Should elderly patients always be admitted to the hospital?

95-year old patients who go to the emergency department, more likely than not, will get admitted to the hospital.

But is that always what’s best for the patient? Emergency physician Graham Walker suggests not. He notes, correctly, that, “the group with the highest odds of having something seriously wrong with them are probably also the most likely to have something go wrong with them while they’re in the hospital.”

Indeed, hospital complications, like iatrogenic infections and falls, contribute to the morbidity and mortality of hospitalized elderly patients. Combine this with the fact that 90% of Americans surveyed want to die at home, but 80% die in an institution.

How about a simple discussion with both the patient and family about their wishes to be admitted? If no further intervention is desired, simply discharging these patients home may be beneficial for everybody involved.

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  • Happy Hospitalist

    Why not? Because FREE=MORE

  • Dr. Grumpy

    It depends on the presenting complaint.

    Also, the current “CYA” medical system leans toward admitting these patients.

  • A doctor

    Depends. 95 year old living independently, admit and treat. OTOH, the nursing home should be on a one way street.

  • Michael Kirsch, M.D.

    This issue is not just a geriatric concern. Every patient who is hospitalized should be wary of the risks. I view the hospital as a medical obstacle course, a minefield full of germs and other pools of quicksand waiting for unwitting patients to fall in. Out-patient medical care is safer and preferred, unless hospitalization is unavoidable.

  • Rezmed09

    Sure there are risks, but elderly patients are admitted for so many clusters of reasons: debility, care giver burn out, returns to ER which may be occurring or are expected, angry families, CYA medicine, and of course the presence of insurance – Medicare. Don’t forget, most of us have had the experience of a patient like this sent home only to return – coding, with a hip fracture or worst of all, coming back in at 3am. A 2-3 day admit and everyone is happier, richer and more rested. This will never change until our payment structure, medicolegal system and incentives are changed.

  • jimeyers

    An elderly patient should not be forced to forego necessary treatment for a readily treatable condition and thereby face certain death in order to avoid death by “complications” faced by elderly patients who are admitted. This is certainly “Hobson’s Choice.”
    It is a mistake to assume an elderly patient cannot safely be cared for in a hospital setting. The morbidity our elders face is to a great extent avoidable by assuring that they are kept clean, hydrated fed and as active as their condition permits. Adverse changes in their condition should be promptly recognized and properly and timely treated. This is the level of care all patient’s deserve.
    Because elders are more fragile they require more attention but tend to get less. Elders suffer more complications and more serious consequences not simply because they are fragile but more importantly because they to not receive the surveilance and attention they require.
    The costs imposed on medicare are magnified because of inadequate treatment which results in needlessly prolonged geriatric admissions and readmissions and prolonged and useless rehabilitation admissions.
    When these patients fail to thrive they are simply fullfilling expections. This is a self-fullfilling prophecy. The expectations need to be changed.

  • Doctor D

    In my experience most elderly patients with conditions that would normally be sent home want to go home, but family members are concerned they won’t be able to care for a sick 90 year-old.

    So the doctor admits because we don’t want to have anything bad happen at home once family said they wanted grandpa to stay. CYA medicine and more complications.

    It would be nice to have “on call” home health that could be available to help families immediately. Temporary home health currently just can’t be set up from an ER. It would be cheaper, safer, and more satisfying to patients than hospital admission.

  • Mike

    How come the elderly patients are in the ED in the first place? Did they walk in and want to be treated? Did the nursing home send them in for a chronic complaint on a friday night hoping they will be admitted? Is the caregiver burnt out or going on vacation? Its not like ED’s look for geratric patients so they can admit them, they show up because mostly they are legitimitely sick or there is some underlying social/cant take care of issue/or “I want everything done for him/her” issue for a chronic/terminal complaint. It is rare that a family member brings their parents in, a treatable (or not so treatable) condition is discovered and after discussion the family is ok with going home (even with DNR patients).

  • jimeyers

    Though I do not agree with Kevin’s proposed solution, he has identified an important reality that most of the commentators have ignored. The hospital has become a very dangerous place for the elderly. Should there be a candid discussion with the elderly patient or the family informing them of the high risk of being admitted for a treatable condition, such as UTI and sepsis, and never returning home.

    Some one’s mother-in-law, 95, “Mrs X” and father-in-law, 96, “Mr X” both provide interesting examples of the issue Kevin raises. Mrs X developes urinary tract infection manifested by fever and confusion. Admitted through emergency department and treated sucessfullly but then developed c-diff. Hospitalization prolonged and though infection resolved, patient not fed through this course or mobilized. Transfer to skilled nursing facillity for rehab. Feeding tube not provided for a further week though patient had little oral intake. No range of motion given though ordered. This produced contractions and bed sores. Level of consciousness diminished. Aspiration and then pneumonia and then transfer back to tertiary care center where personel were preoccupied with why the family did not consent to not treating the pneumonia and taking off ventilator. Then a cascade of organ failures led to DNR decision and death.

    Mr.X suffered small stroke at home. He was found by his daughter the next day. Admitted through emergency department. Though he quickly recovered complete neurologic function. He had early on been catheterized. Urinary tract infection sucessfully treated though also followed by c-diff. treated successfully but patient was deconditioned and was discharged and transferred to skilled nursing facillity.
    There he was eventually diagnosed with “adult failure to thrive”. Each day he ate less and less. Though his daughter visited daily and fed him dinner, this was insufficient to prevent his loss of 40 pounds. (admission weight 155-failure to thrive diagnosis 115). Daughter hired private duty nurse to visit daily to assure he ate an additional two meals a day, exercized and that he was washed and didn’t have to wait all day for a linen change. He had become too weak to walk to the bathrooom and attendants did not come when called. Mr X then gained 25 pounds and was discharged to his home where he has lived since with an aide present to assist with dressing, food preparation and to prevent him from falling. Mr X is still alive and well a year later. He suffers some dementia but reads the newspaper every day and enjoys sports on television, bird watching and visits by family members.

    Since most elderly patients do not have the means to have 24 hr assistance at home, perhaps Kevin was right. If we are not prepared to provide the attention the elderly need to avoid the morbidity associated with hospital and skilled nursing facillity care, to choose death by bladder infection at home may represent a reasonable alternative.

  • Health blog

    Sometimes there aren’t any choices right ? You call an ambulance because someone old in your family is ill and all you can do is take them to the hospital ..
    I’m not sure you always have a choice.

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  • Julie Rosen

    Sometimes, providing care at home is just not possible, despite a doctor’s best effort to make this happen. At a recent Schwartz Center Rounds at a Boston hospital, a physician describes his struggle to enable his elderly patient to die at home.

    Julie Rosen

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