1. 
   

   How do elderly patients differ from younger patients?

   
   
2. 
   

   What are the risk factors for functional decline in the hospital?

   
   
3. 
   

   What are the risk factors for the development of geriatric syndromes as a complication of hospitalization?

   
   
4. 
   

   What items in the history and physical exam require customization for the geriatric patient?

   
   
5. 
   

   What are the factors that predict higher mortality post-discharge of elderly patients?

Elderly patients differ from younger ones in many ways, including some that influence their care in the hospital. Optimal geriatric hospital care takes these special characteristics into account, and entails the use of a particular systematic approach, no matter what patients’ admitting diagnoses may be. This chapter begins with a description of differences between older and younger hospital patients; describes the importance of self-care function among the elderly; summarizes key features of well-studied acute geriatric interventions; provides tips for care of the older patient on admission day, daily work rounds, and discharge; and finishes with information about prognosis in this population.

One characteristic difference between older and younger patients is in how they present with common diseases. Younger patients generally present with complaints and findings that anatomically point to the diseased organ: they have productive cough and dyspnea with pneumococcal pneumonia, or chest pain with myocardial infarction. Older patients may demonstrate the same signs and symptoms, but often they present with one of two often-overlapping pictures. The first is acute functional loss—the sudden loss of self-care capability, such as independence in bathing or dressing. The other is the geriatric syndrome, which is a clinical syndrome (such as acute confusion, fall, dizziness or syncope, new-onset urinary incontinence) reflecting the presence of diminished physiological reserve. A frail elder with pneumonia may have no complaints directed at the thorax, but instead may be brought in by family because of confusion, falls, and new difficulties in the shower.

A variety of physiological changes occur as a result of normal aging in humans; Table 164-1 summarizes some of the most prominent.

It is apparent that, in every physiologic system, aging results in a loss of physiological resilience, a reduced ability of the older body to maintain normal functioning when confronted with an external stressor. (Common stressors include pharmacologic adverse effects as well as acute illnesses.) Chronic diseases like heart failure, Alzheimer disease, or emphysema detract still further from the older patient’s physiological reserve. Geriatricians have long noted the “weakest link principle” among their patients—an elder’s illness presentation will reflect failure of that physiological system with the least reserve, rather than the system that is the locus of the new acute ailment. Hence, the elder whose circulatory system is weak comes to attention for syncope when struck down by a viral infection.

Two corollaries result from older patients’ atypical presentations and chronic multimorbidity. First, the wise diagnostician casts a wide net when confronted with sick older patients. Whether the frail elder’s complaint is new confusion or a fall, the admitting physician should consider a wide variety of incipient illnesses, and conduct a correspondingly comprehensive evaluation. Second, Occam’s razor, which motivates us to uncover a unifying diagnosis for multiple findings, more often fails in treating older patients.

Another crucial difference between older and younger patients is that the former show greater fragility in the hospital. Elderly hospitalized patients have been shown to suffer almost twice the incidence of preventable adverse events related to medical procedures, drug effects, and falls than do younger patients. Older age is also a well-established risk factor for activities-of-daily-living decline in the hospital.

Finally, older patients, by virtue of the fact that they are closer to the end of their lives than the beginning, often evince different health care goals than younger patients. The typical younger patient seeks rescue or life prolongation as a consequence of hospital care. Many older patients, of course, have the same desires, but a substantial number emphasize instead maintenance of independence or achieving symptomatic relief. This greater diversity in health care goals among older patients compels hospital providers to address the issue head on, a matter taken up later.

Function refers to the set of behaviors needed to remain independent in daily life. Functional domains include the following:

• Basic activities of daily living (ADLs): bathing, dressing, toileting, transfers, continence, and feeding.
  
• Instrumental activities of daily living (IADLs): using the telephone, shopping, food preparation, housekeeping, laundry, transportation, managing medications, and managing money.
  
• Mobility: including the ability to ambulate in the home or community, negotiate stairs, etc.

The trajectories of physiological and functional measures often differ greatly during elders’ hospitalizations. Whereas physiological markers (vital signs, laboratory assessments) typically improve by discharge, functional measures commonly show worse status. Studies have shown, for example, that 20% to more than 30% of older patients admitted to hospital general medical wards lose independence in one or more ADLs by the time of discharge. One study of almost 2300 elders on the general medical service of two hospitals found that 35% were discharged with worse-than-baseline function. This 35% was composed of the following subgroups: 12% showed decline in the hospital only, 18% had prehospital decline from baseline but failed to recover, and 5% demonstrated both prehospital and in-hospital decline.

Scholars of geriatric patients’ function have enunciated certain principles of ADLs and IADLs: (1) ADLs reflect more than simply physical function, but reflect the match between a patient’s physical abilities and her environment (including social support). (2) As people age, ADLs are typically lost in an orderly fashion: the ability to bathe independently is lost first, the ability to feed oneself last. (3) ADL loss progresses through predictable stages: first, one can do the ADL without difficulty; later, one can do it, but with difficulty; still later, one can’t do it alone, but can do it with assistance; and finally, one can’t do it, as there is insufficient help. (4) IADLs reflect higher-order cognitive skills needed for individuals to live independently, and with most conditions (especially dementing disorders). IADLs are lost before ADLs.

Patients’ mobility often follows a different trajectory than their ADL or IADL function. Cognitively impaired patients, in particular, commonly maintain their mobility while suffering ADL and IADL losses. An older patient’s mobility may be assessed by asking: Do you have difficulty walking up or down stairs? Do you have difficulty walking several blocks? Do you have difficulty walking across a room?

Although physicians appear in some studies to be unaware of their patients’ functional abilities or at least commonly neglect to document them, functional capacity is a potent predictor of outcomes in older patients. Function reveals the extent to which a patient is impacted by her various diagnoses. Poor function has been shown to predict mortality, institutional placement, caregiver burden, quality of life, length of stay, and cost of care.

Functional loss in the hospital probably reflects complex interactions between diseases, age, and hospital care itself.

Table 164-2 lists factors that have been found in various studies to increase the risk of in-hospital functional decline. Predictors include preexisting functional impairment, brain disease (dementia, delirium, depression), malnutrition, mobility difficulties (including bed rest), and older age. Regarding age, one research group found that older hospitalized patients are less likely to recover ADL function that they lost from their baseline preceding admission, and are more likely to develop new functional impairments during their hospital stay. Others have reported that cognitive impairment present at hospital admission predicts failure of functional recovery at three months following hospital discharge.