Abstract
OBJECTIVES: To assess multiple geriatric syndromes in a sample of older hospitalized adults discharged to skilled nursing facilities (SNFs) and subsequently to home to determine the prevalence and stability of each geriatric syndrome at the point of these care transitions. DESIGN: Descriptive, prospective study. SETTING: One large university-affiliated hospital and four area SNFs. PARTICIPANTS: Fifty-eight hospitalized Medicare beneficiaries discharged to SNFs (N = 58). MEASUREMENTS: Research personnel conducted standardized assessments of the following geriatric syndromes at hospital discharge and 2 weeks after SNF discharge to home: cognitive impairment, depression, incontinence, unintentional weight loss, loss of appetite, pain, pressure ulcers, history of falls, mobility impairment, and polypharmacy. RESULTS: The average number of geriatric syndromes per participant was 4.4 ± 1.2 at hospital discharge and 3.8 ± 1.5 after SNF discharge. There was low to moderate stability for most syndromes. On average, participants had 2.9 syndromes that persisted across both care settings, 1.4 syndromes that resolved, and 0.7 new syndromes that developed between hospital and SNF discharge. CONCLUSION: Geriatric syndromes were prevalent at the point of each care transition but also reflected significant within-individual variability. These findings suggest that multiple geriatric syndromes present during a hospital stay are not transient and that most syndromes are not resolved before SNF discharge. These results underscore the importance of conducting standardized screening assessments at the point of each care transition and effectively communicating this information to the next provider to support the management of geriatric conditions.