A hospital may provide emergency medical care, diagnostic testing, intensive treatment, or surgery, which may or may not require admission. Older patients use hospitals more than younger patients; they have more admissions to the hospital from the emergency department and more and longer hospital stays, and they use more resources while in the hospital.
Emergency department care
In 2015, almost 57,000 adults over age 65 visited the emergency department (ED), and 33.6% of those patients were admitted to the hospital, a 20% decrease from the 42% admitted in 2006 (1 Emergency department care reference A hospital may provide emergency medical care, diagnostic testing, intensive treatment, or surgery, which may or may not require admission. Older patients use hospitals more than younger patients... read more ). Older patients tend to be sicker. Some hospitals now have special geriatric EDs staffed with geriatric-trained nurses and physicians, which may be contributing to the reduction in hospital admissions (2 Emergency department care reference A hospital may provide emergency medical care, diagnostic testing, intensive treatment, or surgery, which may or may not require admission. Older patients use hospitals more than younger patients... read more ). More than 50% are prescribed new drugs. Older adults may use the ED as a substitute for primary care or may come because they are not receiving adequate attention from their primary care physician. ED visits are often caused by a breakdown in the social structure of a frail older patient—eg, absence or illness of their caregiver may result in people calling an ambulance rather than going to their physician's office. However, in many cases, the reasons for coming are true emergencies.
A visit to an ED may create more stress for older adults because there are typically no special accommodations for them (eg, quiet rooms, lower beds, extra pillows, indirect lighting). However, some hospital systems are creating special geriatric EDs, which are spaces in the regular ED dedicated to the care of older adults. These geriatric EDs have geriatric-trained physician and nursing staff as well as specialized equipment, such as gurneys with pressure-reducing mattresses that reduce risk of pressure injuries and improved lighting and acoustics to promote vision and hearing.
Evaluation of an older adult usually takes longer and requires more diagnostic tests because many older patients do not present with clear-cut or typical symptoms and signs of a disorder. For example, myocardial infarction manifests as chest pain in < 50% of patients > 80 years. Instead, older patients may complain of feeling generally weak or just not feeling themselves.
Factors that are not apparent (eg, polypharmacy, adverse drug effects) may affect an older patient’s presentation. For example, a fall may result from abuse, an adverse drug effect (eg, oversedation), hazards in the home, physical problems (eg, poor vision), depression, or chronic alcoholism. Adverse drug effects account for at least 5% of hospital admissions for older adults.
About 30 to 40% of older patients who come to the ED are cognitively impaired but do not have a diagnosis of dementia; in 10%, cognitive impairment consistent with delirium is unrecognized. When indicated (eg, if an older patient is having difficulty with orientation to person, place, or time), a standardized cognitive assessment How to Assess Mental Status The patient’s attention span is assessed first; an inattentive patient cannot cooperate fully and hinders testing. Any hint of cognitive decline requires examination of mental status ( see Examination... read more should be done in the ED. However, a standardized cognitive assessment is appropriate for any older patient coming to the ED. Cognitive impairment affects the reliability of the patient history as well as the diagnosis, increases the risk of delirium during a hospital stay, and must be considered when planning the patient’s disposition. Knowing whether onset of cognitive impairment is recent helps determine whether the impairment should be fully assessed in the ED. Cognitive impairment of recent onset may indicate sepsis, occult subdural hemorrhage, or an adverse drug effect.
Suicide risk, fall risk, incontinence, and nutritional and immunization status should be assessed in the ED so that follow-up care can be arranged.
Communication among practitioners
Good communication among ED physicians and patients, caregivers, primary care physicians, and staff members of long-term care facilities greatly enhances the outcome of older patients with complicated problems. Advance directives should be promptly and clearly communicated to emergency medicine practitioners. Baseline information from the patient’s personal physician facilitates assessment and management planning in the ED. Reports to the patient’s primary care physician should describe even simple injuries (eg, ankle sprain, Colles wrist fracture) because such injuries can dramatically affect functional ability and independence.
Discharge planning may be complex because acute illness or injury may impair functional ability more in older patients (eg, a simple ankle sprain may be incapacitating unless patients have good support at home). Discharge planning may be improved when nurses, social workers, and primary care physicians are involved. It should include the following:
Strategies to manage problems (eg, depression, alcoholism, impaired functional status) identified during the ED assessment
Determination of whether patients can obtain and take drugs as directed and can obtain the necessary follow-up care
Assessment of caregiver capabilities (eg, whether respite services are needed)
Many older patients are hospitalized after they are evaluated in the ED.
Occasionally, older patients are brought to the ED by a caregiver who refuses to take them home or who leaves, abandoning them in the hospital.
Emergency department care reference
1. Sun R, Karaca Z, Wong HS: Trends in Hospital Emergency Department Visits by Age and Payer, 2006-2015. HCUP Statistical Brief #238, 2018. Agency for Healthcare Research and Quality.
2. Hwang U, Dresden SM, Rosenberg MS, et al: Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use. J Am Geriatr Soc. 2018;66(3):459-466. doi:10.1111/jgs.15235
Almost half of adults who occupy hospital beds are ≥ 65 years; this proportion is expected to increase as the population ages. Inpatient hospitals and skilled nursing facilities, home health care related to a hospital stay, and hospice care are estimated to cost Medicare about $216.9 billion in 2020, representing 25% of such expenditures for hospital care in the US (1 Hospitalization references A hospital may provide emergency medical care, diagnostic testing, intensive treatment, or surgery, which may or may not require admission. Older patients use hospitals more than younger patients... read more ).
Hospitalization can magnify age-related physiologic changes and increase morbidity.
Only seriously ill older patients who cannot be appropriately cared for elsewhere should be hospitalized. Hospitalization itself poses risks to older patients because it involves confinement, immobility, diagnostic testing, and treatments (particularly changes in drug regimens). When patients are transferred to or from a hospital, drugs are likely to be added or changed, leading to a higher risk of adverse effects Reasons for Drug-Related Problems Drug-related problems are common in older adults and include drug ineffectiveness, adverse drug effects, overdosage, underdosage, inappropriate treatment, inadequate monitoring, nonadherence... read more . Treatment in hospitals can be dehumanizing and impersonal. Acute hospital care should last only long enough to allow successful transition to home care, a skilled nursing facility, or an outpatient rehabilitation program.
The outcome of hospitalization appears to be poorer with increasing age, although physiologic age is a more important predictor of outcome than is chronologic age. Outcome is better for patients hospitalized because of elective procedures (eg, joint replacement) than for those hospitalized because of serious disorders (eg, multisystem organ failure).
About 75% of patients who are ≥ 75 and functionally independent at admission are not functionally independent when they are discharged; 15% of patients ≥ 75 are discharged to skilled nursing facilities. The trend toward abbreviated acute hospital stays followed by subacute care and rehabilitation in a skilled nursing facility may partially explain why these percentages are high. However, even when a disorder is treatable or appears uncomplicated, patients may not return to prehospital functional status. Studies have shown that patients who receive moderate intensity exercise while in the hospital, particularly exercises that focus on walking, resistance, and balance training, did not experience any functional decline during their hospitalization (2 Hospitalization references A hospital may provide emergency medical care, diagnostic testing, intensive treatment, or surgery, which may or may not require admission. Older patients use hospitals more than younger patients... read more ). This highlights the importance of ensuring that older adults start physical therapy as soon as possible while in the hospital.
The following strategies can help reduce functional decline and improve care of older patients:
Geriatric interdisciplinary team Geriatric Interdisciplinary Teams Every 4 years, the US Department of Health and Human Services (HHS) updates its strategic plan and defines its mission and goals. The current HHS strategic plan (2018-2022) includes the following... read more : To identify and meet the complex needs of older patients and to watch for and prevent problems that are common among them and that may develop or worsen during hospitalization
Primary care nurse (one nurse with around-the-clock responsibility for a particular patient): To administer the team’s care plan, to monitor response to nursing and medical care, and to teach and counsel patients, staff members, and family members
Changes in the hospital environment, often made by nurses: For example, to move disruptive patients into the hall near the nursing station or to change roommates for a patient
Rooming-in programs for a family member: To provide better one-on-one care, to relieve staff members of some caregiving tasks, to allay patient anxiety (particularly if patients have delirium or dementia), and to enable a family member to participate actively in the patient’s recovery
High quality communication among practitioners: To prevent errors in and duplication of diagnostic procedures and treatments (particularly drugs); to implement better systems of communication such as walking rounds and warm handoffs. A warm handoff is a transfer of care that is conducted in person, between 2 members of the health care team, in front of the patient (and family, if present).
Documentation of drug regimen: To state the indication for each new drug, to maintain a daily list of drugs prescribed and received, and thus to avoid using unnecessary drugs and help prevent drug interactions
Advance directives Advance Directives Advance directives are legal documents that extend a person's control over health care decisions in the event that the person becomes incapacitated. They are called advance directives because... read more : To document the patient’s choice of health care proxy and health care decisions
Early mobilization and participation in functional activity: To prevent physical deterioration due to decreased activity during illness and hospitalization; close collaboration with physical and occupational therapists to create integrated care plans that include targeting functional status in older adults and incorporating mobility and strength training to the extent tolerated by each patient
Discharge planning: To ensure that appropriate care is continued in the next level of care
Acute care of the elderly (ACE) units: To provide effective care for the hospitalized older adults by using most of the strategies listed above
Advance directives, if already prepared, should be brought to the hospital as soon as possible. Practitioners should reaffirm these choices during acute hospitalization. If directives were not documented, practitioners should make every effort to determine the patient’s wishes.
Problems common among older adults require specific consideration during hospitalization, particularly during postoperative care Postoperative Care Postoperative care begins at the end of the operation and continues in the recovery room and throughout the hospitalization and outpatient period. Critical immediate concerns are airway protection... read more ; many of them can be remembered using the acronym ELDERSS ELDERSS: Some Important Issues for Hospitalized Older Adults . In the hospital, older patients frequently experience nighttime confusion (sundowning), fracture a bone with no identifiable trauma, fall, or become unable to walk. Hospitalization may precipitate or worsen undernutrition, pressure injuries, urinary incontinence, fecal impaction, and urinary retention. Such problems can prolong convalescence.
2. Cadore EL, Rodríguez-Mañas L, Sinclair A, et al: Effects of different exercise interventions on risk of falls, gait ability, and balance in physically frail older adults: a systematic review. Rejuvenation Res 16(2):105-114, 2013. doi:10.1089/rej.2012.1397
Adverse Drug Effects and Hospitalization
Hospitalization rates due to adverse drug effects are 4 times higher for older patients (≈ 17%) than for younger patients (4%). Reasons for these effects include
Age-related changes in pharmacokinetics and pharmacodynamics
Changes in drugs (intentional and unintentional) during hospitalization and at discharge ( see Drug-Related Problems in Older Adults Drug-Related Problems in Older Adults Drug-related problems are common in older adults and include drug ineffectiveness, adverse drug effects, overdosage, underdosage, inappropriate treatment, inadequate monitoring, nonadherence... read more )
Comorbid conditions requiring multiple different medications
Maintaining a daily list of drugs prescribed and received can help prevent adverse drug effects and drug interactions.
Because drug distribution, metabolism, and elimination vary widely among older patients, the following should be done:
Drug doses should be carefully titrated.
Creatinine clearance for renally excreted drugs should be calculated when doses are adjusted.
Serum drug levels should be measured.
Patient responses should be observed.
Certain drugs or drug categories should be avoided in older adults ( see Table: Potentially Inappropriate Drugs in Older Adults (Based on the American Geriatrics Society 2019 Beers Criteria® Update) Potentially Inappropriate Drugs in Older Adults (Based on the American Geriatrics Society 2019 Beers Criteria® Update) ). Use of hypnotic drugs should be minimized because tachyphylaxis may occur and risk of falls and delirium is increased; measures to improve sleep hygiene Approach to the Patient With a Sleep or Wakefulness Disorder Almost half of all people in the US report sleep-related problems. Disordered sleep can cause emotional disturbance, memory difficulty, poor motor skills, decreased work efficiency, and increased... read more should be tried before drugs. If drugs are necessary, short-acting benzodiazepines are usually the best choice. Antihistamines have anticholinergic effects and should not be used for sedation. Prescribers should regularly review medications to determine if doses might be decreased or if the drug could be discontinued safely to reduce the number of drugs an older adult takes and to reduce the risk of drug-to-drug interactions.
Bed Rest Effects
Prolonged bed rest, as can occur during hospitalization, causes deconditioning and is seldom warranted. The resulting inactivity has the following effects:
With complete inactivity, muscle strength decreases by 5% per day, increasing risk of falls.
Muscles shorten and periarticular and cartilaginous joint structure changes (most rapidly in the legs), limiting motion and contributing to development of contractures.
Aerobic capacity decreases markedly, substantially reducing maximum oxygen uptake.
Bone loss (demineralization) is accelerated.
Risk of deep venous thrombosis is increased.
After even a few days of bed rest, older patients who have reduced physiologic reserves but can still function independently may lose that ability. Even if the loss is reversible, rehabilitation requires extensive, expensive, and relatively lengthy intervention.
In older patients, bed rest can cause vertebral bone loss 50 times faster than in younger patients. The loss incurred from 10 days of bed rest takes 4 months to restore. Nurses should ensure that the hospital aligns care with the American Academy of Nursing recommendation that walking during the hospital stay is critical for maintaining functional ability in older adults.
Unless prohibited for a specific reason, activity (particularly walking) should be encouraged. If assistance with walking is needed, therapists may provide it at scheduled times. However, physicians, nurses, and family members should also assist patients with walking throughout the day. Hospital orders should emphasize the need for and promote activity.
If immobilization is necessary or results from prolonged illness, procedures to prevent deep venous thrombosis are recommended unless contraindicated.
Rehabilitation is often needed. Realistic goals for rehabilitation at home can be based on the patient’s prehospitalization activity level and current needs; orders for home physical and/or occupational therapy should be considered.
Age-related changes (eg, baroreceptor insensitivity, decreased body water and plasma volume) result in a tendency to develop orthostatic hypotension. These changes plus effects of bed rest and use of sedatives and certain antihypertensives increase risk of falls (and syncope).
Among hospitalized older patients, > 60% of falls occur in the bathroom; often, patients hit hard objects. Some patients fall while getting out of chairs and hospital beds. Patients are in a strange bed and in a strange environment, and they may easily become confused. Although bed rails may help remind older patients to call for assistance before attempting to get up, bed rails may also tempt patients to climb over or around them and thus may contribute to patient falls. Bed rails are generally discouraged because of the increased fall risk.
Usually, bed rails should be removed or kept down. The best alternatives to the use of physical or chemical restraints are to identify, carefully analyze, and modify or correct risk factors for falling (including agitation) and to closely observe patients at risk. Using low beds with padding on the floor next to the bed for patients with cognitive impairment, making sure any fluid spills are cleaned up promptly, and keeping pathways in rooms and hallways clear may also help reduce the risk of falls.
Urinary or fecal incontinence develops in > 40% of hospitalized patients ≥ 65, often within a day of admission. Reasons include the following:
An unfamiliar environment
A cluttered path to the toilet
Disorders that impair ambulation
A bed that is too high
Hampering equipment such as IV lines, nasal oxygen lines, cardiac monitors, and catheters
Psychoactive drugs that may reduce the perception of the need to void, inhibit bladder or bowel function, or impair ambulation
Drugs that may result in urinary incontinence (eg, anticholinergic drugs and opioids, causing overflow urinary incontinence; diuretics, causing urge incontinence)
Bedpans may be uncomfortable, especially for postsurgical patients or patients with chronic arthritis. Patients with dementia or a neurologic disorder may be unable to use the call bell to request toileting assistance.
Fecal impaction, gastrointestinal tract infection (eg, Clostridium difficile–induced colitis), adverse effects of drugs, and liquid nutritional supplements may cause uncontrollable diarrhea.
With appropriate diagnosis and treatment, continence can be reestablished in many cases.
Mental Status Changes
Older patients may appear confused because they have dementia, delirium, depression, or a combination. However, health care practitioners must always remember that confusion may have other causes, and its presence requires thorough evaluation.
Confusion may be due to a specific disorder ( see Table: Causes of Delirium Causes of Delirium ). However, it may develop or be exacerbated because the hospital setting exacerbates the effects of acute illness and age-related changes in cognition. For example, older patients who do not have their eyeglasses and hearing aids may become disoriented in a quiet, dimly lit hospital room. Patients may also become confused by hospital procedures, schedules (eg, frequent awakenings in strange settings and rooms), the effects of psychoactive drugs, exposure to anesthesia, and the stress of surgery or illness. In an intensive care unit, the constant light and noise can result in agitation Agitation, Confusion, and Neuromuscular Blockade in Critically Ill Patients Intensive care unit (ICU) patients are often agitated, confused, and uncomfortable. They can become delirious (ICU delirium). These symptoms are unpleasant for patients and often interfere with... read more , paranoid ideation, and mental and physical exhaustion.
Family members can be asked to bring missing eyeglasses and hearing aids. Placing a wall clock, a calendar, and family photographs in the room can help keep patients oriented. The room should be lit well enough to enable patients to recognize what and who is in their room and where they are. When appropriate, staff and family members should periodically remind patients of the time and place. Procedures should be explained before and as they are done.
Use of physical restraints is discouraged. For agitated patients, restraints invariably increase the level of agitation. Identifying and modifying risk factors for agitation and closely observing patients can help prevent or minimize it. Invasive and noninvasive devices attached to patients (eg, pulse oximeters, urinary catheters, IV lines) can also cause agitation; the risk:benefit ratio of these interventions should considered.
Pressure injuries Pressure Injuries Pressure injuries are areas of necrosis and often ulceration (also called pressure ulcers) where soft tissues are compressed between bony prominences and external hard surfaces. They are caused... read more (previously called pressure ulcers or pressure sores) often develop in older hospitalized patients because of age-related changes in the skin. Direct pressure may cause skin necrosis in as few as 2 hours if the pressure is greater than the capillary perfusion pressure of 32 mm Hg. During a typical emergency department visit, pressure injuries can start developing while older patients are lying on a hard stretcher waiting to be examined. After short periods of immobilization, sacral pressures reach 70 mm Hg, and pressure under an unsupported heel averages 45 mm Hg. Shearing forces result when patients sitting in wheelchairs or propped up in beds slide downward. Incontinence, poor nutrition, and chronic disorders may contribute to pressure injury development.
A protocol to prevent and treat pressure injuries Prevention Pressure injuries are areas of necrosis and often ulceration (also called pressure ulcers) where soft tissues are compressed between bony prominences and external hard surfaces. They are caused... read more should be started immediately at admission with a risk assessment using a validated tool such as the Braden Scale or Norton Scale The Norton Scale for Predicting Pressure Ulcer Risk* . It should be followed daily by the patient’s care providers and reviewed regularly by an interdisciplinary team. Pressure injuries may be the only reason patients are discharged to a nursing home rather than to the community.
Undernutrition and Hospitalization
In the hospital, older patients can become undernourished quickly, or they may be undernourished when admitted. Prolonged hospitalization exacerbates preexisting problems and often results in significant nutritional loss. Undernutrition Overview of Undernutrition Undernutrition is a form of malnutrition. (Malnutrition also includes overnutrition.) Undernutrition can result from inadequate ingestion of nutrients, malabsorption, impaired metabolism, loss... read more is particularly serious for hospitalized patients because it makes them less able to fight off infection, maintain skin integrity, and participate in rehabilitation; surgical wounds may not heal as well.
Hospitalization contributes to undernutrition in several ways:
Rigidly scheduled meals, use of drugs that may impact hunger and taste, and changes in environment can affect appetite and nutritional intake.
Hospital food and therapeutic diets (eg, low-salt diets) are unfamiliar and often unappetizing.
Eating in a hospital bed with a tray is difficult, particularly when bed rails and restraints limit movement, or when the patient has dysphagia.
Older patients may need help with eating; help may be slow to come, resulting in cold, even less appetizing food.
Older patients may not drink enough water because their thirst perception is decreased, water is difficult to reach, or both; severe dehydration may develop (sometimes leading to stupor and confusion).
Dentures may be left at home or misplaced, making chewing difficult; labeling dentures helps prevent them from being lost or discarded with the food tray.
Patients with preexisting nutritional abnormalities should be identified when admitted and be treated appropriately. Physicians and staff members should anticipate nutritional deficiencies in older patients.
The following measures can help:
Rescinding restrictive dietary orders as soon as possible
Monitoring nutritional intake daily
Conferring with patients and family members about food preferences and attempting to tailor a reasonable diet specific to each patient
Encouraging family members to join the patient at mealtimes because people eat more when they eat with others
Making sure patients are fed adequately at all times (eg, ensuring that meals are saved if patients are out of their unit for tests or treatment during mealtime)
Considering use of temporary parenteral nutrition or gastrointestinal tube feedings for patients too sick to swallow
Giving explicit oral fluid orders (eg, providing a fresh and readily accessible bedside water pitcher or other fluids unless fluids are restricted; advising family members, friends, and staff members to regularly offer patients a drink)
Transitions of care
A care transition is whenever a patient moves from one setting of care to another. In the last decade, significant research has shown that patient care during transitions is fragmented, frequently rushed, and lacks communication between practitioners, all of which result in poor patient outcomes. Transitions of care are when the greatest numbers of errors occur, creating increased risk for morbidity and mortality, particularly to older adults who cannot always advocate for themselves. Practitioners who provide care to older adults must pay special attention to the many transition points that occur when an older adult comes into the health care system. Best practices include ensuring that
All relevant health records are transferred
The patient and family are fully informed of what to expect in the new health care facility
A warm handoff occurs—at least a telephone call between the discharging and receiving organizations, and ideally, a telephone call between the discharging and receiving practitioner
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
National Transitions of Care Coalition (NTOCC): Tools for health care professionals, government leaders, patients, and caregivers to raise awareness about transitions of care, increase the quality of care, reduce medication errors, and enhance clinical outcomes
Discharge Planning and Transfers
Early, effective discharge planning has many benefits:
Shortening the hospital stay
Reducing the likelihood of readmission
Identifying less expensive care alternatives
Facilitating placement of equipment (eg, hospital bed, oxygen) in the patient’s home
Helping increase patient satisfaction
Possibly preventing placement in a nursing home
As soon as a patient is admitted, all members of the interdisciplinary team begin discharge planning. A social worker or discharge planning coordinator evaluates the patient’s needs within 24 hours of admission. Nurses help physicians determine when discharge is safe and which setting is most appropriate.
Patients being discharged to their home need detailed instructions about follow-up care, and family members or other caregivers may need training to provide care. If patients and family members are not taught how to give drugs, implement treatment, and monitor recovery, adverse outcomes and readmission are more likely. Writing down follow-up appointments and drug schedules may help patients and family members. At discharge, a copy of a brief discharge summary plan should be given to patients or family members in case they have questions about care before the primary care physician receives the official summary plan.
To another health care facility
When a patient is discharged to a nursing home or to another facility, a written summary should be sent with the patient, and a full copy should be sent electronically to the receiving institution, also, a phone call should be made to the receiving facility. Ideally, the discharging practitioner should call the physician, nurse practitioner, or physician assistant who will be caring for the patient in the new facility. The summary must include complete, accurate information about the following:
The patient’s mental and functional status
Times the patient last received drugs
List of drugs being currently taken and the dosage, route, and times to be taken
Known drug allergies or adverse reactions
Advance directives, including resuscitation status
Family contacts and support status
Follow-up appointments and tests
A summary of care provided in the hospital including copies of relevant tests and procedures
Names and phone numbers of a nurse and physician who can provide additional information
A written copy of the patient’s medical and social history should accompany the patient during transfer and may also be sent electronically to the receiving facility to ensure that there are no information gaps.
Effective communication between staff members of institutions helps ensure continuity of care. For example, the patient’s nurse can call the receiving institution to review the information shortly before the patient is transferred and can call the nurse who will care for the patient after discharge.