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). 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). 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 visiting the ED 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 of age. 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 a chronic alcohol use disorder. Adverse drug effects account for at least 5% of hospital admissions for older adults.
About 30 to 40% of older patients who visit 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 should be done in the ED. However, a standardized cognitive assessment is appropriate for any older patient visiting 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.
Hospitalization
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 $227.1 billion in 2023, representing 25% of such expenditures for hospital care in the US (1).
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, exposure to infectious organisms. 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 and of miscommunication of the drug change. 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). This highlights the importance of ensuring that older adults start physical therapy as soon as possible while in the hospital.
Adverse Drug Effects
Hospitalization rates due to adverse drug effects are 4 times higher for older patients (about 17%) than for younger patients (4%). Reasons for these effects include
Polypharmacy
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)
Comorbid conditions requiring multiple different drugs
Prevention
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)). Use of hypnotic drugs should be minimized because tachyphylaxis may occur and risk of falls and delirium is increased; measures to improve sleep hygiene 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 drugs to determine whether doses might be decreased or if a drug could be stopped safely to reduce the number of drugs an older adult takes and to reduce the risk of drug interactions.
Bed Rest Effects
Prolonged bed rest, which 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's recommendation that walking during the hospital stay is critical for maintaining functional ability in older adults (2014).
Prevention
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.
Falls
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.
Prevention of falls
Usually, beds should be placed at their lowest level with padding on both sides for patients at risk of falls. Bed rails should be removed or kept down unless patients are at risk of rolling out of the bed. 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 use of sedative drugs) and to closely observe patients at risk. As mentioned, returning beds to their lowest level if they were raised to provide care, placing padding on the floor next to the bed, 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.
Incontinence
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
Bed rails
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, Clostridioides 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). 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, paranoid ideation, and mental and physical exhaustion.
Prevention of mental status changes
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. Staff should identify themselves and their role when entering the room.
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 be considered.
Pressure Injuries
Pressure injuries (also called pressure ulcers) 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.
Prevention of pressure injuries
A protocol to prevent and treat pressure injuries should be started immediately at admission with a risk assessment using a validated tool such as the Braden Scale or the Norton Scale (see table 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
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 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.
Prevention of undernutrition
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, increasing the risk of morbidity and mortality, particularly in 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
Medications (particularly changes) are clearly documented and communicated
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
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
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
American Academy of Nursing: Don’t let older adults lie in bed or only get up to a chair during their hospital stay (2014)
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.
Discharge to home
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.
Discharge 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.
Alternatives to Hospitalization
In the past few years, several new models of health care delivery have been developed in which the patient is managed in the home (see also Home Health Care). The overall goal of these models is to provide a higher quality of care and management that keeps older adults out of both hospitals and skilled nursing homes and promotes aging in place. Overall, these are known as home- and community-based services that include traditional home health services but have been expanded to include other models, some of which have been initiated as demonstration projects.
Independence at Home (IAH) is a demonstration project that is sponsored by the Centers for Medicare and Medicaid Services (CMS). This model started in 2012 and has been renewed multiple times. In this model, homebound, frail older adults receive physician or advanced practice provider (eg, nurse practitioners, physician assistants) services in their home. The goal of this model is to keep the patient in their home and out of the hospital. To be included in this model of care, patients must be homebound and have 2 or more chronic conditions. Patients have benefited from the IAH model with fewer hospitalizations and greater satisfaction.
The Hospital at Home (HAH) model enables organizations to provide hospital-level care in the patient's home. Most of the participating patients are acutely ill older adults. The goal of this model is to decrease the number of days a patient spends in the hospital, reduce hospital costs, improve patient satisfaction, and improve outcomes. In most cases, these patients are generally stable but require extended hospital-level skilled care such as daily visits from a physician or advanced practice provider and daily monitoring of their medical condition. The benefits of this model include lower morbidity, less delirium caused by sedating drugs, less use of restraints, and high caregiver satisfaction.
The Emergency Triage, Treat, and Transport (ET3) model developed by CMS allows ambulance care teams to have greater flexibility in deciding where a patient should receive care. Instead of transporting a patient to a hospital emergency department, the ambulance care team, often in consultation with an advanced practice provider (APP), can divert the patient to an urgent care center or physician office or can facilitate care in the patient's home with the help of an APP who may be in the ambulance or accessible via telehealth.
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
Center for Medicare and Medicaid Services (CMS): Independence at Home Demonstration: A resource providing information about this care-in-the-home test model
CMS: Emergency Triage, Treat, and Transport (ET3): A resource providing details about this care model
