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Ideas and Opinions |4 February 2014

When Frail Elderly Adults Get Sick: Alternatives to Hospitalization

Muriel R. Gillick, MD

Article, Author, and Disclosure Information
Author, Article, and Disclosure Information
  • From Harvard Pilgrim Health Care Institute/Harvard Medical School, Boston, Massachusetts.

    Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-1793.

    Requests for Single Reprints: Muriel R. Gillick, MD, Department of Population Medicine, Harvard Pilgrim Health Care Institute/Harvard Medical School, 133 Brookline Avenue, 6th Floor, Boston, MA 02215; e-mail, muriel_gillick@hphc.org.

    Author Contributions: Conception and design: M.R. Gillick.

    Drafting of the article: M.R. Gillick.

    Critical revision of the article for important intellectual content: M.R. Gillick.

    Final approval of the article: M.R. Gillick.

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Providing high-quality, cost-effective medical care to the sickest, oldest, and frailest patients remains a formidable challenge. The 18 million people older than 65 years with chronic conditions and limitations in their ability to carry out basic daily activities make up 6% of the noninstitutionalized U.S. population but consume 25% of total health care spending (1). The lion's share of these resources go to hospital care: 63% of Medicare patients with 6 or more chronic conditions are hospitalized each year (vs. 13% of those with 2 to 3 chronic conditions) and account for 70% of Medicare 30-day rehospitalizations (2). Although the hospital offers sophisticated and often life-prolonging diagnostic and treatment methods, it can also be a dangerous environment for frail elderly patients. Providing safe and excellent care for this population will probably require developing viable alternatives to hospitalization.
Frail patients are at high risk for exacerbations of the conditions that make them frail. Frailty, by definition, entails a heightened susceptibility to acute illness, disability, and death (3).
Clinicians have devoted considerable effort to trying to stave off acute illness, but the propensity of frail adults to become ill remains stubbornly high. Although comprehensive geriatric assessment has improved physician prescribing practices, increased patient satisfaction, and enabled patients to avoid nursing home placement, it has not prevented acute illness that is severe enough to warrant hospitalization (4). Programs to prevent geriatric syndromes (for example, falls or delirium) have similarly provided only modest benefits.
The hazards of hospitalization in...
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Gillick MR. When Frail Elderly Adults Get Sick: Alternatives to Hospitalization. Ann Intern Med. 2014;160:201–202. doi: 10.7326/M13-1793

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Published: Ann Intern Med. 2014;160(3):201-202.

DOI: 10.7326/M13-1793

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