What interventions can prevent hospitalizations in geriatric patients?

Interventions to Prevent Hospitalizations in Geriatric Patients

Implement comprehensive geriatric assessment (CGA) combined with post-discharge home intervention by an interdisciplinary team, as this approach reduces initial hospital length of stay by approximately 9 days, decreases immediate nursing home placement rates, and may reduce unplanned hospital readmissions in community-dwelling frail older adults. 1, 2

Screening and Early Identification

Screen all geriatric patients for high-risk factors using validated tools at initial contact points, particularly in emergency departments and primary care settings. 3

• Implement screening tools that identify patients needing additional resources, focusing on: functional dependence (requiring regular help), recent increased care needs, recent hospitalizations (within 6 months), visual impairment, memory problems, and polypharmacy (>3 medications daily) 3
• Family/caregiver participation in the triage and screening process is highly encouraged to improve accuracy of assessment 3
• ED visits in geriatric patients, even for minor issues, represent "red flag" events heralding functional decline and should trigger intervention 3

Multidisciplinary Team Interventions

Establish a multidisciplinary team with geriatric expertise including physicians, nurses, pharmacists, social workers, physical therapists, occupational therapists, and dietitians to deliver coordinated care. 3, 4

Core Team Components:

• Geriatric-trained physicians and nurses providing 24-hour coverage with at least 4 hours of geriatric-specific CME annually for physicians and 8 hours every 2 years for nurses 3
• Pharmacists for medication reconciliation and review, particularly for patients with polypharmacy or high-risk medications 3
• Social workers/case managers for care coordination and transition planning 3
• Physical and occupational therapists for functional assessment and fall prevention 3

Nutritional Interventions

Screen all hospitalized geriatric patients for malnutrition and dehydration, and implement individualized nutritional care plans that continue after discharge. 3

• Comprehensive individualized nutritional interventions improve energy and protein intake, reduce complications, decrease antibiotic use, reduce readmissions, and improve quality of life 3
• Nutritional support by dietetic assistants during hospitalization increases energy intake and decreases mortality in trauma units and within 4 months post-discharge 3
• Critical caveat: Nutritional interventions must continue after hospitalization, as effects persist only as long as nutritional care is provided 3
• Liberalize dietary restrictions in older adults, as restrictive diets (low salt, low cholesterol, diabetic) increase malnutrition risk without clear benefit in this population 3

Specific Nutritional Actions:

• Identify and eliminate causes of poor intake: swallowing problems, dental issues, medication side effects (anorexia, xerostomia, dysgeusia), eating/feeding problems 3
• Provide assistance with food provision and eating for patients who need help 3
• Use texture-modified diets only when indicated by swallowing evaluation 3

Delirium Prevention

Implement multi-component non-pharmacological interventions that include hydration and nutrition management for all hospitalized older patients at moderate-to-high risk of delirium or undergoing urgent surgery. 3, 5

Delirium Prevention Protocol:

• Screen for dehydration and malnutrition as potential causes or consequences of delirium 3
• Address reversible causes first: pain, hypoxia, urinary retention, constipation, infections, dehydration, electrolyte disturbances 5
• Implement the ABCDEF bundle: Assessment of pain, Both spontaneous awakening and breathing trials, Choice of sedation, Delirium monitoring, Early mobility, Family engagement 5
• Provide cognitive reorientation, sleep enhancement, early mobilization, vision/hearing optimization 5
• Avoid routine antipsychotic use—reserve only for severe distress with hallucinations/delusions or imminent harm risk 5

Medication Management

Conduct comprehensive medication reconciliation for all geriatric patients, screening for polypharmacy (>5 medications) and high-risk medications, with pharmacist review for at-risk patients. 3

• Medication reconciliation involving patients, caregivers, and family is critical for accuracy 3
• Refer patients with polypharmacy or high-risk medications to multidisciplinary team including pharmacist to minimize drug-drug interactions 3
• Reducing medication complexity and number of high-risk medications lowers adverse drug reaction risk 3
• Common pitfall: Polypharmacy is associated with therapeutic omissions, less benefit from beneficial medications, and increased harm 3

Fall Prevention

Implement comprehensive fall risk assessment and prevention strategies for all geriatric patients, as falls are a leading cause of hospitalization and morbidity. 3

Fall Prevention Measures:

• Environmental modifications: rubber/nonskid floor surfaces, even floors, handrails, aisle lighting, bedside commodes, grab bars, properly positioned bedrails 3
• Assess all geriatric patients presenting after falls for both traumatic injuries and fall causes 3
• Expedited outpatient follow-up including home safety assessments for discharged patients 3
• Physical and occupational therapy evaluation for all admitted patients after falls 3
• Multimodal interventions combining nutritional support (including calcium and vitamin D), oral care, and group exercise reduce fall incidence 3

Transition of Care and Follow-Up

Establish robust transition of care protocols with post-discharge home intervention to reduce rehospitalization and nursing home placement. 3, 1, 6

• Comprehensive geriatric assessment combined with post-discharge home intervention reduces length of initial hospital stay (33.5 vs 42.7 days), immediate nursing home placement (4.4% vs 8.1%), and subsequent readmission length (22.2 vs 35.7 days) 1
• Home care programs based on CGA and case management reduce hospitalizations by 56% and hospital days by 36%, with 29% cost reduction 6
• Medication reconciliation and pharmacy review at discharge are essential 3
• Care transitions are critical opportunities to reevaluate treatment complexity and adherence 3

Early Mobilization and Rehabilitation

Initiate early mobilization and rehabilitation within 24 hours of medical stability to prevent functional decline and reduce hospital length of stay. 7

• Begin range-of-motion exercises within first postoperative days to prevent joint contractures 7
• Minimize bed rest aggressively, as prolonged immobility causes 25% muscle strength loss over 5 weeks 7
• Implement intermittent sitting or standing with appropriate support to prevent orthostatic deconditioning 7
• Critical consideration: Address nutritional status concurrently, as malnutrition significantly impairs functional recovery 7

Environmental Modifications

Optimize the physical environment to enhance safety, communication, and patient comfort. 3

• Improve lighting with combination of ambient and spot lighting while reducing glare 3
• Enhance acoustical environment with sound-absorbing materials to reduce background noise and improve privacy 3
• Provide portable hearing assist devices to enhance communication 3
• Reduce loud noise sources (overhead paging, machines) 3

Cost-Effectiveness

The evidence demonstrates substantial cost savings with these interventions: comprehensive geriatric assessment with home intervention reduces direct costs by approximately $4,000 per patient per year 1, and integrated home care programs save approximately $1,260 per patient over 6 months 6. Multimodal nutritional interventions are also cost-effective 3.