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What are the essential aspects of geriatric assessment that should occur routinely in the hospital?
How should the geriatric assessment differ from admission assessments of younger patients?
What should the assessment of the physical function domain include? The psychological domain? The social domain?
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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.
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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.
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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.
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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 ...