INTRODUCTION
Patients 65 years and older represent a large proportion of hospitalized patients. They tend to have more comorbid chronic illnesses and disability, and they 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 65 years and older hospitalized at least once during the year while only 8 percent of adults 45 to 64 years required hospitalization [1]. The leading diagnoses for admission among older patients include sepsis and cardiovascular disease [2]. Older adults have a similar average length of stay (five days) when compared with adults 45 to 64 years [3]. Yet older adults require more support after discharge, perhaps because of medical complexity and functional disability. Adults 65 years and older require post-acute 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) adults who receive post-acute care only 23 percent of the time [4].Despite the aging of the population, the number of formally trained physicians in geriatrics has not changed. Geriatric medical education programs and positions have only grown by 1 percent since 2000 [5]. 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].
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. Measuring physiologic vulnerability in older adults can be challenging. Diminished renal function can be detected with serum creatinine or cystatin C measurement, but quantifying the decline in organ function in other systems, such as the liver, heart, lungs, and brain, is more challenging. Often, vulnerability only becomes evident in hindsight after organ failure. Muscle strength and reserve also decline with aging, with detrimental impact on physical function. (See "Normal aging", section on 'Age-associated physiologic changes'.)