Chapter 11. Reducing Functional Decline in 

Hospitalized Elderly

Ruth M. Kleinpell, Kathy Fletcher, Bonnie M. Jennings 

Background 

The elderly, or those older than 65 years, currently represent 12.5 percent of the U.S. 

population, and are projected to increase to 20 percent of the population by 2030—growing from 

35 million to 72 million in number.1, 2 By 2050, 12 percent of the population, or one in eight 

Americans, will be 75 years of age or older.3 In 2002, the elderly accounted for 12.7 million (41 

percent) of the 31.7 million hospitalizations in the United States,4

 and these numbers are 

expected to increase significantly as the population ages. Targeting the care needs of the 

hospitalized elderly and awareness of risks for illness-related complications are urgent concerns 

for managing acute health care conditions in this population.4 

Hospitalization and Patient Safety 

Considerations for the Elderly 

It is estimated that almost half of adults who are hospitalized are 65 years of age or older, 

although those older than 65 years represent only 12.5 percent of the population. The proportion 

of hospitalized adults who are elderly is only expected to increase as the population ages.

4 The 

average hospital length of stay for patients age 65 and older has decreased to 5.7 days, down 

from 8.7 days in 1990.3 Shorter lengths of stay heighten the challenge to properly assess and 

address the care needs of older adults during hospitalization as well as their discharge needs. The 

focus of assessment and care is generally on resolving the immediate problem that triggered 

hospitalization; less attention is given to the underlying risk of functional decline and the 

vulnerability to hospital-associated complications.

A primary focus for improvement in health care is on promoting patient safety and avoiding 

injuries to patients.5 This becomes especially important for hospitalized elders, who are at risk 

for functional decline due to altered mobility levels as well as iatrogenic risks. For the frail 

elderly in particular, hazards of hospitalization include falls, delirium, nosocomial infections, 

adverse drug reactions, and pressure ulcer development.6–8 

A dissonance exists between the hospital environment and therapeutic goals for the 

hospitalized elderly. The hospital environment, a tertiary care setting, has traditionally focused 

on medically managing illness states, not on improving patient functioning. The environment is 

designed for the rapid and effective delivery of care—not for enhancing patient function.

Hospital redesign to address the care needs of the elderly have been proposed.9, 10 Consideration 

of the milieu as well as age-related physiological changes are important aspects of creating a safe 

hospital environment for the hospitalized elderly. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Age-Associated Changes 

A number of known physiological changes occur with aging, including reduced muscle 

strength and aerobic capacity, vasomotor instability, baroreceptors insensitivity and reduced total 

body water, reduced bone density, reduced ventilation, and reduced sensory capacity.4, 11, 12

Comorbid conditions and chronic illness may heighten these changes. Muscle mass and muscle 

strength are reduced with aging and contribute to a reduction of physical activity.12 With aging, 

alterations in autonomic function, including baroreceptor insensitivity, occurs. Age-associated

reduction in body water and plasma volume may predispose the elderly to syncope. Respiratory 

mechanics are also altered with aging, with reduced ventilation, increased residual capacity, and 

reduced arterial oxygen tension.12 Other age-associated changes include reduced bladder 

capacity and increased urine production, prostrate enlargement, bone demineralization, loss of 

taste and smell, decreased skin integrity, and reduction in sensory input.12, 13

As a result, the elderly are at higher risk for adverse physiological consequences during acute 

illness, including impairment in functional status. Frailty—a state of musculoskeletal weakness 

and other secondary, widely distributed losses in structure and function—has been found to be 

attributed to decreased levels of activity and has been linked to the process of aging.14 Advanced 

age, acute and chronic disease and illness, functional limitations, and deconditioning all 

contribute to the older adult’s vulnerability to functional decline during hospitalization.

Functional decline—the inability to perform usual activities of daily living due to weakness, 

reduced muscle strength, and reduced exercise capacity—occurs due to deconditioning and acute 

illness during hospitalization.15

Functional Status 

Functional status is determined by the ability to perform activities of daily living (ADLs)—

eating, dressing, bathing, ambulating, and toileting—and instrumental ADLs (IADLs)—

shopping for groceries, meal preparation, housework, laundry, getting to places beyond walking 

distance, managing medications, managing finances, and using a telephone.4 It is estimated that 

up to 8 percent of community-dwelling elders need assistance with one or more ADLs. Among 

those age 85 and older, the percentage who live at home but need assistance or who live in a 

nursing home increases significantly to 56 percent of women and 38 percent of men.4 Chronic 

illness and comorbidities can directly impact functional status in the elderly. Chronic health care 

conditions that are most prevalent in the elderly include heart disease, hypertension, arthritis, 

diabetes, and cancer.3 Acute illness due to chronic disease and chronic comorbidities accounts 

for a significant number of hospitalizations in the elderly.

Functional Decline During Hospitalization 

During hospitalization, the elderly patient often experiences reduced mobility and activity 

levels. Functional decline, including changes in physical status and mobility, has been identified 

as the leading complication of hospitalization for the elderly.16 The hazards of bed rest during 

hospitalization are well established and include immobility, accelerated bone loss, dehydration, 

malnutrition, delirium, sensory deprivation, isolation, sheering forces on the skin, and 

incontinence (see Table 1).12, 17

Bed rest results in a reduction of exercise capacity due to several physiologic changes that 

occur, including reductions in maximal stroke volume, cardiac output, and oxygen uptake.17 The 

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Reducing Functional Decline

muscle fatigue that results is associated with reduced muscle blood flow, red cell volume, 

capillarization, and oxidative enzymes.17 Accelerated bone loss can lead to a higher risk for 

injury to bones and joints, including hips and spine.18

Table 1. Effects of Bed Rest

System Effect

Cardiovascular ↓ Stroke volume, ↓ cardiac output, orthostatic hypotension 

Respiratory ↓ Respiratory excursion, ↓ oxygen uptake, ↑ potential for atelectasis 

Muscles ↓ Muscle strength, ↓ muscle blood flow 

Bone ↑ Bone loss, ↓ bone density 

GI Malnutrition, anorexia, constipation 

GU Incontinence 

Skin Sheering force, potential for skin breakdown 

Psychological Social isolation, anxiety, depression, disorientation 

Sources: Amella EJ. Presentation of illness in older adults. Am J Nurs 2004;104:40-52. Creditor MC. Hazards of 

hospitalization of the elderly. Ann Intern Med 1993;118: 219-23. Convertino VA. Cardiovascular consequences of bed 

rest: effect on maximal oxygen uptake. Med Sci Sports Exerc 1997;29:191-6. 

Deconditioning, which results in a decrease in muscle mass and the other physiologic 

changes related to bed rest, contributes to overall weakness.19 Functional decline can then occur 

as a consequence of those physiologic changes and result in inability to perform usual ADLs.19

Low levels of mobility and bed rest were common occurrences during hospitalization for the 

elderly.20 Deconditioning and functional decline from baseline was found to occur by day 2 of 

hospitalization in elderly patients.21 Loss of functional independence during hospitalization 

resulted from not only the effects of acute illness, but also from the inability to maintain function 

during hospitalization.22 In assessing physical activity of 500 hospitalized elderly patients, those 

who remained in bed or who had chair activity rarely received physical therapy, had physician 

orders for exercises, or performed bedside strengthening exercises.21 Comparisons of functional 

assessment at baseline and day 2 of hospitalization in 71 patients over the age of 74 years 

demonstrated declining ability in mobility, transfer, toileting, feeding, and grooming.23 Between 

day 2 and discharge, 67 percent demonstrated no improvement and 10 percent experienced 

further decline, highlighting the potential for delayed functional recovery in the hospitalized 

elderly.23 A followup of 489 hospitalized elders age 70 years and older revealed that the 

prevalence of lower mobility in hospitalized elderly was significant, with 16 percent 

experiencing low levels of mobility, 32 percent experiencing intermediate levels of mobility, and 

29 percent experiencing a decline in an ADL activity.20 Yet for almost 60 percent of bed-rest 

episodes, there was no documented medical indication for limiting mobility status. 

Preadmission health and functional status of the elderly can indicate risk of further functional 

decline associated with hospitalization. In examining the baseline functional status of 1,212 

hospitalized patients age 70 years and older, the use of ambulation assistive devices, such as 

canes and walkers, was predictive of functional decline associated with hospitalization.24 Use of 

a walker was associated with a 2.8 times increased risk for decline in ADL function by the time 

of hospital discharge (P = 0.0002). Moreover, 3 months after discharge, patients who had used 

an assistive device prior to hospitalization were more likely to have declined in both ADL status 

(P = 0.02) and IADL status (P = 0.0003).24 Other risk factors found to be predictive of 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

functional decline in the elderly during hospitalization included having two or more 

comorbidities, taking five or more prescription medications, and having had a hospitalization or 

emergency room visit in the previous 12 months.25

Associations between functional status and other risk factors such as cognitive status must 

also be considered. Hospital-related complications or inadequate hospital care have been linked 

to the development of delirium in the hospitalized elderly.26 Impairment in cognitive status was 

found to be associated with changes in functional status in the hospitalized elderly. A study of 

2,557 patients from two teaching hospitals examined the association between level of impaired 

performance on a cognitive status screen and maintenance and recovery of functioning from 

admission through 90 days after discharge. Performance on a brief cognitive screen on admission

was strongly related to subsequent change in function. Among patients who needed help 

performing one or more ADLs at the time of admission, 23 percent of patients with moderate to 

severely impaired cognitive performance, 49 percent of patients with mildly impaired cognitive 

performance, and 67 percent of patients with little or no impairment in cognitive performance

recovered the ability to independently execute an additional ADL by discharge (P < 0.001).22

Additional studies identified that prolonged recovery and continued ADL limitations occurred 

after hospitalization. In following 1,279 patients age 70 years and older after hospital discharge, 

a study found that 59 percent reported no change in ADL status, 10 percent reported 

improvement, and 39 percent reported declined ADL status at discharge when compared to 

preadmission status. At 3 months after discharge, 40 percent reported a new ADL or IADL 

disability compared with preadmission, reflecting the potential for continued functional decline 

after hospitalization for acute illness.27

Yet, the loss of functional independence is not an inevitable consequence of hospitalization 

for the elderly.28, 29 Evidence exists that targeted interventions can impact the degree of 

functional independence for hospitalized elders.30

Research Evidence 

Targeted measures that have proven beneficial in mitigating functional decline during 

hospitalization have included comprehensive geriatric assessments to identify patients at risk, 

structured geriatric care models, dedicated hospital units for acute care of the elderly, and the use 

of specific resources to enhance care for the hospitalized elder.

Comprehensive Geriatric Assessment 

Comprehensive geriatric assessment (CGA) is used to create a plan of care for hospitalized 

elders. A specific goal of the CGA is early identification of elder care needs in order to provide 

interventions to minimize high-risk events such as falls or the onset of delirium.31

A CGA should include assessment of ADL and IADL performance as well as assessment of 

cognition, vision and hearing, social support, and psychological well-being.19 A number of 

geriatric assessment tools can be used to make initial and ongoing evaluations of hospitalized 

elders. Commonly used tools include the Katz Index of Independence in Activities of Daily 

Living,32 the Lawton Instrumental Activities of Daily Living Scale,33 and the Hospital Admission 

Risk Profile (HARP), among others (see Table 2). 

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Reducing Functional Decline

Table 2. Commonly Used Geriatric Assessment Measures* 

Instrument Areas of Assessment Reference 

SPICES Sleep, problems with eating or 

feeding, incontinence, 

confusion, evidence of falls, 

skin breakdown 

Fulmer 199159

Wallace 199866

Geriatric Institutional Assessment Profile Hospital staff knowledge of 

geriatric care principles, 

organizational environment 

Abraham 199941

Hospital Admission Risk Profile (HARP) ADL, IADL, cognitive status Sager 199634

Lawton Instrumental Activities Daily Living Scale IADL activities: medication 

management, housekeeping, 

food preparation, 

transportation, shopping, 

managing finances, laundry 

Lawton 196933

Functional Independence Measure (FIM) Functional status in 7 areas: 

self-care, locomotion, 

communication, social 

cognition, cooperation, 

problem-solving, sphincter 

control 

Kidd 199567 

Keith 198768

Timed UP and Go Test Mobility, balance, gait, transfer 

ability, walking 

Podsiadlo 199169

2 Minute Walk Test Exercise tolerance and exercise 

capacity 

Brooks 200170

* For additional geriatric assessment resources, the Try This series can be found at 

www.hartfordign.org/resources/education/tryThis.html.

As part of CGA, baseline admission assessments have proved beneficial in identifying 

patients at risk for functional decline during hospitalizations. The HARP was used in one study 

to assess preadmission risk factors among more than 800 patients age 70 years and older who 

were hospitalized for acute medical illness.34 The HARP includes assessment of ADL status, 

IADL status, and cognitive status. Researchers found that three factors independently predict 

functional decline: increasing age, lower admission cognitive status, and lower preadmission 

IADL function. Patients at low risk of functional decline were more likely to recover ADL 

function and avoid nursing home placement at 3 months after discharge. 

Another functional status instrument that can be used to assess baseline activity and 

functional levels is the Mobility Classification Tool, described by Callen and colleagues.35 The 

tool may prove useful for nurses to assess, quantify, and communicate baseline levels and 

changes in mobility. Baseline assessments can provide useful information for structuring care 

during hospitalization and establishing goals for the care.

Aside from the use of formal assessment instruments that measure ADL and IADL function, 

a general idea of functional status can be ascertained by assessing mobility and activity 

performance during hospitalization. The frequency of hallway ambulation in hospitalized elders 

was examined in an observational study of 118 patients age 55 years and older in a single 

setting.36 While all patients were considered by their primary nurse as able to walk the hallways, 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

72.9 percent did not walk at all per 3-hour period of observation, 18.6 percent walked once, 5.1 

percent twice, and only 3.4 percent walked more than twice.35 The median time of ambulation 

was 5.5 minutes. Of the 32 patients who walked in the hallways, 46.8 percent (n = 15) did so 

alone, 41 percent (n = 13) walked with a therapist, 41 percent (n = 13) walked with a member of 

the nursing staff, and 18.8 percent (n = 6) walked with a family member. 

Based on the results of the CGA, functional problems or potential problems are identified 

and specific interventions can be implemented to promote functional ability in hospitalized 

elders. A number of interventions, including structured exercise, progressive resistance strength 

training, and walking programs, have been implemented to target elder care functioning during 

hospitalization.35, 37, 38 A randomized control trial of a hospital-based general exercise program 

with 300 hospitalized elders that was started during hospitalization and continued for 1 month 

after discharge did not affect length of stay, but did demonstrate better IADL function at 1 month 

after discharge.38 Measures to improve endurance—including exercise to enhance orthostatic 

stability, daily endurance exercise to maintain aerobic capacity, or specific resistance exercises to 

maintain musculoskeletal integrity17, 39, 40—need further study on their impact in reducing 

functional decline in hospitalized elders. As hospital-based exercise programs require 

coordination and focused implementation plans, strategies for adopting them need to recognize 

the shortened length of hospital stay and the effects of acute illness on the patients’ ability to 

participate. 

In addition to utilizing tools to assess the elderly hospitalized patient, assessments of the 

hospital culture for providing elder care can also be beneficial. The Geriatric Institutional 

Assessment Profile was specifically developed to assess hospital workers’ knowledge, attitudes, 

and perceptions of caring for elders, as well as the adequacy of the institutional environment to 

meet hospitalized elders’ needs.41 It is recommended to help identify both the strengths in elder 

care and the opportunities for improvement.42

Structured Geriatric Care Models

For more than 20 years, the concept of hospital-based geriatric assessment and 

interdisciplinary team care to improve outcomes for hospitalized elders has been implemented in 

various models. Early studies on the use of geriatric evaluation and geriatric evaluation units 

demonstrated an impact on reducing disability and nursing home placement.43–45 Several 

hospital-based geriatric resource models of care have also demonstrated benefits in promoting 

evidence-based care for hospitalized elders, including the use of geriatric interdisciplinary team 

training46 and the use of a geriatric resource nurse.47 National programs for geriatric 

interdisciplinary team training were created in 1997 to enhance the knowledge of caring for 

elders among a variety of health professions. While evaluation data have demonstrated 

improvement of geriatric interdisciplinary team trainees, most notably in attitudinal measures,46 

further study on the impact on geriatric care planning is needed. 

Several focused models of care designed to prevent functional decline of the hospitalized 

elderly have demonstrated significant results. The Hospital Elderly Life Program, a structured 

screening program for hospitalized patients age 70 years and older, concentrates on admission 

screening of six risk factors: cognitive impairment, sleep deprivation, immobility, dehydration, 

vision loss, and hearing impairment.16 More than 1,500 patients were screened, and targeted 

interventions based on the presence of admission risk factors were instituted. Patients were 

followed by an interdisciplinary team that included a geriatric nurse specialist, Elderly Life 

specialists, and geriatricians who worked in conjunction with the patient’s primary care nurse to 

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Reducing Functional Decline

formulate an individualized plan of care. Use of the program demonstrated significant results: 

only 14 percent of patients had a decline on ADL scores, compared to a decline in 33 percent of 

the control group. 

Acute Care for Elderly (ACE) units. Models of care incorporate a variety of interventions 

to promote positive outcomes for the hospitalized elderly. Specific programs have also been 

tested on specialized units within the hospital setting. These units, termed Acute Care for the 

Elderly (ACE units), provide dedicated care to the hospitalized elderly. 

Originating in the early 1990s, the ACE unit concept has been adopted by organizations as a 

strategy to provide care to elderly patients during hospitalization.48–49 ACE units promote a 

focused model of care that integrates geriatric assessment into medical and nursing care of 

patients in an interdisciplinary environment.50 The focus is to provide expert care while 

simultaneously keeping patients mobile and preventing the loss of normal daily routines.49 ACE 

units include specially designed environmental changes to promote activity such as ambulation 

in hallways, exercise facilities, and social gathering areas.51 Multidisciplinary teams composed of 

geriatric physicians; nurses; dietician; social worker; pharmacist; and occupational, speech, and 

physical therapists regularly discuss the plan of care for each patient.49 Major components of the 

ACE unit concept include patient-centered nursing care (daily assessment of functional needs by 

nursing, nursing-based protocols to improve outcomes, daily rounds by a multidisciplinary team), 

a prepared environment, planning for discharge, and medical care review.10, 52

Another model, designed to improve functional outcomes of acutely ill hospitalized elders, 

was tested in a randomized control trial with 1,794 patients 70 years of age and older in one unit 

of a hospital. A number of interventions were implemented under the direction of the primary 

nurse, including baseline and ongoing assessment of risk factors; following protocols to improve 

self-care, continence, nutrition, mobility, sleep, skin care, and cognition; conducting daily rounds 

with a multidisciplinary team; and environmental enhancements such as handrails, uncluttered 

hallways, large clocks and calendars, elevated toilet seats, and door levers.29 Results indicated 

that 21 percent of intervention patients were classified as much better in ADL activity abilities, 

13 percent as better, 50 percent as unchanged, 22 percent as worse, and 9 percent as much worse.

In the control group, 13 percent were classified as much better, 11 percent as better, 54 percent 

as unchanged, 13 percent as worse, and 8 percent as much worse (P = 0.0009). While the 

program interventions improved functional status in a significant percentage of the patients, the 

majority of the patients in both the intervention and control groups were unchanged or worse at 

the time of discharge. At 3 months after discharge, the groups did not differ significantly in terms 

of ADL or IADL abilities.29 The results of this study suggested that while targeted interventions 

can improve functional independence in the hospitalized elderly, some patients will continue to 

experience functional decline, despite focused interventions. 

Research comparing ACE units and standard medical care units has demonstrated positive 

outcomes, with improvements in ADL function and fewer transfers to nursing home settings 

after discharge.29 A randomized controlled study of 1,531 elders age 70 years and older 

demonstrated that use of an ACE unit improved processes of care and promoted patient and 

provider satisfaction without increasing hospital length of stay or costs.51 Additional study on the 

cost effectiveness of ACE units has demonstrated significant reductions in average length of stay 

(0.8 day) and a cost savings of $1,490 compared to control patients on two medical-surgical units, 

a savings that translated to $1.3 million in 9 months48 as well as no increase in hospital costs.53

The NICHE model. An additional model focusing on improving hospital care for the elderly, 

the Nurses Improving Care of Health System Elders (NICHE) project, was initiated in the early 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

1990s. The project is a national program focused on promoting evidenced-based care for 

elders.42, 54 Resources include best practice protocols, educational materials, nursing care models 

to replicate, and assessment tools. A unique series of online assessment tools, Try This, is 

available at www.hartfordign.org/resources/education/tryThis.html. Assessments of the NICHE 

program indicate that fewer patients were acutely confused at discharge,55 restraint use was 

reduced by more than 60 percent, serious injuries related to falls were reduced by 30 percent, 

there were beginning signs of reduction in the incidence of aspiration pneumonia and urinary 

tract infection, and patient mobility equipment was standardized.56 Outcome reports from 

implementation of NICHE also included increased nursing knowledge of geriatric care, 

decreased length of stay, and reduced costs.42, 56–58 The NICHE model of care is currently a 

voluntary program, and while additional outcomes-based research is needed, implementation of 

the program components by all hospital settings would facilitate best practices for elder care. 

The geriatric resource nurse model is the most widely used NICHE model. In the geriatric 

resource nurse model, unit-based nurses acquire competency in elder care and improve care by 

modeling best practices and providing consultation for elder care.42, 56, 57 Implementation reports 

highlight anecdotal evidence of benefit, but researched-based outcome evaluations is limited.

One study of 173 hospitalized elders demonstrated improvements in outcome measures, 

including functional and cognitive status from admission to discharge when managed by the 

geriatric resource nurse model; however, a comparison of a subset of the intervention patients 

and a control group of patients revealed no differences in patient outcomes.30 Further research on 

this model of care for hospitalized elders is required.

Other Measures to Enhance Care for the Hospitalized Elder 

Additional resources to promote hospital-based elder care that are evidence based include

nursing staff education to enhance geriatric assessment and care, promotion of nursing 

certification in geriatric care, and promotion of family participation in caring for hospitalized 

elders.59–62 Other focused interventions—including geriatric consultation on specific units, 

comprehensive discharge planning, and nutritional support—have had beneficial effects on 

clinical outcomes of hospitalization of the elderly.63, 64 Ongoing initiatives that have the potential 

for impacting the care of hospitalized elders include strategies for enhancing geriatric content in 

nursing school curriculum, advanced practice nurse training in geriatric care, centers of geriatric 

nursing excellence, and geriatric nursing scholar work. Yet, much remains to be learned about 

not only the causes of functional decline during hospitalization for the elderly, but also the best 

approaches for comprehensively modifying the hospital care environment to promote best 

outcomes. As nurse staffing levels have been demonstrated to impact the quality of hospital 

care,65 exploration of innovative models of nurse staffing to enhance care for the hospitalized 

elderly is also needed. In addition, there is limited research on hospital designs to improve 

functioning for hospitalized elders. Hallway walking is not always encouraged, and hospital 

hallways are often designed for transport of supplies, equipment, staff, and patients. The effect of 

environmental designs to enhance functioning of hospital elders, such as designated walking 

tracts on nursing units with shock-absorbing flooring and railings solely for patient use, require 

further exploration. 

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Reducing Functional Decline

Table 3. Summary of Key Points Based on Research Evidence 

• Functional status or the ability to perform self-care and physical needs activities is an important 

component of independence for the elderly. Maintaining function is central to fostering health and 

independence in the hospitalized elderly. 

• The hospitalized elderly are at risk for decreased mobility and functional decline.

• Hospitalization has been shown to be associated with low mobility and functional disability. 

• Comprehensive initial and ongoing geriatric assessments assist in identifying the older adult at 

risk for decline, enabling timely and targeted implementation strategies. 

• Targeting risk factors—cognitive impairment, prehospitalization functional impairment, and low 

social activity level—that can contribute to functional decline during hospitalization can promote 

better outcomes for elders.

• Encouraging activity during hospitalization can help to prevent functional decline. Interventions 

such as structured exercise, progressive resistance strength training, and walking programs have 

been implemented to target elder care functioning during hospitalization. 

• Redesign of the environment and processes of hospital care can improve the quality of the care 

delivered to the hospitalized elderly. 

• Key elements and features of successful intervention programs targeting functional outcomes in 

the hospitalized elderly include 

○ Baseline and ongoing assessment of risk factors 

○ Protocols aimed at improving self-care, continence, nutrition, mobility, sleep, 

skin care, and cognition 

○ Daily rounds with a multidisciplinary team 

○ Protocols to minimize adverse effects of selected procedures (e.g., urinary catherization) 

and medications (e.g., sedative-hypnotic agents) and limit the use of mobility restrictors 

(lines, tubes, and restraints) 

○ Environmental enhancements, including handrails, uncluttered hallways, large 

clocks and calendars, elevated toilet seats, and door levers 

○ Encouraging mobilization during hospitalization 

• Specialty geriatric nursing care can positively impact elder care in the hospital setting. 

• The potential for delayed functional recovery should be considered in discharge planning for 

hospitalized elders. 

Evidence-Based Practice Implications 

Table 4 outlines several evidence-based strategies for care of the hospitalized elder. A 

number of evidence-based practice guidelines that pertain to hospitalized elder care can be used 

to structure care to promote best practices in a variety of areas, including pain management, 

strategies for assessing and treating delirium, fall prevention for older adults, prevention of 

pressure ulcers, and changing the practice of physical restraint use in acute care. The guidelines 

can be found at www.guideline.gov. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Table 4. Evidence-Based Strategies for Care of the Hospitalized Elder. 

• Conduct an institutional assessment of your facility to determine knowledge and awareness of 

principles of geriatric care and best practices. 

• Consider integrating baseline and ongoing assessment of hospitalized elders. 

• Integrate established protocols aimed at improving self-care, continence, nutrition, mobility, sleep, 

skin care, and cognition. 

• Conduct daily rounds with a multidisciplinary team. 

• Institute protocols to minimize adverse effects of selected procedures (e.g., urinary catherization) 

and medications (e.g., sedative-hypnotic agents). 

• Use environmental enhancements for elder care, including handrails, uncluttered hallways, large 

clocks and calendars, elevated toilet seats, and door levers. 

• Consider participation in best practice models for elder care, including Geriatric Interdisciplinary 

Team Training (GITT) and Nurses Improving Care of Health System Elders (NICHE). 

• Utilize established resources, including geronurseonline (www.geronurseonline), University of 

Iowa Gerontological Nursing Intervention Research Center resource 

(http://www.nursing.uiowa.edu/centers/gnirc/protocols.htm), and NICHE online resources 

(www.hartfordign.org/resources/education/tryThis.html).

A number of important considerations for addressing potential risks for the hospitalized elder 

are outlined in Table 5. 

Table 5. Practice Implications to Avert Potential Risks 

Potential Risks for the Hospitalized Elderly Practice Implication 

1. Decreased mobility and functional decline Conduct comprehensive initial and ongoing geriatric 

assessment to formulate targeted strategies to enhance 

mobility levels and functional status, such as structured 

exercise, progressive resistance strength training, and 

walking programs. 

2. Adverse effects of immobility and bed rest Incorporate the use of practice guidelines to address 

potential adverse effects, including prevention of skin 

breakdown, fall prevention, treating delirium, prevention 

of pressure ulcers, and management of urinary 

incontinence.

3. Altered nutrition or dehydration Incorporate the use of practice guidelines to enhance 

nutritional status and hydration during acute illness. 

4. Impaired sleep and rest Integrate established protocols aimed at improving 

sleep and rest during hospitalization. 

5. Alterations in self-care Promote participation in activities of daily living; 

promote normal daily routine activities. 

6. Cognitive alterations Conduct ongoing assessment of cognitive status 

changes and implementation of measures to address 

confusion and delirium. 

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Reducing Functional Decline

Potential Risks for the Hospitalized Elderly Practice Implication 

7. Complications of acute illness (e.g., 

infection, aspiration, pneumonia) 

Use multidisciplinary care models to address 

management of acute illness and implementation of 

prevention measures. 

Research Implications 

To improve the quality and safety of care for hospitalized elderly patients, the following 

questions deserve further investigation:

• What interventions are the most effective in enhancing functional status in the 

hospitalized elderly? 

• What is the impact of single-site successful models of care in multiple hospital care 

settings? 

• What is the cost effectiveness of intervention programs aimed at targeting functional 

decline in the hospitalized elderly? 

Future research on reducing functional decline in the hospitalized elderly should target the 

following significant gaps in research: 

• Additional research on the impact of models of care for the hospitalized elderly 

(including NICHE) is needed to build evidence-based practice recommendations. Most of 

the existing “evidence” comes from small randomized studies, nonrandomized studies, 

case studies, and expert opinion. 

• Hospital design outcomes research is warranted to further evaluate the impact of redesign 

interventions in enhancing outcomes for hospitalized elders. 

• Most research on interventions targeting functional status during hospitalization of the 

elderly was conducted at single-site locations. Therefore, it is not clear if the findings can 

be generalized to other settings. Additional research is needed that focuses on 

multidisciplinary interventions with larger sample sizes and in multicenter, randomized 

clinical studies. 

• A conceptual model for targeting functional decline in the hospitalized elderly is needed.

Factors to be considered include the fact that the elderly are a heterogeneous group—

some are frail upon admission and others are robust. The hospitalized elderly come to the 

hospital with different comorbidities and reasons for admission. Polypharmacy in the 

elderly needs to also be considered. In addition, the tertiary care environment is not a 

living environment, creating a dissonance between the goals of restorative care and 

environmental function.

• While structured models of care focusing on assessment, physical therapy, ADL protocol 

use, and multidisciplinary team care have demonstrated significant benefits on 

independence for hospitalized elders, relatively simple interventions such as hallway 

walking, communal dining, and group therapy need to be further examined. 

• Nursing-focused interventions aimed at promoting functional independence for 

hospitalized elders need further exploration in formal research studies. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Conclusion 

This chapter has presented an overview of research and evidence-based practices for elderly 

care during hospitalization to prevent functional decline. A number of other chapters in this book 

further address related areas, such as averting patient falls, preventing pressure ulcers, symptom 

management, and other aspects of care for the hospitalized elder. Continued research and 

dissemination of best practices will lead to additional strategies that nurses can use to improve 

the quality of health care and outcomes for hospitalized elders. Assessment of function and 

targeting interventions during hospitalization are critically important to acute care of older 

adults.71 The impact of functional decline on resource utilization and health care costs may 

further reinforce the need to assess and intervene to prevent functional decline.72 Additional 

research on factors influencing functional decline will also provide information for nurses to 

present to administrators to develop programs to identify and mitigate functional decline in the 

hospitalized elderly.

Acknowledgments 

The authors would like to acknowledge Mary H. Palmer, Ph.D., R.N.C., F.A.A.N., Helen W. 

& Thomas L. Umphlet Distinguished Professor in Aging, University of North Carolina at Chapel 

Hill, and Eileen M. Sullivan-Marx, Ph.D., C.R.N.P., F.A.A.N., associate professor, associate 

dean for Practice & Community Affairs, and Shearer Endowed Term Chair for Healthy 

Community Practices, University of Pennsylvania School of Nursing, for their review and 

suggestions for editing of the chapter. 

Author Affiliations 

Ruth M. Kleinpell, Ph.D., R.N., F.A.A.N., Rush University College of Nursing, Chicago, 

Illinois; e-mail: Ruth_M_Kleinpell@rush.edu. 

Kathy Fletcher, R.N., G.N.P., A.P.R.N.-B.C., F.A.A.N., University of Virginia Health 

System, Charlottesville, Virginia; e-mail: krf8d@virginia.edu. 

Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N., Colonel, U.S. Army (Retired), and health care 

consultant; e-mail: bmjennings@cox.net. 

12 
Reducing Functional Decline

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