Hospital admission in an older adult: how to reduce the harm

Hospitals treat the acute problem well and impose costs that fall disproportionately on older patients. The literature describes this as hospital-associated disability: a substantial proportion of older adults leave hospital less functionally capable than they arrived, independent of the illness that brought them in.

Estimates vary by population, but studies of medical admissions consistently find that roughly a third of patients over seventy decline in activities of daily living during the stay, and that many never fully recover.

What causes it

Immobility. Studies using accelerometers on hospitalised older patients find they spend the overwhelming majority of the day in bed, often more than 20 hours. Muscle strength falls measurably within days of bed rest, and faster in older adults. A week in bed can cost the equivalent of a year of age-related decline.

Delirium, which affects a large minority and independently predicts worse functional outcomes.

Undernutrition. Missed meals for tests, unfamiliar food, no help with eating, absent dentures, and increased metabolic demand from illness.

Sleep deprivation from noise, light and overnight observations.

Medication changes. Drugs are added acutely, and some are never reviewed. Sedatives started for one bad night continue for years.

Catheters and lines, which restrict movement and carry infection risk.

What to bring, and why each item matters

• Glasses and hearing aids, plus spare batteries. Sensory deprivation is a leading contributor to delirium and to being written off as confused.
• Dentures. Without them, eating is difficult and speech is affected.
• A current medication list, ideally the actual boxes, including anything bought over the counter and any supplements.
• Non-slip footwear with a back. Hospital socks are slippery and backless slippers cause falls. This directly affects whether staff feel able to mobilise the patient.
• A written summary of the person's baseline — how they normally manage, what they do independently, whether they are usually orientated, what their usual routine is. Staff cannot detect deterioration from a baseline they have never seen.
• A photograph and a few personal items, which help orientation and help staff see the person rather than the patient.
• Contact details for the family member who should be called, clearly displayed.

Questions worth asking during the stay

What is the plan for today, and what has to happen before discharge? Has anyone from physiotherapy seen them? Is the catheter still needed? Are they eating, and does anyone help them? What new medications have been started and which are meant to be short-term?

That last question is worth pressing. Drugs started in hospital have a strong tendency to become permanent, and the person best placed to notice is a relative who knew the original list.

Discharge, where a great deal goes wrong

Transitions are the highest-risk points in the whole episode. Medication errors at discharge are common — omissions, duplications, and drugs stopped in hospital that get restarted at home from an old repeat prescription.

Before leaving, establish:

• A reconciled medication list: what has been started, stopped and changed, and why. Compare it against what they were taking before.
• Which changes are temporary and when they should be reviewed.
• Who is following up, and when. Whether the GP has been informed.
• What to watch for, and who to call if it happens.
• Whether equipment or care has been arranged, and whether it will actually be there on arrival.
• Whether a falls or bone health assessment is needed — particularly after a fracture.

Discharge summaries frequently reach the GP late. Taking a copy home is worth doing.

Recovery after discharge

The weeks after a hospital stay are the highest-risk period for readmission, and functional recovery is not automatic.

Two things predict a better trajectory: getting moving again promptly, with structured activity rather than rest, and eating enough protein and energy to rebuild what was lost. Both tend to be neglected in favour of convalescence, which was the standard advice for a century and is largely wrong for this population.

If the person is not back to their previous level within a few weeks, that warrants a conversation rather than acceptance. Community rehabilitation exists in many systems and is under-referred.

The uncomfortable question

For some very frail people, admission itself carries more risk than benefit, and there are situations where treatment at home — with community nursing, hospital-at-home services where available, and clear plans — produces better outcomes and a better experience.

That is a decision to make in advance, calmly, rather than at two in the morning. It is one of the more useful things to have discussed as part of advance care planning.