A Prospective Cohort Study of Geriatric Syndromes Among
Older Medical Patients Admitted to Acute Care Hospitals
Prabha Lakhan, RN, PhD,*¶ Mark Jones, PhD,†,‡ Andrew Wilson, MD, PhD,§ Mary Courtney,
PhD,§∥ John Hirdes, PhD,#** and Leonard C. Gray, MD, PhD*
OBJECTIVES: To identify the prevalence of geriatric syn-
dromes in the premorbid for all syndromes except falls
(preadmission), admission, and discharge assessment peri-
ods and the incidence of new and significant worsening of
existing syndromes at admission and discharge.
DESIGN: Prospective cohort study.
SETTING: Three acute care hospitals in Brisbane,
Australia.
PARTICIPANTS: Five hundred seventy-seven general med-
ical patients aged 70 and older admitted to the hospital.
MEASUREMENTS: Prevalence of syndromes in the pre-
morbid (or preadmission for falls), admission, and dis-
charge periods; incidence of new syndromes at admission
and discharge; and significant worsening of existing syn-
dromes at admission and discharge.
RESULTS: The most frequently reported premorbid syn-
dromes were bladder incontinence (44%), impairment in
any activity of daily living (ADL) (42%). A high propor-
tion (42%) experienced at least one fall in the 90 days
before admission. Two-thirds of the participants experi-
enced between one and five syndromes (cognitive impair-
ment, dependence in any ADL item, bladder and bowel
incontinence, pressure ulcer) before, at admission, and at
discharge. A majority experienced one or two syndromes
during the premorbid (49.4%), admission (57.0%), or dis-
charge (49.0%) assessment period.The syndromes with a
higher incidence of significant worsening at discharge (out
of the proportion with the syndrome present premorbidly)
were ADL limitation (33%), cognitive impairment (9%),
and bladder incontinence (8%). Of the syndromes exam-
ined at discharge, a higher proportion of patients experi-
enced the following new syndromes at discharge (absent
premorbidly): ADL limitation (22%); and bladder inconti-
nence (13%).
CONCLUSION: Geriatric syndromes were highly preva-
lent. Many patients did not return to their premorbid func-
tion and acquired new syndromes. J Am Geriatr Soc
59:2001–2008, 2011.
Key words: geriatric syndromes; hospital
Geriatric syndromes such as falls and functional declineare common in older medical patients in hospital
settings1–5 but may not be recognized and managed
adequately.6 Studies investigating the prevalence of geriat-
ric syndromes in general medical inpatients have mainly
focused on single syndromes.7–11 Those investigating the
prevalence of more than one syndrome have investigated
syndromes present before and at admission9,12–16 or have
examined syndromes as risk factors for outcomes such as
length of stay, institutionalization, and mortality.2,10–11,17–18
One small study examined the presence of more than one
syndrome (mobility, toileting, grooming, transfer, feeding,
bladder or bowel incontinence, and mental status) in 71
medical patients aged 74 and older 2 weeks before admis-
sion, on Day 2 of hospitalization, at discharge, and 1 week
after discharge.19
No recent studies have quantified the presence of multi-
ple geriatric syndromes in a single cohort of medical
patients. Rockwood et al.20 pointed out that conceptual
models of multiple syndromes are useful for developing geri-
atric medicine, arguing that studies quantifying the presence
of a number of syndromes are as important as those examin-
ing the types of syndromes. A good understanding of the
prevalence and incidence of an array of geriatric syndromes
would facilitate more precise clinical care.21 The current
article reports on the prevalence and incidence of geriatric
syndromes from a prospective observational study, designed
From the *Centre for Research in Geriatric Medicine, The University of
Queensland, ¶Deakin-Southern Health Nursing Research Centre, Deakin
University, ‡School of Population Health, The University of Queensland,
†Centre for Healthcare Related Infection Surveillance and Prevention,
Queensland Health, §Faculty of Health, Queensland University of
Technology, Brisbane, Australia; ∥Faculty of Health and Social
Development, University of British Columbia, Vancouver, British
Columbia; #University of Waterloo, Waterloo, Ontario; and **Homewood
Research Institute, Guelph, Canada.
Address correspondence to Prabha Lakhan, Centre for Research in
Geriatric Medicine, The University of Queensland, Brisbane, Australia. E-
mail: p.ramritu@uq.edu.au
DOI: 10.1111/j.1532-5415.2011.03663.x
JAGS 59:2001–2008, 2011
© 2011, Copyright the Authors
Journal compilation © 2011, The American Geriatrics Society 0002-8614/11/$15.00

primarily to identify predictive factors for in-hospital acqui-
sition of geriatric syndromes.22 The findings on predictive
factors will be reported in subsequent articles.
METHODS
This prospective cohort study included 577 patients aged
70 and older admitted to general medical units of three
acute care hospitals in metropolitan Brisbane, Australia,
between 2005 and 2008 with an anticipated length of stay
of longer than 48 hours. Patients admitted to coronary or
intensive care units or for terminal care only or transferred
out of the general medical unit within 24 hours of admis-
sion to the ward were excluded. Ethical approval was
obtained from each participating hospital’s human
research and ethics committee and the University of
Queensland’s medical research ethics committee.
Data Collection
Table 1 describes the geriatric syndromes examined in
this article. The interRAI Acute Care (interRAI AC)
assessment instrument was used for collection of all data
required for the study.23,24 Data items in the instrument
include sociodemographic information, cognition, com-
munication, mood and behavior, activities of daily living
Table 1. Definitions of Geriatric Syndromes Examined in Study
Falling before hospital admission and during hospitalization: A fall was defined as an unintentional change in position from lying, sitting, or
standing to a lower level or resting on the ground.
Falls before admission: at least one fall experienced in the 90 days before the day of admission to the hospital. Falling during hospitalization:
At least one fall experienced in the hospital from admission to the ward to discharge. New fall during hospitalization: At least one new fall
in hospital and no fall in 90 days before day of admission.
Pressure ulcer
Presence of pressure ulcer can be scored from Stages 2 to 5. A pressure ulcer was present if there was partial skin loss (Stage 2), deep craters
in skin (Stage 3), skin break exposing muscle or bone (Stage 4), or a necrotic ulcer (Stage 5).
Significant worsening of an ulcer: decline of an existing pressure ulcer by two stages or more between the premorbid and admission, admission
and discharge, or premorbid and discharge periods.
A new pressure ulcer: Stage 2 or greater pressure ulcer present at admission and discharge and not present premorbidly; present at discharge
and absent at admission.
Delirium during hospitalization
Nurse assessment of delirium: Presence of each of the four items in the previous 24 hours was assessed: being easily distracted, episodes of
disorganized speech, varying mental function, and acute change in mental status from the person’s baseline.
Geriatrician assessment: the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria were used to assess all patients for
presence of delirium at admission assessment (depending on availability of geriatrician). During hospitalization, a geriatrician evaluated
presence of delirium if the nurse assessment identified the presence of delirium at admission and during hospitalization and the patient had not
been assessed at admission or it was new-onset delirium (absent at admission assessment).
Limitation with activities of daily living (ADLs)
Seven items included in the interRAI Acute Care (AC) assessment were assessed individually for assistance received with performing each
activity premorbidly, at admission, and at discharge: bathing, personal hygiene, walking, toilet use, toilet transfer, eating and bed mobility.
Scores for each item ranged from 2 = supervision to 6 = total dependence, with scores of
2 points considered an impairment.
Receiving assistance with ADLs was also assessed using the short-ADL (sADL) Scale, which comprises four items: personal hygiene, walking,
toilet use, and eating. Each item was scored from 1 = requires supervision to 4 = total dependence.
A significant worsening (score differences of
2 points) in ability to perform ADL function at admission and discharge assessments from the
premorbid period and between admission and discharge using sADL Scale scores.
A new ADL impairment (sADL Scale) present at admission and discharge: score differences of
2 points at admission and at discharge from a
premorbid score of 0; and at discharge from admission score of 0.
Instrumental activity of daily living (IADL) impairment
Eight items constitute the IADLs in the interRAI AC, which scores the assistance required in performance of each activity premorbidly: meal
preparation, ordinary housework, managing finances, managing medications, using the telephone, ascending a full flight of stairs, shopping,
and transportation. Scores of
2 points indicated IADL impairment (2 = supervision; 3 = limited assistance; 4 = extensive assistance;
5=maximal assistance; 6=total dependence; 8 = activity did not occur, is recoded to 6 for all items except for ascending stairs).
Cognitive impairment
Cognitive impairment was measured using the Cognitive Performance Scale (CPS) which includes five interRAI AC items: cognitive skills for daily
decision-making, short-term memory problems, procedural memory problems, making self understood, and eating ability. Scores range from 0
to 6; any scores
2 indicated impairment.
A significant worsening of cognition: CPS score differences of
2 points from the premorbid to admission, admission to discharge, premorbid
to discharge period. New cognitive impairment at admission and discharge: CPS score of
2 at admission and at discharge in patients with
premorbid CPS score of 0 (no impairment); and at discharge with admission scores of 0.
Bladder incontinence
Bladder incontinence was scored ranging from 2=infrequent to 5=absence of any control (1=presence of indwelling urinary catheter).
A significant worsening of bladder incontinence was a score difference of
2 points from premorbidly to admission and discharge and from
admission to discharge.
New bladder incontinence at admission and discharge: A score difference of
2 in patients with a premorbid score of 0; and admission score of 0.
Bowel incontinence
Bowel incontinence was scored ranging from 2=infrequent incontinence to 5=lack of any control (1=presence of any ostomy).
A significant worsening (
2 points) of bowel continence from premorbidly to admission and discharge and from admission to discharge.
New bowel incontinence at admission and discharge: a score difference of
2 in patients with a premorbid score of 0; and admission score of 0.
2002 LAKHAN ET AL. NOVEMBER 2011–VOL. 59, NO. 11 JAGS