Chapter 169. The Frail Hospitalized Patient

1. How do you identify frail, hospitalized older patients?

2. What adverse outcomes are common among this population?

3. How can an interdisciplinary team prevent adverse outcomes for frail older patients?

4. What are the opportunities to improve long-term health outcomes?

5. What are the steps for establishing a safe and thorough discharge plan?

Older patients disproportionately face many complications during hospitalization, including deconditioning from immobility, nosocomial infections, pressure ulcers, falls, and delirium. Hospital-associated deconditioning may lead to rapid functional decline. One in three older hospitalized patients loses the ability to perform at least one activity of daily living (ADL) by the time of discharge. Losing the ability to bathe or toilet independently may result in discharge to a nursing home for a patient who has previously lived independently. One in five hospitalized older patients is discharged to a nursing home due to a new loss of function. The frailest patients are at highest risk for hospital-associated functional decline and institutionalization.

If asked what a frail older patient looks like, many physicians would say, “I know it when I see it.” The thin older person who slowly ambulates with a walker is easily identified as frail. Nevertheless, recognizing frailty in clinical practice may not always be so straightforward. Frailty does not fit into classic organ-specific models of disease, and it may not be evident to clinicians, patients, or family members that there has been a decline in health. Declines in strength, mobility, cognitive function, and nutrition may be gradual. Patients or clinicians may attribute these changes to old age and not appreciate that a response is indicated to reverse the process.

Frailty may be particularly difficult to identify in the hospital setting. A physically robust older patient may be indistinguishable from a frail older patient at first glance if they are both acutely ill, dressed in hospital gowns, and lying in hospital beds. Without asking the right questions and assessing important factors such as mobility, cognitive function, and nutritional status, the health care team may fail to identify the frail patient and take appropriate steps to reduce the hazards of hospitalization.

Frailty manifests with a variety of clinical features including loss of strength, weight loss, low levels of activity, and slowed performance. The biological basis of frailty involves a combination of age- and disease-related physiological changes including skeletal muscle loss, changes in endocrine function, and chronic inflammation. Endocrine changes include decreases in estrogen, testosterone, growth hormone, and insulin-like growth factor, each of which has been implicated in muscle loss. Frail older patients have been shown to have increased levels of proinflammatory cytokines, such as interleukin-6 and C-reactive protein. Although these laboratory findings contribute to our understanding of the physiologic basis of frailty, they are not useful for diagnostic purposes, especially in hospitalized patients who have changes in inflammatory markers and endocrine function stemming from acute illness. Frailty remains a clinical diagnosis based on history, physical examination, and functional assessment. Frailty ...