Introduction: The Shift from Disease to Syndrome
In modern clinical practice, the management of older adults in acute care settings has traditionally focused on the primary reason for admission—the ‘chief complaint’ or the acute physiological derangement. However, as the global population ages, clinicians are increasingly encountering patients whose outcomes are dictated less by their primary diagnosis and more by their underlying physiological reserve and the presence of geriatric syndromes. These syndromes, which include frailty, delirium, and polypharmacy, represent a complex interplay of multiple organ systems and psychosocial factors. Despite their known impact, their cumulative prevalence and independent association with short-term mortality in resource-limited and diverse international settings have remained insufficiently characterized.
The Creating a Hospital Assessment Network in Geriatrics (CHANGE) study addresses this gap, providing a robust analysis of how the ‘syndrome count’ serves as a primary driver of post-hospitalization survival. This research shifts the focus from binary disease states to a holistic, multidomain assessment of vulnerability.
Highlights
- Hospitalized older adults present with a high burden of geriatric syndromes, with a median of five concurrent syndromes per patient.
- Disability and polypharmacy are the most prevalent syndromes, affecting 70.8% and 61.7% of the cohort, respectively.
- There is a clear dose-response relationship between the number of geriatric syndromes and 90-day mortality, ranging from 8.4% for those with 0-2 syndromes to 47.0% for those with 11 or more.
- Each additional geriatric syndrome is associated with a 22% increase in the risk of death within 90 days.
Study Design and Methodology
The CHANGE study was a multicenter, prospective cohort study conducted across 43 hospitals in Brazil, Angola, Chile, Colombia, and Portugal. This international scope is particularly relevant, as it includes data from both middle-income and high-income regions, offering a broader perspective than previous single-center studies in Western Europe or North America.
Patient Population
The study enrolled 2,556 consecutive patients aged 65 years or older who were admitted under geriatric teams between June 2022 and December 2023. To ensure the findings reflected common geriatric practice, patients were enrolled within 48 hours of admission. Notably, patients with terminal illnesses were excluded to avoid confounding the mortality data with expected end-of-life trajectories.
The 14 Geriatric Syndromes
The researchers utilized a standardized Comprehensive Geriatric Assessment (CGA) to capture 14 distinct syndromes: loneliness, dementia, depressive symptoms, sensory impairment (visual or hearing), disability, immobility, incontinence, falls, frailty, malnutrition, pressure ulcers, polypharmacy (five or more medications), potentially inappropriate medications (PIMs), and delirium. The primary exposure of interest was the within-patient count of these syndromes, treated as a cumulative burden score.
Key Findings: The Prevalence of Vulnerability
The results underscore the high complexity of the geriatric inpatient population. The mean age of participants was 79 years, and 56.2% were female. The median number of syndromes was five, indicating that the ‘average’ older adult in these hospitals is managing a significant number of concurrent geriatric challenges.
Prevalence Rates
The most common syndromes identified were:
- Disability: 70.8% (95% CI, 69.1%-72.6%)
- Polypharmacy: 61.7% (95% CI, 59.8%-63.6%)
- Frailty: 58.2% (95% CI, 56.3%-60.1%)
- Sensory Impairment: 54.7% (95% CI, 52.8%-56.7%)
Mortality and the Cumulative Burden
The study found a striking and incremental increase in 90-day all-cause mortality as the number of syndromes increased. The mortality rates were stratified as follows:
- 0 to 2 syndromes: 8.4% mortality
- 3 to 4 syndromes: 12.7% mortality
- 5 to 6 syndromes: 25.4% mortality
- 7 to 8 syndromes: 30.4% mortality
- 9 to 10 syndromes: 39.5% mortality
- 11 or more syndromes: 47.0% mortality
After adjusting for potential confounders, including age, sex, and comorbidities, the researchers found that each additional geriatric syndrome was associated with a hazard ratio (HR) of 1.22 (95% CI, 1.15-1.30) for 90-day mortality. This risk was particularly pronounced in the oldest age groups, suggesting that the cumulative effect of these syndromes becomes more lethal as physiological reserve diminishes.
Expert Commentary and Clinical Implications
The CHANGE study provides compelling evidence that geriatric syndromes are not just ‘complications’ of aging but are central to the prognosis of the hospitalized older adult. The independent association between the syndrome count and mortality suggests that these syndromes represent a more accurate measure of biological age and vulnerability than chronological age or a simple list of chronic diseases.
Integrating CGA into Standard Care
The findings advocate for the integration of multidomain assessments into standard hospital care. Often, clinicians prioritize the management of heart failure or pneumonia while overlooking sensory impairment or loneliness. However, the data show that these ‘soft’ geriatric syndromes are powerful predictors of survival. Addressing polypharmacy, ensuring sensory aids are available, and implementing delirium prevention protocols should be viewed as life-saving interventions, not merely ‘quality of life’ improvements.
Resource Allocation and Triage
From a health policy perspective, the syndrome count could serve as a valuable tool for risk stratification and resource allocation. Identifying patients with high syndrome counts (e.g., 7 or more) early in their admission could trigger intensive geriatric intervention, specialized discharge planning, and closer post-hospitalization follow-up to mitigate the high risk of 90-day mortality.
Limitations and Future Directions
While the study is robust, it is important to note that the participants were admitted under geriatric teams, which may introduce a degree of selection bias compared to patients admitted to general internal medicine or surgical wards. Additionally, while the study establishes a strong association with mortality, further research is needed to determine which specific combinations of syndromes carry the highest risk and whether targeted interventions for specific syndromes (like malnutrition or immobility) can reverse the mortality trend.
Conclusion
The CHANGE study confirms that hospitalized older adults carry a substantial burden of geriatric syndromes, with a median of five per patient. The clear, incremental relationship between the number of syndromes and 90-day mortality emphasizes the need for a paradigm shift in hospital medicine. To improve outcomes for this vulnerable population, acute care must evolve beyond treating isolated diseases to addressing the cumulative phenotypic complexity that defines the geriatric experience.
References
Avelino-Silva TJ, et al. Geriatric Syndromes and Mortality Among Hospitalized Older Adults. JAMA Netw Open. 2026;9(1):e2555740. doi:10.1001/jamanetworkopen.2025.55740.
