The recent death of my father has left me trying to understand why it felt as though we were always fighting to get his physicians to more aggressively treat him. It is hard not to feel that even previously healthy older adults often face therapeutic nihilism, inadequate pain management, and premature discussions focused on the withdrawal of care. So what’s to be done?
Recognizing Common Biases
Attributing symptoms to “just aging” – Delirium dismissed as dementia, pain attributed to “arthritis,” or functional decline accepted as inevitable rather than investigated. The list goes on. We need to recognize that today, a healthy 75 to 85 -year-old may have decades of potential quality life ahead and deserves the same diagnostic rigor as the 35 to 45-year-old.
Underestimating physiologic reserve – Many hospitalists unconsciously assume elderly patients cannot tolerate aggressive treatment, leading to suboptimal interventions. Yet chronological age poorly predicts surgical outcomes or treatment tolerance compared to current functional status and frailty measures.
Anchoring on worst-case scenarios – When individuals focus on potential complications rather than potential for recovery it can create self-fulfilling prophecies of poor outcomes.
Strategies for Improvement
Assess function, not just age. Use validated tools like the Clinical Frailty Scale or baseline ADL status. A robust 82-year-old who hikes weekly has vastly different treatment considerations than a frail 82-year-old with multiple comorbidities. Make treatment decisions based on premorbid function, not the number. A simple question to ask….What were you doing yesterday? (or ask the family the same question).
The “what if this was my parent test.” Before recommending conservative management, ask yourself: “If this were my parent with this same functional baseline, would I accept this level of workup and treatment?” This mental exercise reveals hidden biases.
Proactive shared decision-making. Engage patients and families early about goals, presenting realistic options without steering toward age-based rationing. Many elderly patients want full treatment; others may choose comfort measures. The key is informed choice, not paternalistic assumptions or conclusions one may make when you have only just met the patient and they may be terribly ill.
Aggressive symptom management. Elderly patients receive inadequate pain control due to opioid-phobia and polypharmacy concerns. Pain catastrophizes outcomes – use multimodal analgesia, regional techniques, and appropriate opioids without age-based dose reductions that leave patients suffering. Elderly patients have less reserve than their younger counterparts. If they aren’t fed, they lose weight faster, if they get septic, they have less ability to recover. For this reason they need providers to act quickly rather than passively.
Geriatric co-management. For surgical patients, involving geriatricians or geriatric-trained hospitalists reduces complications, length of stay, and improves functional outcomes. They optimize medications, prevent delirium, and coordinate rehabilitation.
Preoperative optimization. Don’t just clear elderly patients for surgery – optimize them. Address anemia, nutritional status, glycemic control, and cardiac medications. Consider prehabilitation programs that improve functional capacity before elective procedures.
Prevent iatrogenic harm. Hospital-acquired complications disproportionately affect elderly patients. Implement mobility protocols (avoid bedrest), minimize bladder catheters, careful fluid administration to avoid electrolyte abnormalities, prevent delirium (avoid benzodiazepines, ensure hearing aids/glasses), and carefully review medications daily. The elderly need extra attention to avoid adding to the burden of any other medical condition they may be dealing with.
Multidisciplinary rounds. Include PT/OT, pharmacy, dietary, social work, and nursing perspectives. Early mobility and rehabilitation planning is even more important in the elderly to prevent functional decline leading to further morbidity risks.
Systems-Level Changes
Quality metrics tracking age-based disparities. Monitor whether treatment intensity, consultation rates, and procedure utilization differ by age after controlling for comorbidities and patient preferences. Make data transparent and share the performance between teams.
Geriatric education integration. Most hospitalists receive minimal geriatric training. Mandatory education on geriatric pharmacology, delirium prevention, functional assessment, and age bias recognition should be standard.
Elder-friendly care protocols. Implement HELP (Hospital Elder Life Program) or ACE (Acute Care for Elders) units that modify care delivery to preserve function and prevent complications.
Challenging nihilistic language. When colleagues say “they’re 85, what do you expect?” or “at that age, surgery is risky” – gently reframe: “They were independent last week. What changed?” or “What’s the surgical risk based on their frailty score, not their birth certificate?”
The Mindset Must Shift
The American population is aging and the fundamental error is viewing elderly patients as categorically different rather than as individuals with varying reserves and goals. An 80-year-old with preserved function facing pneumonia deserves the same ICU consideration as a 50-year-old. An 88-year-old needing hip fracture repair should get the same preoperative cardiac optimization as anyone else.
Age becomes relevant when integrated with function, frailty, patient preferences, and disease trajectory – but it should never be the primary decision-making factor. The goal isn’t to treat every elderly patient maximally regardless of wishes, but to ensure age alone doesn’t preclude options that could restore quality of life.
Excellent geriatric hospital care requires seeing beyond the number to the person – their baseline vitality, their goals, their potential for recovery – and then delivering the same evidence-based, compassionate care we’d want for ourselves at any age.
Let’s stop looking at gray hair and instead ask a simple question…. “What was this person doing just before they got sick or had this surgery?”