The Geriatric Syndrome: A Non-Organ-Based Approach to the Older Adult

Dr Neeraj Manikath  , claude.ai

Abstract

Geriatric syndromes—including frailty, delirium, and functional decline—represent complex, multifactorial conditions that defy traditional organ-based diagnostic paradigms. As the population ages and hospital medicine increasingly becomes synonymous with geriatric care, clinicians must pivot from mechanistic problem lists to holistic, person-centered approaches. This review explores the conceptual framework for recognizing geriatric syndromes as primary diagnoses, provides practical tools for their identification and management, and advocates for a paradigm shift that prioritizes functional outcomes and patient-centered goals from admission through discharge.

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Introduction

Traditional medical training emphasizes organ-system pathology: the failing heart, the infected lung, the ischemic brain. However, older adults frequently present with syndromes that transcend these boundaries—conditions characterized by vulnerability rather than discrete anatomical lesions. The 80-year-old admitted with "altered mental status" may have no single culprit on imaging or laboratory testing, yet represents a constellation of age-related physiological decline, polypharmacy, acute stressors, and environmental disruption. This is the essence of geriatric syndromes.

Pearl: Geriatric syndromes are the clinical manifestations of cumulative impairments in multiple systems that compromise homeostasis and increase vulnerability to situational challenges.¹

The challenge for hospitalists is recognizing when frailty, delirium, or functional decline should headline the diagnosis list—not buried beneath "pneumonia" or "urinary tract infection." This mindset shift transforms clinical practice, influencing everything from medication management to discharge planning.

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The "Vulnerable Brain": Delirium as a Vital Sign, Not a Nuisance

Reconceptualizing Delirium

Delirium affects 20-50% of hospitalized older adults and is associated with increased mortality, prolonged hospital stays, accelerated cognitive decline, and loss of independence.^2,3 Yet it remains underrecognized, often dismissed as "sundowning" or an expected consequence of hospitalization.

Oyster: Delirium is not a diagnosis of exclusion—it is a medical emergency signaling acute brain dysfunction and systemic decompensation.

The pathophysiology involves neuroinflammation, neurotransmitter imbalances (particularly cholinergic deficiency and dopaminergic excess), oxidative stress, and blood-brain barrier disruption.⁴ Precipitating factors include medications (especially anticholinergics, benzodiazepines, and opioids), infections, metabolic derangements, hypoxia, and environmental disruption. Predisposing factors—advanced age, baseline cognitive impairment, sensory deficits, and frailty—determine the threshold for delirium development.

Systematic Detection

Hack: Use the Confusion Assessment Method (CAM) systematically on every geriatric admission—not just when "confusion" is reported by nursing staff.

The CAM requires:

1. Acute onset and fluctuating course
2. Inattention
3. Disorganized thinking OR altered level of consciousness⁵

Screen for hypoactive delirium—the more common, more dangerous subtype that lacks agitation and is frequently missed. These patients appear "pleasantly confused" but have worse outcomes than their hyperactive counterparts.

Prevention and Management: The ABCDEF Bundle

Evidence-based delirium prevention incorporates multicomponent interventions:⁶

• Assess, prevent, and manage pain
• Both spontaneous awakening and breathing trials (avoid oversedation)
• Choice of appropriate analgesia and sedation
• Delirium monitoring and management
• Early mobility and exercise
• Family engagement and empowerment

Pearl: Non-pharmacological interventions—reorientation, sleep hygiene, early mobilization, glasses and hearing aids at bedside, avoiding catheters and restraints—reduce delirium incidence by 30-40%.⁷

Pharmacological management should be reserved for severe agitation threatening patient or staff safety. Haloperidol (0.25-0.5 mg) remains the traditional choice, though evidence for antipsychotics preventing or shortening delirium is limited and concerns about adverse effects (extrapyramidal symptoms, prolonged QTc, mortality) are significant.⁸

Hack: Before reaching for haloperidol, ask: "Is the patient distressed, or am I?" True hyperactive delirium with distress warrants treatment; confusion without agitation warrants patience and environmental optimization.

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The Frailty Phenotype: How to Spot It and Why It Changes Your Management

Defining Frailty

Frailty represents a state of decreased physiological reserve and resistance to stressors, resulting in increased vulnerability to adverse outcomes including falls, disability, hospitalization, and death.⁹ It exists on a continuum from robust to pre-frail to frail.

Two dominant conceptual models exist:

1. The Phenotype Model (Fried criteria)¹⁰: Frailty diagnosed by ≥3 of:

   • Unintentional weight loss (>10 lbs in past year)
   • Self-reported exhaustion
   • Weakness (grip strength)
   • Slow walking speed
   • Low physical activity

2. The Cumulative Deficit Model: Frailty as accumulation of health deficits across multiple domains (cognition, mood, function, comorbidities, laboratory values)—quantified by tools like the Clinical Frailty Scale.¹¹

Bedside Recognition

Hack: The eyeball test works. Can the patient rise from a chair without using armrests? Walk across the room steadily? If hospitalization represents a decline from baseline independence, assume frailty until proven otherwise.

The Clinical Frailty Scale (CFS, 1-9 rating from very fit to terminally ill) can be assessed in under two minutes using collateral history about pre-admission function.¹¹ A CFS ≥5 (mildly frail or worse) predicts poor outcomes from critical illness, major surgery, and aggressive interventions.

Why Frailty Changes Everything

Frailty fundamentally alters the risk-benefit calculus of medical interventions:

• A frail patient admitted with pneumonia faces higher risk of ICU-related complications, delirium, iatrogenic harm, and functional decline than their robust counterpart—even with identical pneumonia severity scores.¹²
• Aggressive diagnostic testing may cause more harm (radiation, contrast nephropathy, procedural complications, cascade effects) than benefit in patients with limited life expectancy.
• The same beta-blocker that reduces mortality in a robust 70-year-old may cause falls, fractures, and functional decline in a frail 85-year-old.

Pearl: Recognize frailty on admission and explicitly document it. Write "frail phenotype" as a diagnosis. This signals to the entire care team that standard protocols require modification.

Oyster: Frailty is dynamic, not deterministic. With appropriate intervention—particularly addressing malnutrition, physical deconditioning, and polypharmacy—some patients can improve on the frailty spectrum.

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Deprescribing on Admission: The "Brown Bag" Medication Review

The Problem of Polypharmacy

Older adults average 5-8 chronic medications, with many taking >10.¹³ Polypharmacy increases risks of adverse drug events, drug-drug interactions, non-adherence, cognitive impairment, falls, and hospitalizations. Yet medications accumulate over time—each specialist adding another agent, rarely subtracting.

Hack: The admission medication reconciliation is not just documentation—it's the single best opportunity for deprescribing. Encourage patients or caregivers to bring all medications (the "brown bag review") including over-the-counter drugs and supplements.

Identifying Medications for Deprescribing

Use structured approaches:

1. The Beers Criteria¹⁴: Lists potentially inappropriate medications in older adults (PIMs), including:

   • Anticholinergics (causing cognitive impairment, constipation, urinary retention)
   • Benzodiazepines (falls, delirium, dependence)
   • NSAIDs (GI bleeding, renal injury, cardiovascular risk)
   • Proton pump inhibitors beyond 8 weeks without indication (C. difficile, osteoporosis)
   • First-generation antihistamines (sedation, anticholinergic effects)

2. The STOPP/START Criteria¹⁵: Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert to Right Treatment—identifies both overprescribing and underprescribing.

3. Medication Appropriateness Index: Assesses whether each medication has clear indication, appropriate dosing, practical directions, clinically significant interactions, and therapeutic duplication.¹⁶

The Deprescribing Process

Step 1: Identify all medications and their indications. For any medication without clear current indication—stop it.

Step 2: Assess medications where risk outweighs benefit in this patient's context (frailty, life expectancy, goals).

Step 3: Prioritize deprescribing medications with:

• Anticholinergic properties (delirium risk)
• CNS-active effects (falls risk)
• Narrow therapeutic windows in setting of renal/hepatic impairment
• Preventive intent in patients with limited life expectancy

Step 4: Taper medications requiring gradual withdrawal (beta-blockers, proton pump inhibitors, benzodiazepines, antidepressants).

Pearl: Frame deprescribing positively: "We're going to reduce medications that may be causing harm and focus on those that will help you feel better and maintain your independence."

Oyster: Statins, antiplatelet agents, and tight glycemic control become questionable in frail older adults with limited life expectancy. A patient with severe frailty (CFS 7-8) likely won't live long enough to benefit from primary prevention but will experience immediate adverse effects.¹⁷

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Goals of Care as the First Order: Why It's Cruel to Wait Until the Patient Is Crashing

The Imperative of Early Goals-of-Care Discussions

Medicine's default setting is aggressive intervention. We order tests, consult specialists, escalate care—often without clarifying whether this aligns with the patient's values and goals. For frail older adults, this default can lead to ICU admissions, mechanical ventilation, CPR attempts, and deaths in hospitals rather than at home—outcomes many would not choose if given informed options.

Hack: Make goals-of-care discussions standard on admission for any patient with frailty, advanced age (>80), or serious illness—not a crisis intervention when the patient is decompensating.

Structuring the Conversation

Use frameworks like the "Best Case/Worst Case" approach:¹⁸

1. Assess understanding: "What's your understanding of your current health situation?"
2. Provide prognostic information: "Many patients with your combination of conditions face difficult choices about medical care..."
3. Present scenarios: "The best-case scenario is... The worst-case scenario is... The most likely scenario is..."
4. Explore values: "What's most important to you? What are you willing to endure to achieve that?"
5. Make recommendations: Based on clinical judgment and patient values—don't force patients to make purely autonomous medical decisions without guidance.

Pearl: Distinguish between treatment preferences (code status, intubation, feeding tubes) and broader goals (living independently, avoiding suffering, spending time with family, religious considerations). Goals inform specific treatment decisions; asking only about code status misses the essential framework.

Documenting Goals

Document clearly:

• Patient's understanding of prognosis
• What matters most to the patient
• Treatment preferences in context of goals
• Surrogate decision-maker if patient lacks capacity

Use formal advance directive or POLST (Physician Orders for Life-Sustaining Treatment) forms when appropriate.¹⁹ Ensure documentation is accessible across care transitions.

Oyster: Many patients with frailty choose comfort-focused care when presented with realistic scenarios. This is not "giving up"—it's aligning medical care with human priorities. The cruelty is waiting until crisis, when decisions are made in chaos, families feel guilt, and outcomes are predetermined by emergency interventions.

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Discharge to Function: Planning for the Home Environment, Not Just Medical Status

The Functional Lens

Traditional discharge planning focuses on medical stability: normalized vital signs, resolving infection, stable comorbidities. For older adults, this is necessary but insufficient. The critical question is: Can this patient function safely in their home environment?

Hospitalization causes functional decline in 30-60% of older adults, particularly those with baseline frailty.²⁰ Bed rest, acute illness, medications, sleep disruption, and hospital routines all contribute. Many patients leave medically "cleared" but unable to perform activities of daily living (ADLs) they managed before admission.

Comprehensive Functional Assessment

Assess throughout hospitalization:

ADLs: Bathing, dressing, toileting, transferring, continence, feeding IADLs: Medication management, finances, transportation, housekeeping, meal preparation

Hack: Observe real-world function. Don't just ask "Can you walk?"—walk with the patient to the bathroom. Don't ask if they can manage medications—have them demonstrate opening pill bottles.

Addressing Barriers to Safe Discharge

1. Physical Environment: Home safety assessment—stairs, bathrooms, fall hazards, adequate lighting. Occupational therapy consultation for adaptive equipment.

2. Social Support: Who will assist with ADLs, IADLs, medical appointments? Isolation is a major risk factor for readmission.

3. Cognitive Function: Can the patient recognize danger (stove left on), follow medication regimens, summon help if needed?

4. Nutrition: Many frail older adults have inadequate oral intake. Weight loss during hospitalization predicts poor outcomes.

5. Mobility: Physical therapy assessment of fall risk, need for assistive devices, home exercise programs.

Pearl: The "Hospital-to-Home" transition is high-risk. Medication changes, new equipment, altered routines, caregiver stress, and delayed follow-up all contribute to 30-day readmissions in 20-25% of older adults.²¹

Post-Acute Care Options

Not every patient can safely discharge home. Consider:

• Home health services: Nursing visits, PT/OT, social work—for homebound patients needing continued skilled care
• Acute rehabilitation: Intensive (3 hours/day) therapy for patients with rehabilitation potential
• Skilled nursing facility: Subacute rehabilitation or long-term care when home discharge is unsafe
• Palliative care/hospice: For patients with life-limiting illness prioritizing comfort

Hack: Initiate discharge planning on admission—not on day 4 when the medical team declares the patient "ready." Early PT/OT consults, family meetings, and case management involvement prevent delays and optimize transitions.

Oyster: Successful discharge to function requires humility about medicine's limitations. We can treat pneumonia, but we cannot restore a 90-year-old's pre-frailty state. Sometimes the most appropriate discharge plan is home with hospice—accepting mortality while maximizing quality of remaining life.

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Conclusion: Reimagining Hospital Medicine Through a Geriatric Lens

The future of hospital medicine is geriatric medicine. As the population ages and older adults with multimorbidity increasingly occupy our beds, we must evolve beyond organ-based algorithms toward holistic, person-centered approaches that recognize geriatric syndromes as primary pathology.

This requires:

1. Vigilance for delirium as a vital sign signaling acute brain vulnerability
2. Recognition of frailty as a diagnosis that transforms treatment decisions
3. Proactive deprescribing to reduce iatrogenic harm
4. Early goals-of-care discussions that honor patient autonomy and prevent crisis-driven decisions
5. Functional outcome prioritization in discharge planning

By shifting from "What tests should I order?" to "What matters to this person and how can I help them achieve it?", we practice medicine that respects the whole human—not just the failing organ system.

Final Pearl: The measure of success in geriatric hospital medicine is not 30-day mortality—it's preserving independence, maintaining dignity, and aligning care with what patients value most.

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Author's Note: This review emphasizes practical, bedside-applicable approaches to geriatric syndromes. By recognizing frailty, delirium, and functional decline as primary diagnoses rather than ancillary findings, clinicians can deliver care that honors the complexity and humanity of older adults while improving outcomes that matter most to patients and families.