enough support for older adults with an illness such as pneumonia or a urinary tract infection. If such services align with the patient's desired intensity of care and are medically appropriate, the hazards of hospitalization can be avoided.
Home hospital care (ie, providing hospital-level care in the patient's home) instead of hospitalization is associated with improved physical activity and reduced costs of care, without changes in patient experience, quality, or safety [123]. Care at home can reduce the risk of delirium and save hospital bed usage [124,125]. This has become an increasingly common example of a high-value model of care [126,127] in the United States and internationally.
In a trial conducted in nine communities in the United Kingdom enrolling 1055 patients (mean age 83), those randomized to hospital at home plus comprehensive geriatric assessment had similar rates of living at home, and a lower rate of admission to long-term care at six months compared with those receiving standard hospital admission [128]. In both groups, the most common presenting problem was acute functional deterioration, and the most common diagnosis was infection.
PALLIATIVE/COMFORT-FOCUSED CARE —
Guidelines have been suggested to help clinicians identify patients at the time of hospital admission who might benefit from palliative care (table 13 and table 14) [129]. If a patient has a life-threatening illness and other markers of vulnerability (eg, resides in a long-term care facility, is dependent on care to complete their activities of daily living, requires continuous supplemental oxygen at baseline, or has multiple complex and difficult to manage medical conditions), it is prudent to ensure the hospital care team understands the patient's goals of care. Specifically, the care offered to the patient should align with the patient's preferred intensity of care with shared decision making around invasive or aggressive treatments.
Larger hospitals often have special palliative care teams to provide care to this population, although the core tenants of this care can and should be addressed by all clinicians:
●Does the patient have distressing symptoms (physical or psychological)?
●Does the patient understand their condition and prognosis?
●What are the patient's goals of care and how can the treatment(s) offered align with these goals?
●What are the components of a safe and sustained discharge plan?
The care team should partner with the patient to optimize the care plan to meet these goals to ensure the best outcome. It is critical to minimize medications and treatments that are perceived as burdensome to the patient who has chosen care with a focus on comfort. Providers should identify patients experiencing pain or other troublesome symptoms (eg, confusion, constipation, nausea, and dyspnea) and work to address these symptoms to improve comfort. Patients with limited life expectancy whose goals of care are comfort-focused can be referred to hospice. (See "Hospice: Philosophy of care and appropriate utilization in the United States".)
DISCHARGE PLANNING —
During the transition from hospital to home or skilled nursing facility (SNF), older patients are particularly vulnerable to medication errors and confusion about follow-up care. It is increasingly rare for a single clinician to provide both inpatient and outpatient care, which further increases the challenges of maintaining high-quality care during this transition [121]. While most younger patients are discharged to home, 40 percent of patients aged 85 years and older are discharged to an SNF prior to going home, which adds a second transition and a third set of care providers [130]. Moreover, due to higher rates of cognitive impairment, older adults may be less able than younger patients to participate actively in their discharge plan of care.
Hospital discharge is a good time to review any medications started during the hospitalization which may not be necessary in the outpatient setting. This is discussed in elsewhere. (See "Deprescribing", section on 'Hospitalized patients'.)
Few data are available demonstrating that discharge interventions prevent hospital readmission [131]. Clinicians and others working with older patients at the time of discharge should strongly consider partnering with the patient's family or other social supports to increase the likelihood that the care transition will go smoothly. A discharge checklist can be particularly helpful to ensure that the clinician covers the most salient issues for a smooth transition out of the hospital (table 15) [132]. Select interventions at discharge are reviewed separately. (See "Hospital discharge and readmission".)
Several programs have been developed to improve the hospital discharge process and are discussed separately. (See "Hospital discharge and readmission", section on 'Multiple interventions'.)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Going home from the hospital (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Scope of the issue – 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. (See 'Scope of the issue' above and 'Recognize increased vulnerability' above.)
●Patient assessment on admission – The complete assessment of older hospitalized adults extends beyond the traditional history and physical to include assessment of physical function and cognition, social supports, and living situation as well as medication reconciliation, evaluation for possible polypharmacy, and attention to advance directives (table 1). (See 'Patient assessment on admission' above.)
●Preventing adverse events – Since many older adults live at a balance point between independence and functional dependence, even a small decline in function during hospitalization can place them in a position of newly acquired dependence. However, many adverse outcomes encountered by older adults during hospitalization can be prevented. Strategies include (see 'Preventing specific adverse outcomes' above):
•Falls
-Avoid activity orders for bed rest unless absolutely required. Patients who have difficulty ambulating on their own or pose a significant fall risk may need supervision (eg, a nurse, physical therapy). (See 'Functional decline' above.)
-Implement strategies to help prevent falls. (See 'Falls' above and "Falls: Prevention in nursing care facilities and the hospital setting".)
-Avoid tethers whenever possible, including urinary catheters, intravascular lines, cardiac telemetry leads, and physical restraints. (See 'Tethers' above.)
•Other adverse events
-Utilize effective measures to prevent delirium including orientation protocols, environmental modification, nonpharmacologic sleep aids, early mobilization, use of visual and hearing aids, adequate pain treatment, and reduction in polypharmacy (particularly psychoactive drugs) (algorithm 1). (See 'Delirium' above and "Delirium and acute confusional states: Prevention, treatment, and prognosis".)
-Implement strategies to prevent sleep deprivation. (See 'Sleeplessness/sleep deprivation' above.)
-Standard precautions are recommended in the care of all hospitalized patients, including hand hygiene before and after every patient contact to prevent nosocomial infections (table 11). (See 'Nosocomial infections' above.)
-Simple interventions such as getting an older patient out of bed at mealtime and providing assistance are important in maximizing nutritional intake. (See 'Malnutrition' above.)
-Limiting time spent in one position can help prevent pressure ulcers. Bedbound patients should be repositioned at least every two hours, with proper repositioning techniques to minimize shear forces. (See 'Pressure ulcers' above and "Prevention of pressure-induced skin and soft tissue injury".)
-Minimize the use of nonessential medications to reduce the risk of an adverse drug event. Avoiding high-risk drugs (table 12) and starting with the smallest possible therapeutic dose can similarly help avoid adverse drug events. (See 'Adverse drug events' above and "Drug prescribing for older adults" and "Deprescribing".)
●Sites of care – The most important factor in determining if the intensive care unit (ICU) is appropriate for an older patient is to consider whether or not intensive care is congruent with an individual patient's care wishes. Geriatric care units or alternatives to hospital care may be appropriate for some patients. (See 'Sites of care' above.)
●Discharge planning – Older patients are particularly vulnerable to medication errors and confusion about follow-up care. A discharge checklist can be particularly helpful to ensure that the clinician covers the most salient issues for a smooth transition out of the hospital (table 15). (See 'Discharge planning' above.)
