Patient and Hospital Factors That Lead to Adverse Outcomes in Hospitalized Elders

  • Edgar Pierluissi
  • Deborah C. Francis
  • Kenneth E. Covinsky
Part of the Aging Medicine book series (AGME)


Hospitalization is a sentinel event in the life of an older person. Despite appropriate treatment for the reason for admission to the hospital, older adults suffer high rates of hospitalization-associated disability (HAD) and other complications such as delirium, falls, and pressure ulcers with long-term consequences. HAD carries a poor prognosis for further disability, nursing home placement, and increased mortality and confers significant costs to patients, families, and society. Patients at risk for HAD can be identified and hospital processes of care that contribute to HAD are well known. The Acute Care for Elders (ACE) model of care addresses both patient and hospital-level risk factors and has demonstrated its effectiveness in reducing HAD, improving patient satisfaction, while reducing costs compared to usual care. The ACE model of care achieves the triple aim of improving care, improving patient satisfaction, and reducing costs.


Functional decline Hospitalization-associated disability Low mobility Delirium Falls Pressure ulcers Inappropriate prescribing Iatrogenesis 



Acute Care for Elders


Adverse drug event


Activity of daily living


Agency for Healthcare Research and Quality


Established Populations for Epidemiologic Studies of the Elderly


Hospitalization-associated disability


Hospital admission risk profile


Hospital-acquired pressure ulcer


Instrumental activity of daily living


Life-Space Assessment


Precipitating Events Project


Potentially inappropriate Medication


Randomized controlled trial


Registered nurse


Skilled nursing facility


PROgettoDImissioni in GEriatria Study


St. Thomas Risk Assessment Tool in Falling Elderly


Screening Tool of Older Persons’ potentially inappropriate Prescriptions


  1. 1.
    Pierluissi E, Sotelo M. Hospital care. In: Durso SC, Sullivan GM, editors. Geriatrics review syllabus: a core curriculum in geriatric medicine. 8th ed. New York: American Geriatrics Society; 2013. p. 142–51.Google Scholar
  2. 2.
    Covinsky KE, Pierluissi E, Johnston CB. Hospitalization-associated disability: “She was probably able to ambulate, but I’m not sure”. JAMA. 2011;306(16):1782–93.PubMedCrossRefGoogle Scholar
  3. 3.
    Schimmel E. Hazards of hospitalization. Ann Intern Med. 1964;60:100–10.PubMedCrossRefGoogle Scholar
  4. 4.
    Creditor M. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118(3):219–23.PubMedCrossRefGoogle Scholar
  5. 5.
    Walter LC, Brand RJ, Counsell SR, et al. Development and validation of a prognostic index for 1-year mortality in older adults after hospitalization. JAMA. 2001;285(23):2987–94.PubMedCrossRefGoogle Scholar
  6. 6.
    Murphy SL, Xu JQ, Kochanek KD. Deaths: preliminary data for 2010. National vital statistics reports; vol 60 no 4 [PDF-725 KB]. Hyattsville: National Center for Health Statistics; 2012.Google Scholar
  7. 7.
    Boyd CM, Landefeld CS, Counsell SR, et al. Recovery of activities of daily living in older adults after hospitalization for acute medical illness. J Am Geriatr Soc. 2008;56(12):2171–9.PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Gill TM, Kurland B. The burden and patterns of disability in activities of daily living among community-living older persons. J Gerontol A Biol Sci Med Sci. 2003;58(1):70–75.PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Russo CA, Elixhauser A. Hospitalizations in the elderly population, 2003. Statistical brief #6. Rockville: Agency for Healthcare Research and Quality; 2006.
  10. 10.
    Wier LM, Pfuntner A, Steiner C. Hospital utilization among oldest adults, 2008. HCUP Statistical brief #103. Rockville: Agency for Healthcare Research and Quality; 2010.
  11. 11.
    Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychological function. JAMA. 1963;185:914–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Warshaw GA, Moore JT, Friedman S, et al. Functional disability in the hospitalized elderly. JAMA. 1982;248(7):847–50.PubMedCrossRefGoogle Scholar
  13. 13.
    Hirsch CH, Sommers L, Olsen A, Mullen L, Winograd CH. The natural history of functional morbidity in hospitalized older adults. J Am Geriatr Soc. 1990;38(12):1296–303.PubMedGoogle Scholar
  14. 14.
    Sager M, Franke T, Inouye S, Landefeld CS, Morgan TM, Rudberg MA, et al. Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med. 1996;156:645–52.PubMedCrossRefGoogle Scholar
  15. 15.
    Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart AL, Kresevic D, et al. Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: increased vulnerability with age. J Am Geriatr Soc. 2003;51(4):451–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Palleschi L, De Alfieri W, Salani B, Fimognari FL, Marsilii A, Pierantozzi A, et al. Functional recovery of elderly patients hospitalized in geriatric and general medicine units. The PROgettoDImissioni in GEriatria Study. J Am Geriatr Soc. 2011;59(2):193–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Gill TM, Allore HG, Holford TR, Guo Z. Hospitalization, restricted activity, and the development of disability among older persons. JAMA. 2004;292(17):2115–24.PubMedCrossRefGoogle Scholar
  18. 18.
    Brown CJ, Roth DL, Allman RM, Sawyer P, Ritchie CS, Roseman JM. Trajectories of life-space mobility after hospitalization. Ann Intern Med. 2009;150(6):372–8.PubMedCentralPubMedCrossRefGoogle Scholar
  19. 19.
    Boyd CM, Xue QL, Guralnik JM, Fried LP. Hospitalization and development of dependence in activities of daily living in a cohort of disabled older women: the Women’s Health and Aging Study I. J Gerontol A Biol Sci Med Sci. 2005;60(7):888–93.PubMedCrossRefGoogle Scholar
  20. 20.
    Goodwin JS, Howrey B, Zhang DD, Kuo YF. Risk of continued institutionalization in older adults. J Gerontol A Biol Sci Med Sci. 2011;66A(12):1321–7.PubMedCentralCrossRefGoogle Scholar
  21. 21.
    Rudberg MA, Sager MA, Zhang J. Risk factors for nursing home use after hospitalization for medical illness. J Gerontol A Biol Sci Med Sci. 1996;51(5):M189–94.PubMedCrossRefGoogle Scholar
  22. 22.
    Reuben DB, Seeman TE, Keeler E, Hayes RP, Bowman L, Sewall A, et al. The effect of self-reported and performance-based functional impairment on future hospital costs of community-dwelling older persons. Gerontologist. 2004;44(3):401–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Fried TR, Bradley EH, Williams CS, Tinetti ME. Functional disability and health care expenditures for older persons. Arch Intern Med. 2001;161(21):2602–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Inouye SK, Wagner DR, Acampora D, Horwitz RI, Cooney LM, Hurst LD, et al. A predictive index for functional decline in hospitalized elderly medical patients. J Gen Intern Med. 1993;8:645–52.PubMedCrossRefGoogle Scholar
  25. 25.
    Mehta KM, Pierluissi E, Boscardin WJ, Kirby KA, Walter LC, Chren MM, et al. A clinical index to stratify hospitalized older adults according to risk for new-onset disability. J Am Geriatr Soc. 2011;59(7):1206–16.PubMedCrossRefGoogle Scholar
  26. 26.
    Arora VM, Johnson M, Olson J, Podrazik PM, Levine S, Dubeau CE, et al. Using assessing care of vulnerable elders quality indicators to measure quality of hospital care for vulnerable elders. J Am Geriatr Soc. 2007;55(11):1705–11.PubMedCrossRefGoogle Scholar
  27. 27.
    Silverstein N, Maslow K, editors. Improving hospital care for persons with dementia. New York: Springer; 2006.Google Scholar
  28. 28.
    Brown CJ, Friedkin RJ, Inouye SK. Prevalence and outcomes of low mobility in hospitalized older patients. J Am Geriatr Soc. 2004;52(8):1263–70.PubMedCrossRefGoogle Scholar
  29. 29.
    Zisberg A, Shadmi E, Sinoff G, Gur-Yaish N, Srulovici E, Admi H. Low mobility during hospitalization and functional decline in older adults. J Am Geriatr Soc. 2011;59(2):266–73.PubMedCrossRefGoogle Scholar
  30. 30.
    Brown CJ, Williams BR, Woodby LL, Davis LL, Allman RM. Barriers to mobility during hospitalization from the perspectives of older patients and their nurses and physicians. J Hosp Med. 2007;2(5):305–13.PubMedCrossRefGoogle Scholar
  31. 31.
    So C, Pierluissi E. Attitudes and expectations regarding exercise in the hospital of hospitalized older adults: a qualitative study. J Am Geriatr Soc. 2012;60(4):713–8.PubMedCrossRefGoogle Scholar
  32. 32.
    Kortebein P, Ferrando A, Lombeida J, Wolfe R, Evans WJ. Effect of 10 days of bed rest on skeletal muscle in healthy older adults. JAMA. 2007;297(16):1772–4.PubMedCrossRefGoogle Scholar
  33. 33.
    Goodpaster BH, Park SW, Harris TB, Kritchevsky SB, Nevitt M, Schwartz AV, et al. The loss of skeletal muscle strength, mass, and quality in older adults: the health, aging, and body composition study. J Gerontol A Biol Sci Med Sci. 2006;61A(10):1059–64.CrossRefGoogle Scholar
  34. 34.
    Landi F, Onder G, Cesari M, Gambassi G, Steel K, Russo A. Pain management in frail, community-living elderly patients. Arch Intern Med. 2001;161(22):2721–4.PubMedCrossRefGoogle Scholar
  35. 35.
    Morrison RS, Flanagan S, Fischberg D, Cintron A, Siu AL. A novel interdisciplinary analgesic program reduces pain and improves function in older adults after orthopedic surgery. J Am Geriatr Soc. 2009;57(1):1–10.PubMedCentralPubMedCrossRefGoogle Scholar
  36. 36.
    de Morton N, Keating JL, Jeffs K. Exercise for acutely hospitalised older medical patients. Cochrane Database Syst Rev. 2007;(1):CD005955.Google Scholar
  37. 37.
    Francis DC, Laahai JM. Iatrogenesis: the nurse’s role in preventing patient harm. In: Boltz B, Capezuti E, Fulmer T, Zwicker D, editors. Evidence-based geriatric nursing protocols for best practice. New York: Springer; 2012. p. 200–28.Google Scholar
  38. 38.
    Rothschild JM, Bates DW, Leape LL. Preventable medical injuries in older patients. Arch Intern Med. 2000;160(18):2717–28.PubMedCrossRefGoogle Scholar
  39. 39.
    Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370–6.PubMedCrossRefGoogle Scholar
  40. 40.
    Levinson DR. Adverse events in hospitals: national incidence among medicare beneficiaries. Washington, DC: Department of Health and Human Services, Office of the Inspector General; 2010.Google Scholar
  41. 41.
    Inouye SK, Westendorp RGJ, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911–22. Scholar
  42. 42.
    Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA. 1996;275(11):852–7.PubMedCrossRefGoogle Scholar
  43. 43.
    Inouye SK, Bogardus Jr ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9):669–76.PubMedCrossRefGoogle Scholar
  44. 44.
    Fox MT, Persaud M, Maimets I, O’Brien K, Brooks D, Tregunno D, et al. Effectiveness of acute geriatric unit care using acute care for elders components: a systematic review and meta-analysis. J Am Geriatr Soc. 2012;60(12):2237–45.PubMedCentralPubMedCrossRefGoogle Scholar
  45. 45.
    Zisberg A, Sinoff G, Gur-Yaish N, Admi H, Shadmi E. In-hospital use of continence aids and new-onset urinary incontinence in adults aged 70 and older. J Am Geriatr Soc. 2011;59(6):1099–104.PubMedCrossRefGoogle Scholar
  46. 46.
    Holroyd-Leduc JM, Sen S, Bertenthal D, Sands LP, Palmer RM, Kresevic DM. The relationship of indwelling urinary catheters to death, length of hospital stay, functional decline, and nursing home admission in hospitalized older medical patients. J Am Geriatr Soc. 2007;55(2):227–33.PubMedCrossRefGoogle Scholar
  47. 47.
    Inouye SK, Studenski S, Tinetti ME, Kuchel GA. Geriatric syndromes: clinical, research, and policy implications of a core geriatric concept. J Am Geriatr Soc. 2007;55(5):780–91.PubMedCentralPubMedCrossRefGoogle Scholar
  48. 48.
    Lyder CH, Wang Y, Metersky M, Curry M, Kliman R, Verzier NR, et al. Hospital-acquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System study. J Am Geriatr Soc. 2012;60(9):1603–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Schoonhoven L, Haalboom JRE, Bousema MT, Algra A, Grobbee DE, Grypdonck MH, et al. Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers. BMJ. 2002;325:797–801.PubMedCentralPubMedCrossRefGoogle Scholar
  50. 50.
    Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. JAMA. 2006;296(8):974–84.PubMedCrossRefGoogle Scholar
  51. 51.
    Bouldin EL, Andresen EM, Dunton NE, Simon M, Waters TM, Liu M. Falls among adult patients hospitalized in the United States: prevalence and trends. J Patient Saf. 2013;9(1):13–7.PubMedCentralPubMedGoogle Scholar
  52. 52.
    Aranda-Gallardo M, Morales-Asencio JM, Canca-Sanchez JC, Barrero-Sojo S, Perez-Jimenez C, Morales-Fernandez A, et al. Instruments for assessing the risk of falls in acute hospitalized patients: a systematic review and meta-analysis. BMC Health Serv Res. 2013;13(1):122–36.PubMedCentralPubMedCrossRefGoogle Scholar
  53. 53.
    Oliver D, Daly F, Martin FC, McMurdo ME. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age Ageing. 2004;33(2):122–30.PubMedCrossRefGoogle Scholar
  54. 54.
    Mion LC, Chandler AM, Waters TM, Dietrich MS, Kessler LA, Miller ST. Is it possible to identify risks for injurious falls in hospitalized patients? Jt Comm J Qual Patient Saf. 2012;38(9):408–13.PubMedCentralPubMedGoogle Scholar
  55. 55.
    Hill KD, Vu M, Walsh W. Falls in the acute hospital setting—impact on resource utilisation. Aust Health Rev. 2007;31(3):471–7.PubMedCrossRefGoogle Scholar
  56. 56.
    Cameron ID, Gillespie LD, Robertson MC, Murray GR, Hill KD, Cumming RG, Kerse N. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2012;(12):CD005465.Google Scholar
  57. 57.
    Hamilton H, Gallagher P, Ryan C, Byrne S, O’Mahony D. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med. 2011;171(11):1013–9.PubMedCrossRefGoogle Scholar
  58. 58.
    Gallagher PF, O'Connor MN, O'Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther. 2011;89(6):845–54.PubMedCrossRefGoogle Scholar
  59. 59.
    Page II RL, Ruscin JM. The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use. Am J Geriatr Pharmacother. 2006;4(4):297–305.PubMedCrossRefGoogle Scholar
  60. 60.
    Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med. 2006;166(9):955–64.PubMedCrossRefGoogle Scholar
  61. 61.
    Institute of Medicine. Keeping patients safe: transforming the work environment of nurses. Washington, DC: National Academies Press; 2003.Google Scholar
  62. 62.
    Shekelle PG. Nurse-patient ratios as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158:404–9.PubMedCrossRefGoogle Scholar
  63. 63.
    Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M. Nurse staffing and inpatient hospital mortality. N Engl J Med. 2011;364:1037–45.PubMedCrossRefGoogle Scholar
  64. 64.
    Frith KH, Anderson EF, Caspers B, Tseng F, Sanford K, Hoyt NG, Moore K. Effects of nurse staffing on hospital-acquired conditions and length of stay in community hospitals. Qual Manag Health Care. 2010;19(2):147–55.PubMedCrossRefGoogle Scholar
  65. 65.
    Boltz M, Capezuti E, Bowar-Ferres S, Norman R, Secic M, Kim H, et al. Changes in the geriatric care environment associated with NICHE (Nurses Improving Care for HealthSystem Elders). Geriatr Nurs. 2008;29(3):176–85.PubMedCrossRefGoogle Scholar
  66. 66.
    Arora VM, Fish M, Basu A, Olson J, Plein C, Suresh K, et al. Relationship between quality of care of hospitalized vulnerable elders and postdischarge mortality. J Am Geriatr Soc. 2010;58(9):1642–8.PubMedCentralPubMedCrossRefGoogle Scholar
  67. 67.
    Agostini JV, Zhang Y, Inouye SK. Use of a computer-based reminder to improve sedative-hypnotic prescribing in older hospitalized patients. J Am Geriatr Soc. 2007;55(1):43–8.PubMedCrossRefGoogle Scholar
  68. 68.
    Parry MF, Grant B, Sestovic M. Successful reduction in catheter-associated urinary tract infections: focus on nurse-directed catheter removal. Am J Infect Control. 2013;41(12):1178–81.PubMedCrossRefGoogle Scholar
  69. 69.
    Padula CA, Hughes C, Baumhover L. Impact of a nurse-driven mobility protocol on functional decline in hospitalized older adults. J Nurs Care Qual. 2009;24(4):325–31.PubMedCrossRefGoogle Scholar
  70. 70.
    Malone ML, Vollbrecht M, Stephenson J, Burke L, Pagel P, Goodwin JS. Acute Care for Elders (ACE) tracker and e-Geriatrician: methods to disseminate ACE concepts to hospitals with no geriatricians on staff. J Am Geriatr Soc. 2010;58(1):161–7.PubMedCentralPubMedCrossRefGoogle Scholar
  71. 71.
    Barnes DE, Palmer RM, Kresevic DM, Fortinsky RH, Kowal J, Chren MM, et al. Acute care for elders units produced shorter hospital stays at lower cost while maintaining patients’ functional status. Health Aff (Millwood). 2012;31(6):1227–36.CrossRefGoogle Scholar
  72. 72.
    Covinsky KE, Fortinsky RH, Palmer RM, Kresevic DM, Landefeld CS. Relation between symptoms of depression and health status outcomes in acutely ill hospitalized older persons. Ann Intern Med. 1997;126(6):417–25.PubMedCrossRefGoogle Scholar
  73. 73.
    Pierluissi E, Mehta KM, Kirby KA, Boscardin WJ, Fortinsky RH, Palmer RM, et al. Depressive symptoms after hospitalization in older adults: function and mortality outcomes. J Am Geriatr Soc. 2012;60(12):2254–62.PubMedCentralPubMedCrossRefGoogle Scholar
  74. 74.
    Levy BR, Slade MD, Murphy TE, Gill TM. Association between positive age stereotypes and recovery from disability in older persons. JAMA. 2012;308(19):1972–3.PubMedCentralPubMedCrossRefGoogle Scholar
  75. 75.
    Fox MT, Sidani S, Persaud M, Tregunno D, Maimets I, Brooks D, O’Brien K. Acute care for elders components of acute geriatric unit care: systematic descriptive review. J Am Geriatr Soc. 2013;61(6):939–46.PubMedCrossRefGoogle Scholar
  76. 76.
    Sager MA, Rudberg MA, Jalaluddin M, et al. Hospital admission risk profile (HARP): identifying older patients at risk for functional decline following acute medical illness and hospitalization. J Am Geriatr Soc. 1996;44(3):251–7.PubMedGoogle Scholar
  77. 77.
    Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc. 1975;23(10):433–41.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Edgar Pierluissi
    • 1
  • Deborah C. Francis
    • 2
  • Kenneth E. Covinsky
    • 3
  1. 1.Department of MedicineSan Francisco General HospitalSan FranciscoUSA
  2. 2.Kaiser Permanente Medical CenterSouth SacramentoUSA
  3. 3.UCSF Division of GeriatricsSan FranciscoUSA

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