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, 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'.)

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) [9]. 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 [10]. The resulting failure of the heart, lungs, kidneys, and/or brain (delirium) appears apart from the original complaint for which the patient was hospitalized [10].

PATIENT ASSESSMENT ON ADMISSION — Aging and the cumulative effects of a lifetime of illness allow for a wide range in functional abilities of older adults, such that actual age may not always correlate with physiologic age; some older patients are fully independent while others are not. 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 [11]. Functional assessment upon admission is appropriate for all older adults. Instruments for the assessment of physical ADL (the Katz index for ADL) and IADL (the Lawton scale for IADL) are shown in tables (table 2 and table 3).

Hospital-associated disability (the loss of one or more of the basic activities of daily living [ADL] needed to live independently) is common, seen in up to one-third of patients at ages >70 years [12-16]. Tools have been developed to predict functional decline in patients admitted with cardiovascular complications based on the presence of impairments in mobility or cognition, loss of appetite, depressive symptoms, or use of restraints at the time of admission [17]. Specific risk factors for new-onset disability in patients admitted to general care units at discharge include age ≥80 years, dependence in three or more criteria in the assessment of instrumental ADL (IADL) two weeks before admission, poor mobility at baseline (as defined by inability to walk uphill or stairs), severe cognitive impairment, metastatic cancer, and albumin <3 g/dL [18]. Impaired arousal on hospital admission has been correlated with increased mortality at six months; arousal can be assessed using the Richmond Agitation-Sedation Scale (RASS) (table 4) [19].

Frailty, the geriatric syndrome whereby a person has increased vulnerability to stress, is one measure of how robust a person is and provides a framework for understanding their risk of adverse events. The Clinical Frailty Scale is a widely used tool to assess a person's degree of frailty [20,21]. While hospitalization is often not planned, assessing frailty prior to elective surgery may help guide decisions around the risks and benefits of elective procedures; in one study of several hundred patients 65 years and older undergoing elective orthopedic surgery, increased preoperative frailty correlated to an increased risk of mortality at one year [22].

Cognitive function — It is important to assess a patient's cognition at the time of admission and regularly throughout their hospitalization. Assessment of cognitive function is described in detail elsewhere. (See "Evaluation of cognitive impairment and dementia".)

Older patients are vulnerable to acute brain failure (delirium) and commonly present with this condition. In one study looking at patients in the emergency department, a RASS score greater than +1 or less than -1 was nearly diagnostic of delirium with a specificity of 99 percent [23]. Preventing delirium and identifying delirium as soon as it develops can help mitigate the morbidity and distress associated with the condition. (See "Delirium and acute confusional states: Prevention, treatment, and prognosis", section on 'Prevention'.)

There are a variety of instruments available to screen patients for delirium, with one of the most widely utilized in the United States being the Confusion Assessment Method (CAM) [24]. Standard of care at many hospitals now requires CAM screening every 8 to 12 hours by frontline nursing staff. Clinicians should be attentive to their patient's CAM scores and conduct brief assessments of cognition daily. The ultrabrief delirium screen and the 3DCAM represent two relatively short and useful tools [25,26].

Patients with dementia are at increased risk for developing delirium. A patient's baseline cognitive status prior to their acute illness is critical to understanding any cognitive changes noted during hospitalization. Diagnosing dementia in the acute setting can be challenging given the prevalence of superimposed delirium. Given the associated morbidity with undetected and untreated delirium, it is best to assess and treat delirium in any patient with altered cognition and avoid the temptation to diagnose dementia in the acute inpatient setting.

Pain — Pain is a common symptom for many older patients [27,28]. It is important to consider the impact pain has on daily functioning in older patients and how it may be contributing to the patient's current presentation. 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 suffers from pain can be challenging, but there are validated tools to aid in this assessment (table 5) [29]. The American Geriatrics Society has developed guidelines to aid clinicians in assessing and treating older adults with pain [30].

Medication review

Reconciliation — Up to 30 percent of hospital admissions are the result of adverse drug events [31,32]. 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 specifically queried about use of over-the-counter medications, including complementary or herbal medication use. 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 — Further, 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".)

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 [33].

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 important 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 supports. 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 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 6 and table 7) [34].

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 supports after discharge. (See "Hospital discharge and readmission".)

Vaccinations — Hospitalization provides an important opportunity to address vaccination status, particularly for pneumococcal and influenza vaccination. The Centers for Disease Control and Prevention (CDC) recommends ensuring vaccination during hospitalization or at the time of discharge. 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 [35]. (See "Geriatric health maintenance", section on 'Immunizations'.)

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 [36]. 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.

Functional decline — Bed rest and lack of mobility combine to hasten physical deconditioning and muscle weakness [37]. Immobility is associated with increased risk for falls, delirium, skin breakdown, and venous thromboembolic disease [38,39]. Improved mobility during hospitalization has been linked to decreased risk of death at two years [40].

Although a few conditions require absolute bedrest (eg, unstable fractures and certain critical illnesses), most medical conditions do not necessitate immobility. 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 [41] and, when possible, encourage patients to walk several times daily.

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 [42]. (See 'Early mobilization programs' below.)

Falls — Older hospitalized adults are at great risk of falling due to the effects of the acute illness compounded by an unfamiliar environment and side effects of treatments. The etiology of a fall is 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".)

●The risks and benefits of medications with significant psychotropic and anticholinergic effects (eg, opioid analgesics, diphenhydramine) should be carefully weighed.

●Patients should be monitored when 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).

●Patients at higher fall risk may need supervision with ambulation.

●Time out of bed throughout the day should be encouraged, whether walking or sitting in a chair, to prevent orthostatic hypotension associated with prolonged immobility [43].

●Intravenous lines and urinary catheters should be discontinued as early as possible. (See 'Tethers' below.)

●Restraints should be avoided since restraints, either physical or pharmacologic (eg, antipsychotics, benzodiazepines), may increase the risk of falling.

Nonetheless, it is likely that the majority of falls that occur in the hospital setting may not actually be preventable. Bed alarms have not been demonstrated to be effective at reducing falls [44] and may increase the risk of alarm fatigue, be distressing to patients, and lead to a false sense of security [45]. In the United States, Medicare does not reimburse hospitals for complications or extended length of stay related to falls that occur during the course of hospitalization. It is important that institutions not adopt potentially deleterious practices, such as increased use of strict bed rest orders, restraints or restraint-like chairs or other devices, in an effort to decrease their revenue losses [46].

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 8) [24,47,48]. 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 for 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 [49]. Pain, interruption in sleep patterns, and several classes of medications are also important risk factors for delirium (table 9) [50,51]. Confusional states can be worsened when sensory input is affected, such as occurs when a patient lacks access to eyeglasses or hearing aids.

Effective measures to prevent 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) [47,48,52]. The management of patients with delirium is summarized in an algorithm (algorithm 1). (See "Delirium and acute confusional states: Prevention, treatment, and prognosis".)

A systemic review and meta-analysis found that there is no evidence to prescribe antipsychotic medication for the prevention or treatment of delirium [53]. Guidelines from the American Geriatrics Society and the American College of Surgeons on the prevention and treatment of postoperative delirium and 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 [54,55].

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 [56], using the T-A-DA method (Tolerate, Anticipate, and Don't Agitate) to guide the approach to caring for delirious patients [57].

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. (See "Insufficient sleep: Definition, epidemiology, and adverse outcomes", section on 'Effects of acute sleep deprivation'.)

The link between poor sleep and delirium remains elusive. However, older hospitalized adults who received a multicomponent intervention, including protocols to address sleep deprivation, had a decreased risk for developing delirium [52]. 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 delirium and other adverse events.

Tethers — Some tethering medical devices, such as urinary catheters, intravascular lines, cardiac telemetry leads, 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 [58-60], 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. As an example, despite the well-publicized risks of indwelling urinary catheters, their use and associated complications have not declined over several decades [61]. (See "Placement and management of urinary bladder catheters in adults", section on 'Inappropriate use of catheters'.)

Clinicians should weigh the risks and benefits of each tethering device and initiate use only when the likelihood of benefit is significant and in 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.

It is important to remove a tether when it is no longer vital for ongoing management. Removing tethers and getting patients out of bed are ways to normalize the daily routine for an older patient. (See "Assessment and emergency management of the acutely agitated or violent adult", section on 'When to apply restraints' and "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. The incidence of C. difficile infection continues to rise.

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 [62,63].

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 [64,65]. 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 10). (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 11):

●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 12); 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".)

Malnutrition — Poor nutrition for older hospitalized patients may result from several factors:

●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

●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 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 [66]. 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 [67].

Nutritional repletion may be provided to restore the patient to a target weight, with recognition that weight correction in the older population is less readily accomplished than in younger people. A meta-analysis of 15 studies in malnourished geriatric patients (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 [68]. (See "Geriatric nutrition: Nutritional issues in older adults", section on 'Treatment of weight loss' and "Nutrition support in critically ill patients: An overview".)

Several issues should be considered before placement of a feeding tube, particularly in older patients with multiple morbidities. Whenever possible, oral feedings are preferred to the use of feeding tubes. The patient and family should be counseled and their wishes known prior to inserting a feeding tube. Feeding tubes have not been demonstrated to prolong survival in patients with dementia, nor have they been shown to provide improved comfort at the end of life [69]. The American Geriatrics Society's 2014 guideline on feeding tubes in patients with advanced dementia recommends against their use [70]. If the patient or their proxy elects to have a feeding tube, the tube should be removed when the patient is able to take nutrition orally, or when tube feeding is no longer consistent with the patient's care plan. (See "Nutrition support in critically ill patients: Enteral nutrition", section on 'Indications and contraindications' and "Enteral feeding: Gastric versus post-pyloric", section on 'Issues for deciding upon the type of enteral nutrition'.)

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 [38]. 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 [71]. (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 13). Multiple medications, often new to the patient during hospitalization, potentiate the risk of nutritional, functional, and cognitive decline in older adults during hospitalization [72], as well as increase the risk of overall mortality [73]. With physiologic decreases in liver and kidney function, older patients have a higher incidence of adverse drug events than younger patients. (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'.)

Hip fracture — Hip fractures are a common cause of hospitalization in older adults and are associated with significant morbidity and mortality (see "Hip fracture in adults: Epidemiology and medical management"). Multidisciplinary hospital interventions may decrease the risk of adverse outcomes. An evaluation of such an intervention (the Integrated Fragility Hip Fracture Program) compared over 400 patients treated with a multidisciplinary and protocol-driven intervention with similar patients admitted in a prior year [74]. Patients who received the intervention, which consisted of preoperative, intraoperative, and postoperative care components, had lower 30-day mortality (2.8 versus 8 percent), as well as fewer adverse drug events, blood transfusions, or unexpected returns to the operating room, and shorter lengths of stay.

HOSPITAL-WIDE INTERVENTIONS — Although limitations in the physiologic reserve for older patients are largely not modifiable, there are several strategies that can improve outcomes for older adults when implemented on a hospital-wide basis. Many of these interventions are based upon preventive interventions for individual adverse outcomes.

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 clinician, geriatrician, nursing staff, physical/occupational/speech therapists, 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 [75]. 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 [76-78].

One model for multidisciplinary care involves dedicated staff in a designated geriatric unit within the hospital. (See 'Geriatric units' below.)

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 [79]. Whether these "virtual" units are as effective as traditional geriatric units is unknown. The lack of a consistent nursing staff trained in the care of older persons may diminish the effectiveness of this model. Other hospitals have combined hospitalist-directed care with mobile geriatric care teams to provide enhanced care to older patients throughout the hospital [80]. In a trial comparing hospitalized patients age >70 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 [81]. 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 [82].

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 [83]. HELP programs may decrease rates of delirium, reduce length of stay, improve patient satisfaction, and reduce hospital costs [84-86].

Checklists and order sets — Checklists can improve quality of care for older patients by integrating reminders into everyday care to ensure practice standards are met [87,88]. Checklists are now commonly embedded into the electronic health record and prompt clinicians with embedded decision support and guidance. These 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 [82], improving outcomes.

Defined admission order sets have been shown to improve adherence with venous thromboembolism prophylaxis and may also address some of the most common concerns affecting older patients, including diet, medications, and advance directives [89]. As an example, clinicians can select a default activity order that directs nursing staff to get patients out of bed at least twice daily, rather than the more common nonspecific order of activity: "ad lib."

Protocols for medication-appropriateness — Potentially inappropriate medication (PIM) use (as defined by the Beers [90] and the Screening Tool of Older Persons’ Prescriptions [STOPP] criteria [91]) in hospitalized older adults is common [92] and associated with functional decline and adverse drug reactions. Successful strategies to limit exposure to PIM include computerized-embedded decision support [82] and interruptive alerts [93].

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 [94,95].

Early mobilization programs — It is important to ensure that patients are mobilized early and often during their hospitalization. Mobilization can help prevent falls [96]. Studies have found that increased mobility in the hospital is associated with less functional decline during hospitalization and shorter lengths of stay [97-100], though whether this represents a healthier population rather than the impact of mobilization is uncertain in the absence of data from a controlled trial. Evidence suggests that even ventilated patients in the intensive care unit (ICU) can benefit from early mobilization programs [101]. Early mobilization after acute stroke is also associated with improved functional outcomes [102].

Hospital-based mobilization programs are an ideal way to ensure that patients are getting out of bed and maintaining some mobility and function during their acute illness. Younger patients may be encouraged to mobilize independently, but most older patients will require assistance to safely navigate out of bed, especially if one or more tethers are present.

Mobilization and exercise — A meta-analysis of trials comparing exercise interventions (mobilization and other exercise) with usual care among acutely hospitalized older adult patients found that the intervention increased the proportion of patients discharged to home and reduced length of stay by approximately one day [103]. The authors estimated that treating 16 patients (95% CI 11-43) with a multidisciplinary intervention would result in one patient discharged to home compared with the control group.

A subsequent trial among 370 acutely hospitalized older adults (mean age 87 years) demonstrated that a twice-daily multicomponent exercise program (resistance, balance, and walking exercises) provided an improvement over usual care in functional capacity at discharge compared with baseline [104]. Functional capacity was assessed by evaluations of balance, gait velocity, and leg strength (Short Physical Performance Battery [SPPB]), and independence in activities of daily living (ADL; Barthel Index). The intervention group had mean increases of 2.2 points (95% CI 1.7-2.6 points) in SPPB scores and 6.9 points (95% CI 4.4-9.5 points) in the Barthel index when compared with the usual care group.

Safety equipment — Many hospitals rely upon specially developed 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. These alarms are not a part of universal fall precautions [105] and 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 [106]. (See "Falls: Prevention in nursing care facilities and the hospital setting", section on 'Restraints and alarms'.)

Beds that are positioned lower to the ground, or at floor level, have been used to lessen the potential height that a patient may fall when the patient rises from bed. Placing the bed in a low position is a part of universal fall precautions [105]. 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 [107].

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) [108,109]. Age alone does not predict survival from a critical medical illness, even in the most vulnerable older patients [110]. 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 [111]. (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 [112]. Several inpatient geriatric unit approaches have been developed in a variety of clinical settings [113]. Within the United States Department of Veterans Affairs hospitals, these are usually referred to as Geriatric Evaluation and Management Units (GEMUs). 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) [114]. 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 at 6- and 12-month follow-up [115]. 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 [116]. 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 [117].

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 [118]. Care at home can reduce the risk of delirium and save hospital bed usage [119,120].

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 [121]. In both groups, the most common presenting problem was acute functional deterioration, and the most common diagnosis was infection.

Unfortunately, reimbursement rules in the United States often prevent the mobilization of adequate resources in the home environment to allow hospital-level care in the home to be a viable option. However, in the fall of 2020, due to the increase in hospitalization from the coronavirus disease 2019 (COVID-19) pandemic, Centers for Medicare and Medicaid Services announced the Acute Hospital Care At Home program, which provided eligible hospitals with the flexibility to treat eligible patients in their homes [122]. Six health systems with extensive experience providing acute hospital care at home were approved for waivers.

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 14 and table 15) [123]. Larger hospitals often have special palliative care teams to provide care to this population. 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 suffering from 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 [116]. While most younger patients are discharged to home, 40 percent of patients 85 years and older are discharged to a SNF prior to going home, which adds a second transition and a third set of care providers [124]. 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 [125]. 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 16) [87]. Select interventions at discharge are reviewed separately. (See "Hospital discharge and readmission".)

Several programs have been developed to improve the hospital discharge process, including Project BOOST and the Care Transitions Program. These, and similar initiatives, are discussed in more detail 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 5^th to 6^th 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 10^th to 12^th 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 '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 12). (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 13) 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".)

●Hospital-wide strategies – Some hospital-wide strategies are associated with improved outcomes for older adults, including care involving multidisciplinary teams, checklists, and early mobilization programs. (See 'Hospital-wide interventions' above.)

●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 16). (See 'Discharge planning' above.)