1. 
   

   What are the essential aspects of geriatric assessment that should occur routinely in the hospital?

   
   
2. 
   

   How should the geriatric assessment differ from admission assessments of younger patients?

   
   
3. 
   

   What should the assessment of the physical function domain include? The psychological domain? The social domain?

The U.S. population of adults age 65 years and older will double within 20 years. In 2005, an estimated 35 million nonfederal hospital discharges occurred in the U.S. excluding newborns, and while older adults (65+) comprise 12% of the population, they accounted for 35% of hospital stays. Increasingly often, geriatric patients enter the hospital through the emergency room. For example, for patients 80 and older, 64% came through the emergency room in 2002, compared with 55% in 1997.

Risk of ICU admission and utilization also rise with age, peaking in the very old: in those age 85 years or more there were 58.2 admissions per 1,000 residents and 195.8 days per 1,000 residents, compared with 3.8 admissions per 1,000 residents and 11.5 days per 1,000 residents in those 18 to 44 years old. Residents 85 years old and older were 3.75 times more likely to be admitted to the ICU than those age 18–44 after controlling for comorbid illness. Risk of ICU admission increased with admission to surgical units, and presence of multiple comorbid illnesses especially cardiovascular and renal disease.

In addition to high personal costs, the impact on health care costs is also high. As one example, the occurrence of delirium more than doubles the impact on health care costs. Annual estimated costs in the U.S. attributable to delirium range from 38 billion to 152 billon dollars due to increased mortality and morbidity, prolonged hospital stay, functional decline, and institutionalization. With 42% of the U.S. national health care budget spent on inpatient care, and readmissions accounting for one-quarter of Medicare inpatient expenditures, reduction in readmissions is becoming a focal point in health care policy, and hospitals may lose reimbursement when preventable readmissions occur.

Normal aging reduces physiologic reserve and the ability to maintain homeostasis under physiologic stress even in the best of circumstances. Chronic disease, the stress of acute illness precipitating admission, and polypharmacy then add to vulnerability in this heterogeneous population. Furthermore, the hospital experience disrupts normal life rhythms in a foreign environment away from familiar cues and supports. Hospital procedures and policies promote dependency and immobility that is often related to physical restraints and expose the patient to multiple unfamiliar people, further exacerbated by unit transfers. Hospitals disrupt sleep and nutrition due to lighting, unit noise, and interruptions such as frequent blood drawing and performance of vital signs and tests. Use of sedatives or medications with anticholinergic side effects—though sometimes unavoidable during anesthesia—and inadequate pain management further exacerbate the risk of hospital acquired complications, including delirium, depression, infection, malnutrition, deconditioning, falls, and pressure ulcers. Adverse outcomes include in death, a prolonged hospital stay, nursing home placement, and increased long-term dependency.

Incident delirium, which is one of the most troublesome complications during hospitalization, ranges from 11% to 42% of admissions and functional deficits related to delirium may persist long after hospital discharge. While the classic association of delirium with urinary tract infection is common and well recognized, many cases of hospital-acquired delirium result from an underlying predisposition complicated by medication side effects, undertreated pain, restraints, constipation, and disrupted routines, producing a cascade of adverse effects. (Refer to section on Infectious Diseases for hospital-acquired infections and delirium).

Studies have also shown that 30% to 60% of older people develop new dependencies in activities of daily living (ADL) during their hospital stay, with a dramatic loss of muscle strength for each day at bed rest. And pressure ulcers, considered a preventable complication of hospitalization, are associated with increased length of stay and health care cost, to the point that they are being called “never” events for which Medicare will refuse to pay. The median incidence of pressure ulcers in hospitalized elderly persons varies from 5% to 16% and has not decreased in recent years. Some pressure ulcers develop early during hospitalization, after only a few hours of immobility induced pressure. One large study found that 6% of patients developed one or more hospital-acquired pressure ulcers within two days of hospital admission. Risk factors for new pressure ulcers include increased age, male gender, African-American ethnicity, immobility (requiring assistance with turning in bed), transfer from nursing home, nutritional compromise, BMI < 18.5, the presence of another pressure ulcer, and urinary and fecal incontinence. (See Chapter 144 Pressure Ulcers and Chapter 164 Principles of Geriatric Care for a discussion of evidence-based models of care to prevent inpatient complications.)

The elderly patient admitted to the hospital should be considered a “high-risk senior,” defined as those at risk for developing health-related crises, simply by virtue of being hospitalized. The admission of any elderly patient to the hospital offers a window of opportunity for identifying those at risk for further functional disability and clarifying targets for timely intervention to prevent or delay further decline and a cascade of readmissions. Patients with five or more chronic illnesses and deficits in activities of daily living or ADLs are at dramatically higher risk of preventable readmission. The hospitalist should provide an actionable assessment that will lead to a multidisciplinary approach utilizing case management, appropriate consultation, disease management programs in patients with lower degrees of comorbidity, and coordinated posthospital care. Optimal practice involves targeting posthospital services to be cost-effective and efficient: the right care, in the right place, at the right time, based on need. And there is a need for an effective handoff, which is too often overlooked.

The admission history and physical examination is the starting point. This is a multistep process of acquiring data that in aggregate leads to a provisional diagnosis. Physicians are taught to seek one diagnosis that will explain all or most aspects of a patient’s signs and symptoms at presentation. However, elderly patients commonly have multiple comorbid conditions of varying severity that may affect the initial presentation of a new illness. Unlike younger patients, whose signs and symptoms refer to the diseased organ, ill elderly patients commonly develop nonspecific symptoms such as lethargy, confusion, falls, and incontinence and decreased ability to perform ADLs. Painless myocardial infarction, pneumonia without cough or fever, apathetic hyperthyroidism, and depression masquerading as dementia are examples of common yet atypical presentations. A change in mental status, gradual debilitation, and nonspecific symptoms are also characteristic of tuberculosis in the elderly; yet this patient population has weakened delayed hypersensitivity reactions so that only 5–10% of 90-year-olds will have a positive initial PPD despite prior exposure. In addition, there may not be one unifying diagnosis to explain all symptoms, some of which may be from drug side effects. Therefore, clinicians need to maintain a high index of suspicion, incorporate risk factors into clinical decision making, carefully review all medications and treatment, obtain information from multiple sources, and perform a comprehensive examination.

To guide the care process, geriatric medicine focuses on functional domains—physical, cognitive, psychological, and social—that can be used to assess quality of life and goals of care. In addition to treating the cause for admission, a multifaceted approach may improve outcomes by identifying disability, taking steps to improve functional performance, instituting preventive measures to limit iatrogenic complications and disability, and by promoting wellness and independence. This chapter will describe the essential history and physical exam components that should routinely be performed for hospitalized elderly patients in addition to the admission history and physical examination ordinarily performed for younger patients, and explains how to factor this information into discharge planning.

In order to obtain a complete patient history, clinicians should communicate with family members and caregivers for information about baseline functioning, and if possible, contact the primary care physician or geriatrician on the day of admission. Providers need this information to achieve goals of hospitalization, which include avoidance of complications that might exacerbate preexisting conditions that make the patient even more vulnerable to prolonged hospital stay and the need for permanent placement upon discharge. The team should encourage liberal visiting by family and friends, especially during meals and evening hours, inform the family of the risks of hospitalization, and engage them in preventive measures such as orienting the patient, explaining the hospital routine, and assisting with ambulation. The family should bring in the patient’s hearing aid, glasses, and assistive devices that will facilitate optimal function. Care must then be taken not to lose these sometimes expensive items during the hospital care process.

Effective communication during the patient interview always begins with speaking in the patient’s native language and at the level appropriate for the patient’s educational background and cognitive function. The clinician should

• Address the patient by his or her last name.
  
• Try to minimize extraneous noise and interruptions.
  
• Sit opposite the patient at eye level, smiling, speaking slowly with a low-pitched voice.
  
• Inquire about hearing deficits, confirming that the patient can hear the conversation, and ask him or her to repeat back what has been heard.
  
• Raise the volume of his or her voice, if necessary, but not shout; shouting may be misinterpreted as anger.
  
• Write questions down in a large print, if the patient does not have his or her hearing aid or still cannot hear.
  
• Allow plenty of time for the patient to respond to questions.
  
• Try to reassure the patient that he or she is in a safe environment.
  
• Engage the patient to speak about his or her interests.
  
• Use visual aids in the room to identify care providers and be available when family members visit.

The Cognitive Domain

The prevalence of cognitive impairment doubles every five years after the age of 65. By age 90, 40% to 50% of patients have some dementia. Family members and friends often notice the changes seen in dementia but may deny the symptoms or neglect to mention the symptoms to busy medical practitioners, especially in the early stages of the condition. Many patients do not complain or volunteer information about memory loss and this problem will be overlooked unless they are specifically questioned or tested to detect the early signs. In general, physicians often fail to identify or document early or mild cognitive impairment. The interviewer should ask the patient and any family caregivers whether the patient suffers from memory loss sufficient to interfere with social functioning in the months or years preceding the acute illness. Dementia is a potent risk factor for hospital-acquired complications including delirium, and recognizing it will help with preventive measures. The sometimes subtle symptoms and signs of dementia are noticeable to the people who live with the older adult and these also may precipitate a hospital admission for “placement,” again requiring a proactive approach from day one. Consider the following example, as it might normally occur and as it might be improved.