ABSTRACT

The acute and post-acute care of the elderly is a process fraught with problems. Elderly patients at high risk are individuals who have to be admitted more frequently to a hospital due to developed complications, who are faced with a constant risk of hospitalization, and who have increased risks of functional decline, nursing home admittance, and death. These adverse outcomes cause discrepancies and problems in the implementation and regulation of treatment and coordination between health entities. Factors increasing these risks vary among these individuals, but existing chronic diseases and geriatric syndromes are the most important underlying causes. The identification of elderly patients at high risk for complications is difficult because of the complex syndromes, chronic diseases, care and socioeconomic problems. Also, these patients are at risk for unplanned hospital admissions. One of every 4 or 5 elderly patients discharged at high risk is re-admitted to a hospital within the first month. In these patients, early diagnosis, followed by a multi-disciplinary team, enhanced discharge planning, medication reconciliation and out of hospital care could contribute to improving the quality of care and more efficient use of the resources. In Turkey there is a need for patient-centered programs on this issue.