Introduction to geriatrics

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Geriatrics is the branch of medicine concerned with the health and care of older adults, defined by the American Geriatrics Society (AGS) as those aged 65 years or older. Normal aging changes (e.g., stiffening of arteries, osteoporosis, decline in cognitive function) predispose older adults to multiple chronic conditions, disability, adverse pharmacological reactions, and decreased quality of life. A comprehensive geriatric assessment, usually performed by a primary care physician, can help identify older adults' health care needs and develop management plans that improve their well-being. This assessment involves evaluating functional status, screening for geriatric syndromes (e.g., frailty, cognitive impairment, and malnutrition), providing appropriate preventive care, assessing medications, and establishing treatment goals and advance directives. Polypharmacy is common in older adults, and evaluating its effects becomes more important as they age. Conservative prescribing practices (assessing appropriateness before starting new medications, performing regular medication reviews, and stopping medications that are no longer indicated) can help reduce pill burden and consequences of polypharmacy (e.g., adverse events due to drug interactions). Older adults with significant impairment or complex care needs may require referral to a geriatrician. Depending on their current functional status and care needs, the appropriate care setting for an older adult may be a private home, a short-term post-acute care facility (an acute inpatient rehabilitation facility or a skilled nursing facility), or a long-term care facility (an assisted living facility, nursing home, or long-term acute care hospital).

General principles ^[2]

• Usually a multidisciplinary assessment led by a primary care physician or geriatrician
• Includes typical elements of a clinical examination with additional emphasis on assessing functional and cognitive abilities
• Explores social and environmental factors impacting a patient's functional status

The geriatric assessment can be performed over multiple scheduled visits as necessary. ^[2]

Indications

• At the start of any hospital admission for older adults ^[3]
• Consider outpatient geriatric assessment if patients present with any of the following: ^[2]
  • Multimorbidity
  • Functional impairment
  • Geriatric syndromes
  • Polypharmacy
  • Transitions in care settings (e.g., entering a nursing home)
  • Concerns about social support and/or safety

Geriatric assessments allow for the early identification and management of conditions that can impact functional status and quality of life. Therefore, they are usually inappropriate for patients with end-stage disease (e.g., advanced dementia, terminal cancer) or complete functional dependence. ^[2]

Components

• Perform a functional status assessment.
• Screen for geriatric syndromes.
• Assess social factors.
• Provide appropriate preventive care.
• Establish a care plan according to the patient's needs and preferences.
• Discuss the importance of establishing timely advance directives regarding:
  • Preferences for future medical care and interventions
  • A surrogate decision-maker

Referrals

• Multiple referrals, e.g., to a nutritionist, physical therapist, and social worker, are often required.
• Consider referral to a geriatrician if the patient is: ^[4][5]
  • Aged ≥ 85 years
  • Aged < 85 years but has:
    • Significant functional impairment
    • A geriatric syndrome
    • Particularly complex medical needs (e.g., involving multiple specialists, polypharmacy)

Functional status assessment ^[6]

Functional status assessments are used to evaluate an individual's ability to perform tasks of daily living in order to determine their care needs.

Over 50% of adults require help with activities of daily living by the age of 90 years. ^[7]

Basic activities of daily living (ADLs)

• Definition: six basic self-care tasks performed daily ^[8]
  • Bathing
  • Dressing
  • Toileting
  • Transferring (getting in or out of bed or standing up from a chair)
  • Continence
  • Eating
• Example screening tools
  • Katz index of independence in activities of daily living
  • Barthel index ^[9]
• Standard physical examination: Look for features suggesting difficulties with ADLs.
  • Grooming and hygiene ^[10]
  • Signs of injuries suggestive of unsteadiness/falls
  • Ability to dress/undress (e.g., button shirt, take off shoes)
  • Ability to move from a chair to the examination table

Always look at the feet! Uncut toenails may provide the first clue to impaired functional status in older adults. ^[10]

Instrumental activities of daily living (IADLs)

• Definition: eight standard activities required to live independently
  • Grocery shopping
  • Doing laundry
  • Using the telephone
  • Preparing meals
  • Housekeeping
  • Managing:
    • Finances
    • Transportation
    • Medications
• Example screening tool: Lawton IADL scale

Advanced activities of daily living (a-ADLs)^[11]

A decline in a-ADLs may indicate early cognitive impairment.

• Definition: nonessential activities that require a high level of cognitive functioning, e.g. : ^[11]
  • Working
  • Hobbies
  • Travel
  • Volunteering
  • Use of electronic devices (e.g., cell phone, computer)
• Example screening tool: Late-life function and disability instrument (LLFDI) ^[12][13]

Confirm that a change in a-ADLs is not due to physical or other limitations (e.g., limited mobility, lack of opportunity) before attributing it to possible cognitive impairment. ^[11]

Overview ^[2][14][15]

• Geriatric syndromes
  • A group of complex health conditions that may result from multiple risk factors and organ system impairments
  • Makes individuals vulnerable to additional physical stressors or insults
  • Risk factors increase with age and may include:
    • Functional impairment (i.e., in ADLs and/or IADLs)
    • Impaired mobility
    • Cognitive impairment

Up to 80% of cognitive impairment diagnoses are missed by primary care physicians. ^[2]

Urinary incontinence in older adults is associated with an increased risk of decubitus ulcers, sepsis, renal failure, UTIs, and death. ^[6]

Frailty assessment ^[16]

Frailty is a geriatric syndrome that encompasses variable impairments in multiple domains (e.g., mobility, strength, cognition), increasing the risk of morbidity and mortality. ^[16][17][18]

• Indications
  • Consider for all older adults.
  • Outpatient screening is particularly important for patients at increased risk, e.g.: ^[16]
    • Current or former smokers
    • Individuals negatively impacted by social determinants of health
    • Patients with specific comorbidities
  • Screen older adults on admission to hospital to help establish prognosis and care goals. ^[17]
• Example screening tools
  • CSHA clinical frailty scale ^[17]
  • FRAIL questionnaire ^[15][27]
  • Edmonton frail scale ^[28][29]
• Management of frailty ^[16]
  • Refer for a multicomponent physical activity program that includes resistance and balance training.
  • Address contributors, e.g., polypharmacy, weight loss, fatigue.
  • Consider the need for social support.

Multiple geriatric syndromes → ↑ risk of frailty → ↑ risk of further geriatric syndromes → ↑ risk of disability, institutionalization, and death. ^[14]

Falls in older adults ^[2][19][30]

The following guidance is based on the current CDC STEADI algorithm for falls. ^[19][20][31]

Screening

• Ask all older adults annually: Have you fallen in the past year?
  • If yes: What were the circumstances of the fall(s)?
  • If no, ask:
    • Do you feel unsteady when standing or walking?
    • Are you worried about falling?
• If yes to any question: at risk for falls; perform a fall risk assessment.
• If no to all questions: Recommend general fall prevention strategies (see “Fall prevention in older adults”).

Older adults should be screened for fall risk annually, beginning with the question, “Have you fallen in the past year?” ^[2]

Fall risk assessment

This should be performed for patients who screen positive for fall risk or who present after an acute fall.

• Identify risk factors, including:
  • Underlying medical conditions (e.g., depression, osteoporosis)
  • Medications associated with increased fall risk, e.g., benzodiazepines, antidepressants (see “Beers Criteria”)
  • Environmental hazards at home (e.g., floor surface, inadequate lighting, furniture location)
• Perform a physical examination, including:
  • Postural vital signs (to identify orthostatic hypotension)
  • Musculoskeletal tests to evaluate gait, strength, and balance, e.g.: ^[2]
    • Get up and go test
      • Ask the patient to get up from a straight-backed chair, walk 3 m (10 ft), turn around, walk back, and sit down again.
      • The result is abnormal if patients have qualitative impairments or the test takes > 12 seconds. ^[32]
    • Performance-oriented mobility assessment (Tinetti test) ^[33]
  • Visual acuity testing
  • Feet and footwear assessment ^[20]
• Consider:
  • A cognitive assessment ^[30]
  • Laboratory studies, e.g.:
    • CBC (to rule out anemia)
    • BMP (to rule out electrolyte abnormalities)
    • Serum vitamin B₁₂ level
    • Serum vitamin D level

Fall prevention in older adults ^[31]

The aim of preventive measures is to maximize the patient's independence and safety in line with their values and preferences.

• All patients
  • Provide general education, e.g., on medication interaction risks, appropriate footwear, home hazards.
  • Recommend regular exercise (including aerobic, balance, and strength training). ^[30]
  • Ask about vitamin D intake (from diet, supplements, sunlight) and risk factors for vitamin D deficiency; consider recommending a supplement. ^{[30][31][34][35]}
• As indicated according to risk assessment
  • Optimize the management of comorbidities, including medication adjustments.
  • Minimize the number of medications that may contribute to falls; (see “Beers Criteria” below for details).
  • Refer to occupational therapy for a home hazard assessment and modification.
  • Evidence of poor gait, strength, or balance: Refer for physical therapy.
  • Consult additional specialists as required (e.g., ophthalmologist, podiatrist).
  • For hospitalized patients, consider additional measures. ^[36]

Falls are the leading cause of injury-related death in adults aged ≥ 65 years. ^[37]

Neuropsychological assessment in older adults ^[2]

Cognitive assessment

• Indications
  • Suspected mild cognitive impairment (MCI) or dementia
  • As part of a Medicare Annual Wellness Visit ^[21][38]
• Example screening tests: see also “Cognitive testing.”
  • Patient: Mini-Cog, MoCA, or MMSE ^[15][21][39]
  • Carer: Informant questionnaire on cognitive decline in the elderly ^[40]
• Management considerations: see also “Management of major neurocognitive disorder.”
  • Consider a diagnosis of delirium (instead of or in addition to dementia), especially in patients with acute or fluctuating symptoms.
  • Early diagnosis of MCI is important, as interventions such as aerobic exercise may help prevent progression to dementia (see “Prevention of dementia”). ^[41]
  • For patients who drive and have a diagnosis of MCI or dementia, check state laws to determine if: ^[15]
    • Patients are required to take an annual test to maintain their driver's license.
    • Physicians are mandated to report MCI diagnoses to the Department of Motor Vehicles.

Dementia affects 30% of adults aged > 85 years, but it is not part of the normal aging process (the term “senile dementia” is a misnomer) and always requires management. ^[2][42]

Continuity of care is important for the early detection of signs of cognitive decline. ^[43]

Mood assessment

• Overview
  • Clinically significant depressive symptoms affect 10–15% of older adults. ^[44]
  • Depression can present in atypical ways in older adults (e.g., pseudodementia, apathy, weight loss). ^[2]
  • Ask the patient about sleep quality. ^[45]
• Indication: Screen all patients annually.
• Example screening tests
  • PHQ-2 (followed by PHQ-9 if score is ≥ 3) or PHQ-9
  • GDS-15 ^[46]
• Management considerations: See “Depression in older adults.”

Cognitive impairment, decreased functional status, and suicide are more common in older adults with depression than younger adults with depression. ^[47]

Nutritional assessment in older adults ^[2]

• Indication: Consider screening all older adults annually.
• Methods
  • Screening options
    • Monitor weight and BMI.
    • Ask the patient if they have lost weight in the past six months.
    • Ask the patient or caregiver to complete the MNA.
  • Any of the following are considered a positive screen and should prompt further evaluation:
    • BMI < 23 kg/m²
    • Unintentional loss of ≥ 5% of weight in 6–12 months
    • MNA score ≤ 11

A BMI < 23 kg/m² is associated with increased mortality in older adults. ^[48]

Unintentional weight loss in older adults ^[49][50][51]

• Etiology: no identifiable cause in ∼ 25% of patients. Causes may include:
  • Malignancy or other acute or chronic disease
  • Psychiatric or neurological conditions
  • Oropharyngeal problems
  • Functional disability
  • Social factors
  • Adverse effects of medications
• Diagnostics
  • History and physical examination
  • Laboratory studies
    • CBC, CMP ^[50]
    • ESR, CRP, LDH ^[50]
    • Thyroid function tests
    • Urinalysis
    • Fecal occult blood test
  • Imaging
    • CXR: all patients ^[50]
    • US abdomen: Consider depending on symptoms.
• Management
  • Treat the underlying cause; if the cause is unknown, consider close observation for 3–6 months, then reevaluate. ^[49]
  • Optimize eating. ^[50][51]
    • Refer to a dietitian for counseling.
    • Recommend smaller, more frequent meals and snacks.
    • Ensure foods are appealing, varied, and adapted for any swallowing difficulties.
    • Encourage eating with others. ^[52]
    • Ensure patients with difficulties feeding themselves receive adequate assistance at mealtimes.
    • Refer to nutritional support programs in the community, if available.
  • Avoid appetite stimulants (e.g., megestrol) and oral nutritional supplements in most patients. ^[49][53][54]
  • Consider supplements for patients who are either : ^[51]
    • Unable to increase caloric intake with foods
    • Currently hospitalized or post-discharge
  • For patients with comorbid depression, mirtazapine may be appropriate. ^[49]
  • Encourage regular exercise. ^[50]

Think of the 9 Ds to remember the causes of weight loss in older adults: dementia, depression, disease, disability (functional impairment), diarrhea, drugs, dysphagia, dysgeusia, and dentition. ^[49]

Do not routinely prescribe appetite stimulants or high-calorie supplements to improve appetite or increase weight in older adults. ^[53]

Patients with advanced dementia should be offered oral feeding with careful assistance, not placement of a percutaneous feeding tube. ^[53]

For information on living arrangements, see “Care settings for older adults.”

• Evaluate for:
  • Social support, e.g., by asking about: ^[55]
    • Who the patient lives with
    • The frequency of visits from friends and/or family
    • The number of close friends available for emotional support
    • Availability of help in case of sickness or disability
  • Financial difficulties, e.g., ability to pay for food, medication, and rent
  • Risk factors for older adult abuse, e.g. : ^[56]
    • Isolation and lack of social support
    • Functional impairment
    • Decreased physical health
    • Lower income
    • Living in a shared space with many household members
• If concerns are identified:
  • Refer to social work or contact Social Services.
  • For patients experiencing loneliness or social isolation, consider: ^[57]
    • Addressing existing sensory impairments that might contribute to isolation, e.g., with hearing aids and vision aids
    • Treating underlying depression ^[58]
    • Referral to community support groups or encouraging group activities (e.g., lunch clubs, dance class)

Social isolation, both objective and perceived, increases the risk of mortality in older adults. ^[59]

Contact Adult Protective Services if older adult abuse is suspected.

• Chronic conditions
  • Take into consideration life expectancy and goals of care when forming management plans. ^[60]
  • Ensure patients understand their diagnosis and how to manage their condition (see “Managing chronic conditions”).
• Immunizations: Determine if vaccinations are up-to-date according to the adult immunization schedule, including
  • Tdap vaccination ^[2]
  • Pneumococcal vaccination
  • Herpes zoster vaccination
  • Influenza vaccination
• Lifestyle factors: If remaining life expectancy is ≥ 5 years, ask about these factors regularly and provide necessary counseling. ^[2]
  • Every visit: smoking (see “Screening for tobacco product use”)
  • Annually
    • Sexual function
    • Physical activity
    • Unhealthy alcohol use; consider using a specialized screening tool, e.g., Short Michigan alcoholism screening test-geriatric version.
• Driving assessment: Assess older adults with risk factors, e.g. : ^[61]
  • Conditions, medications, or symptoms that could impact driving
  • New functional impairment
  • Concerns from caregiver(s)

• The impact of aging on pharmacokinetics increases the likelihood of adverse drug effects and drug interactions in older adults (see “Fundamentals of pharmacology”). ^[62]
• Polypharmacy in older adults is common (especially in those living in long-term care facilities) because of multiple comorbidities. ^[63]
• Older age, polypharmacy, and limited health literacy all contribute to an increased risk of medication errors. ^[64]
• Follow principles of prescribing for older adults.
  • Consider whether new medications are appropriate (see “Initiation of new medications”).
  • Use low starting doses and titrate slowly while assessing for adverse effects. ^[65]
  • Perform regular medication reviews to determine if any need to be adjusted or stopped.
• See also “Prevention of medication errors.”

Overview ^[66]

• The AGS Beers Criteria are recommendations for pharmacological care in older adults to:
  • Improve medication selection
  • Reduce adverse events
• Beers Criteria apply to older adults in all care settings except at the end of life (e.g., hospice).
• Recommendations are divided into the following categories:
  • Medications to avoid in most older adults
  • Medications to avoid in older adults with specific conditions (e.g., heart failure, history of falls)
  • Medications to avoid in older adults with impaired kidney function
  • Medications to be used with caution in older adults
  • Drug interactions

Many commonly prescribed drugs (e.g., NSAIDs, proton pump inhibitors) may be harmful in older adults.

Selected medication recommendations ^[66]

Avoid use of ≥ 2 anticholinergic drugs in combination in most older adults, and avoid any anticholinergic drugs in older adults with delirium, dementia, cognitive impairment, or a history of falls or fractures. ^[66]

Avoid use of benzodiazepines and nonbenzodiazepine hypnotics in most older adults, including those with delirium, dementia, cognitive impairment, or a history of falls or fractures. ^[66]

Approach ^[65][67]

• Determine necessity.
  • Consider if nonpharmacological alternatives, e.g., diet or exercise, are more appropriate. ^[65][67]
  • Check if existing medications may be causing the current symptoms (i.e., avoid the prescribing cascade).
• Determine appropriateness.
  • Consult the Beers Criteria to determine if the medication is suitable in older adults.
  • Review existing medications for potential interactions (see “Polypharmacy”).
  • Use shared decision-making with the patient and/or their carer, considering the following patient factors:
    • Life expectancy ^[67]
    • Goals of care ^[67]
    • Severity of disease symptoms and impact on the patient's life
    • Burden of treatment (e.g., adverse effects, intensity of treatment regimen)
• Select the correct dosage. ^[62][65]
  • Check renal and liver function; adjusted doses or different medications may be necessary.
  • Start at a low dose; follow recommended starting doses for older adults when available.
  • Titrate medications up slowly; before increasing the dosage, assess for risk factors affecting adherence. ^[68]
• Select the correct formulation: Consider difficulties with swallowing. ^[69][70]
• Provide clear instructions. ^[62]
  • Explain what the medication is for and how it works.
  • Support dosage information with written instructions.
  • Advise patients on common adverse effects and what to do if they occur.

Before prescribing a new medication, consult the Beers Criteria (to assess its appropriateness), perform a medication review (to identify potential drug interactions), and discontinue any unnecessary medications. ^[53][63]

For patients requiring multiple medications, consider strategies to help patients take them correctly (e.g., use of pillboxes, written instructions).

Approach ^[65][67]

• Ensure patients receive recommended monitoring. ^[67]
• Perform regular medication reviews.
• Be aware of the risks of polypharmacy, and consider deprescribing when possible.

Medication reviews

• Ask the patient to bring in all the medications they take, including over-the-counter, complementary, and alternative medications (a brown bag medication review).
• Review the indications for each prescribed medication, and ensure proper documentation.
• Determine if all medications are still being taken and, if so, at what dosage.
• Assess if prescribed medications:
  • Are still appropriate for the patient's:
    • Age (e.g., using the Beers Criteria).
    • Condition ^[67]
  • Require dosage adjustments (e.g., renal dosing)
  • Could cause or are causing drug interactions
  • Have benefits that outweigh the potential harms of continued use
  • Could be replaced with a more affordable formulation

A comprehensive medication review should be conducted at each health maintenance visit and considered for each patient visit. ^[63]

Polypharmacy

• Polypharmacy is the routine and concurrent use of multiple medications (usually defined as ≥ 5 medications). ^[63][71]
• Polypharmacy is associated with increased health care spending and poor patient outcomes including: ^[63]
  • Falls, frailty, disability, and death
  • Adverse drug events (e.g., due to drug interactions or medication errors)
  • Drug-induced cognitive impairment causing toxic encephalopathy
  • Taking medications incorrectly (e.g., missing doses, taking additional doses)

Factors that contribute to polypharmacy

• Patient factors ^[63]
  • Age > 62 years
  • Cognitive impairment, mental health conditions, or developmental disability
  • Complex care needs
  • No primary care physician
  • Living in a long-term care facility
• Systemic factors ^[63]
  • Substandard medical documentation and/or transition of care
  • Use of automatic medication refills
  • Prioritization of quality metrics that are condition-specific

Polypharmacy in older adults is associated with an increased risk of adverse drug events, delirium, falls, and cognitive and functional decline. ^[53]

How to safely deprescribe ^[63][72]

Deprescribing is the process of systematically identifying and discontinuing inappropriate medications (e.g., those no longer needed or with unfavorable risk-benefit profiles).

Identification and mitigation of barriers to deprescribing ^[72][73]

• Ask specialists and colleagues why medications were started and whether they can be safely stopped.
• Set aside adequate time, e.g., a separate appointment, for deprescribing.
• Use shared decision-making to determine a patient's goals for continuing medications, e.g.: ^[63]
  • Primary prevention or secondary prevention
  • Slowing disease progression
  • Preventing rapid decline
  • Symptom management
• Ensure patients understand the benefits of deprescribing and address concerns, e.g.:
  • Belief that a particular medication is necessary
  • Concern that stopping a medication could precipitate withdrawal or worsen symptoms
  • Worry that changes to their medication regimen may be difficult to understand or remember

Multiple systemic factors also affect deprescribing, such as the absence of alternative medications in formularies, lack of financial incentives and resources, and limited clinician knowledge about the process and benefits of deprescribing. ^[72][73]

Implementing a deprescription plan ^[63][72]

• There is currently no standardized evidence-based approach to deprescribing; consider the following: ^[63][72]
  • If feasible, discontinue medications (one at a time) that have an unfavorable risk-benefit ratio.
  • Discontinue medications that are least likely to have withdrawal reactions or rebound effects.
  • Slowly taper any medications that can cause disease rebound or withdrawal. ^[63]
• Monitor patients closely (in person or remotely). ^[63]
• If medications cannot be discontinued, consider:
  • Tapering to the lowest effective dose
  • Switching to a safer alternative medication ^[74]

Stop one medication at a time to evaluate and document any unforeseen and/or negative consequences. ^[63]

General principles ^[6]

• There are three basic types of care settings for older adults:
  • Community-based care
  • Short-term post-acute care facilities
  • Long-term care facilities
• When deciding on an appropriate care setting, consider:
  • The patient's functional status assessment
  • Social factors (see “Assessment of social situation”)
  • The needs and preferences of the patient, family, and/or caregiver
• Use the change in care plan as an opportunity to discuss advance care planning. ^[7]
• Periodically reassess the need for relocation to another care setting.

In the US, the Eldercare Locator Hotline (1-800-677-1116) and website (https://eldercare.acl.gov) can be used to find appropriate services.

Community-based care

• Consider the need for a home hazard assessment and modification; for patients with significant physical impairments: ^[75]
  • Renovation work, e.g., adding a bathroom on the first floor, may be necessary.
  • A move to preadapted or more suitable housing (e.g., a single-storey house) may allow independent living for longer.
• Ensure that the individual is able contact emergency services if required.
• Evaluate the need for additional services, such as:
  • A part-time or full-time caregiver (e.g., a home health aide) depending on the individual's functional status
  • Therapy services (e.g., physical therapy, occupational therapy) provided at home or at an outpatient facility
  • Referral to community services, e.g.: ^[15]
    • Adult day centers (may provide a nursing home level of care)
    • Senior centers (for activities and social interaction)
    • Fall prevention programs

Talk separately to the primary caregiver to assess for and prevent caregiver burnout. Informal caregiving (i.e., volunteering to take care of a friend or family member) can impact mental and physical health. ^[76]

Short-term post-acute care facilities ^[7][77][78]

These facilities provide specific services for all adults on a short-term basis following discharge from the hospital.

• Acute inpatient rehabilitation facility
  • Provides multidisciplinary intensive rehabilitation therapies and nursing services
  • To qualify for Medicare reimbursement, patients must both: ^[78][79]
    • Require multiple forms of therapy, at least one of which must be physical or occupational
    • Be able to participate in therapy for 3 hours per day for 5 days per week
• Skilled nursing facility (SNF)
  • Usually a designated unit located within a nursing home ^[77]
  • To qualify for Medicare reimbursement, patients must both:
    • Have been hospitalized for ≥ 3 days in the past 30 days
    • Require either a skilled nursing service or subacute rehabilitation ^[7]

Long-term care facilities ^[7][77]

Residential long-term care is often required if an older adult requires ongoing assistance.

• Assisted living facility
  • Provides personal care services and some health-related care with 24-hour supervision
  • Residents have fewer assistance requirements than nursing home residents. ^[77]
  • A physician is not routinely present.
• Nursing home
  • Typically provides two levels of long-term care:
    • Skilled nursing care ^[77]
    • Custodial (nonmedical) care ^[80]
  • A physician is available 24 hours a day. ^[7]
• Long-term acute care hospital (LTACH) ^[81]
  • Provides care for patients with complex medical needs (e.g., ventilator-dependent), typically following a critical illness
  • Stays are prolonged (≥ 25 days).

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