POPULATION HEALTH MANAGEMENT

Volume 13, Number 4, 2010

ª Mary Ann Liebert, Inc.
DOI: 10.1089/pop.2009.0058

Acute Care for the Elderly: A Literature Review

Nasiya N. Ahmed, M.D. and Shannon E. Pearce, G.N.P.

Abstract

Traditionally, acute medical care has been insufficient to meet the complex care needs of frail older adults.
The purpose of this study was to evaluate the effectiveness of Acute Care for the Elderly (ACE) units at
improving hospitalization outcomes for adults older than 65 years of age. A review of the literature was
performed, focusing on randomized controlled trials, clinical trials, reviews, and meta-analyses from 1990 to
2008. This review revealed ACE to be associated with positive global outcomes (eg, cost, length of stay,
readmission rates, utilization, rehabilitation, cognition, function, patient/staff satisfaction). Furthermore, some
studies may point to a decreased incidence of delirium and polypharmacy. Though larger studies with
consistent operational defi- nitions and replicative studies are needed, the literature presents compelling
evidence that warrants further investigation of ACE as a valuable alternative paradigm of acute geriatric care.
(Population Health Management 2010;13:219–225)

Introduction Hartford Foundation in 1990.2–8 This original intervention

included the following 4 components: a specialized envi-

O LDER ADULTS AGED ≤65 YEARS, account for 48% of

in- patient hospitalization days. Among the cohort
aged
≤65 years, those older than 85 years of age are 2 times
more likely to require hospitalization. 1 As those older than
age 85 remain the fastest growing population, projected to
comprise 25% of the US population by the year 2050,
traditional acute care practices will have to evolve to fit the
unique needs of the frail elderly in the years to come. Older
adults are highly susceptible to the hazards of acute
hospitalization, as imposed bed rest, urinary catheter
utilization, excessive environmental stimulation, and other
characteristics of inpatient care often deplete frail elders of
already limited physiologic reserves. Though patients may
recover from the illnesses that precipi- tate hospitalization,
they are often less functionally indepen- dent and require
higher levels of care or nursing home placement after
discharge.
The Acute Care for the Elderly (ACE) was developed to
disrupt the trajectory of functional decline often
experienced by geriatric patients who are admitted to acute
hospital wards. The ACE model was initiated to challenge
the pre- conceived notion that elder patients would require
posthos- pital rehabilitation to overcome deconditioning
associated with acute hospitalization. Prevention of
functional decline, ‘‘prehab,’’ was the focus of the
interdisciplinary approach of care for older patients. The
first ACE, developed at Uni- versity Hospitals of
Cleveland, was funded by the John A.
ronment, patient-centered care, medical review, and inter-
disciplinary team plans of care. 5 This unit was developed to
disrupt the presumably unavoidable trajectory of functional
decline of geriatric patients who are admitted to acute hos-
pital wards.
Studies of the early ACE units demonstrated improved
functional outcomes and decreased placement in long-term
care. Since this time, additional studies of ACE have dem-
onstrated similarly favorable results regarding the
following: costs of care, lengths of stay (LOS),
patient/provider satis- faction, maintenance of functional
status, and favorable dis- charge disposition. Significant
reductions in delirium, polypharmacy, and readmissions to
the hospital have also been reported as demonstrable
benefits of ACE for hospi- talized patients admitted from
the community. The purpose of the current review is to
determine whether this model contributes to positive patient
care outcomes (ie, rehabilita- tive, cognitive, utilization,
functional, pharmacological, and patient/staff satisfaction)
for acutely hospitalized older adults compared to traditional
medical care.
Characteristics of ACE
The concept of specialized geriatric care for acutely ill
older adults is not new, and was attempted for years prior
to the initiation of the ACE model.5 Results were mixed,

Department of Internal Medicine, Division of Geriatric and Palliative Medicine, University of Texas, and Memorial Hermann—Texas
Medical Center, Houston, Texas.
219
220
probably because of the heterogeneity of study interventions
and measured outcomes. Geriatric Evaluation and Manage-
ment (GEM) units are geared for carefully targeted patients
who are selected to transfer from acute care units to receive
prolonged care to improve their functional status. The GEM
model of care has been well associated with improved hos-
pitalization outcomes, but extensive expenditures that relate
to prolonged hospitalization stays are thought to make this
model cost prohibitive for nonfederal hospitals. 7 Interven-
tions to support elder care were historically directed to
Geriatric Assessment Units (GAUs) for post-acute care pa-
tients, or to geriatric consultation services for acute geriatric
syndromes.5 GAUs differ from GEMs in that they are more
similar to the ACE paradigm of care. 7 They are units that
utilize a multidisciplinary approach through consultation
with a geriatrician lead team to provide specialized, com-
prehensive geriatric care. 5 In contrast to ACE, however,
GAUs lack the environmental modifications, nurse lead
care, and formal, daily interdisciplinary team meetings that
are considered the cornerstone of the ACE paradigm.7
Interdisciplinary teams usually consist of a combination
of geriatricians, nurse case managers, nurses, a nutritionist,
social workers, physical therapists, an occupational
therapist, a pharmacist, and, of course, the patient and his or
her family. Teams can vary according to patient needs and
often may include other disciplines as well, such as
pastors and psychiatrists. The purpose of an
interdisciplinary team is to work collaboratively and in an
integrated manner toward the goals that were agreed upon
for the patient. The team members meet on a regular basis
(often daily in an ACE unit) to assess the patient’s health
status, discuss individual team members’ concerns, and
develop a plan of care for the re- mainder of the hospital
stay as well as discharge. Most teams undergo some formal
training and team-building exercises to learn how to
function and communicate effectively. The leader of the
team varies depending on the patient’s needs. Over the
years, modifications have been implemented by various
institutions to facilitate the implementation of ACE in
additional hospital settings. In 2003, Jayadevappa et al
surveyed 16 ACE units and utilized a stepwise regression
method to determine the basic characteristics of ACE units
throughout the country.9 Most ACE units comprised 10–20
beds and had interdisciplinary teams. 9 No mention was
made of advanced practice nurses in this survey study, but
the original model heavily emphasized the role of advanced
practice nursing in the successful implementation of ACE
interventions.5,8,10
Methods
A comprehensive review of the literature was performed
utilizing PubMed, Ovid, and Scopus databases. Search
terms included the following keywords: ‘‘ACE units,’’
‘‘ACE models,’’ and ‘‘acute care for the elderly.’’ Search
limitations included randomized controlled trials (RCTs),
clinical trials, reviews, and meta-analyses between the years
of 1990–2008. Selected articles were from English language
publications and were limited to the adult population ≤65
years of age who received acute hospital care on ACE units
or ACE and general medicine wards.
The search yielded 462 findings, which included 421 ir-
relevant articles that did not mention the ACE model of care
AHMED AND PEARCE
in the studies. Twenty-one of the remaining articles were
excluded for the following reasons: 2 were not English lan-
guage, 3 were not retrievable, and 16 were duplicate
studies. Consequently, 20 studies were deemed to be the
most rele- vant for the purposes of this review, but it is
important to note the lack of heterogeneity in outcome
variables and operational definitions within these studies.
This review comprised the following: 5 RCTs; 3 literature
reviews; 5 descriptive studies; 1 nonrandomized,
retrospective, case- control design; 1 non-concurrent cohort
study; 2 interven- tional studies; 2 survey studies; and 1
case study.
Data extraction and synthesis
Because ACE is still at a very early stage of development
in the literature, the homogeneity of applicability of RCTs
and clinical trials is limited. Studies were interestingly di-
verse in design and outcome variables of interest; however,
a lack of replication of existing RCTs hindered attempts to
confirm or dispute previous findings. Consequently, all
studies that contributed to the measure of ACE for acutely
hospitalized elders were utilized (Table 1).
Results
Lengths of stay/hospital costs
The ACE model was reported to reduce hospital acute
care days.2,3,11–13 The average reduction for inpatient LOS
was typically 1 day compared to similar cohorts treated on
general medicine wards. Only 1 study demonstrated neutral
results in the determination of comparative LOS for ACE
unit and general medicine unit patients and none showed
increased LOS.12 Factors that contributed favorably to re-
source utilization also included increased discharges to
home versus long-term care, decreased acute care stays, and
re- duced hospital readmissions. Subsequently, despite
higher initial costs, 2,13,14 the total cost of care for patients on
ACE units was statistically significant and demonstrably
less when compared to usual care.3,12
Hospital readmission
Hospital readmission data yielded statistically significant,
positive outcomes for ACE units. The ACE model is well
reported in the literature to reduce overall costs and LOS;
trends toward reduced acute hospital readmissions are also
reported.2,12,13,15,16 Only 2 studies reported neutral findings
regarding readmissions for the intervention group. 3,14 De-
creased readmission rates combined with a decreased length
of stay contribute to reduced overall health care costs. As a
result, patients do not require more frequent acute care ad-
missions.12 Data from these studies suggest that patients
discharged from ACE were presumably more physically,
functionally, and socially prepared to leave the hospital than
patients who were treated on general medical units.
Nursing home placement
Nursing home placement is more often associated with
caregiver burnout than patient disposition.10 The ACE
model likely decreases caregiver burden by maintaining
function and has been associated with decreased
institutionalization com- pared to usual care on general
medicine wards.2,3,11,14,15,17
 TABLE 1. EVIDENCE TABLE for ACUTE CARE for the ELDERLY (ACE) UNIT VERSUS USUAL CARE

Source Study Type Target Population Study Goals ACE Study End Points

Cost
Covinsky RCT (Cleveland, OH) Acutely hospitalized medical patients To compare the cost of acute medical care Higher initial cost of care
et al14 1997 with a mean age of 80 years between ACE and usual care Decreased total cost of care
Decreased LOS
Decreased hospital
readmission
Increased caregiver
satisfaction
Covinsky RCT (Cleveland, OH) Hospitalized older adults To determine if ACE contributed to Decreased LOS
et al2 1998 aged ≤70 years decreased hospitalization costs Increased initial cost
and improved functional Decreased total costs
outcomes versus usual care Decreased functional
decline
Counsell RCT (Cleveland, OH) Hospitalized, community-dwelling To determine if ACE would improve Neutral impact on cost
et al15 2000 adults aged ≤70 years functional outcomes without of care
increasing costs Neutral impact on LOS
Decreased NH placement
Decreased functional
decline
Increased patient/provider
2 satisfaction
2 Asplund RCT (Umea, Sweden) Hospitalized older adults aged 70
≤ To determine if a specialized, Decreased LOS
et al11 2000 years assigned to acute geriatrics-based geriatric approach shortened Decreased NH placement.
ward vs. general medical wards the length of stay and decreased Neutral impact on cost
discharges to nursing home facilities Neutral impact on
functional status
Neutral impact on
readmissions
Neutral impact on
polypharmacy
Jayadevappa Retrospective case-control Hospitalized older adults To determine if ACE decreased cost Decreased hospital costs
et al12 2006 design with a mean age of 79.6 of care and improved hospital outcomes Decreased LOS
(Philadelphia, PA) with an admitting diagnosis when compared to usual care Decreased acute care
of UTI or CHF readmissions
Decreased NH placement
Interdisciplinary Teams
Kresevic Descriptive Study Hospitalized older To define and describe an IDT approach IDT approach/model
et al8 1998 (Akron, OH) adults aged ≤65 years to caring for hospitalized older adults on ACE defined
Krevesic Descriptive Study Hospitalized older To describe a patient-centered approach Patient-centered
et al10 1998 (Cleveland, OH) adults aged ≤65 years to acute geriatric care model described
Palmer6 1995 Descriptive Study Hospitalized older To describe a model of care (ACE) that IDT model defined
(Cleveland, OH) adults aged ≤65 years utilized an IDT approach
to promote functional status
(continued)
 TABLE 1. (CONTINUED)
Source Study Type Target Population Study Goals ACE Study End Points

Benedict Descriptive Study Hospitalized To describe ACE as a model for multidisciplinary Increased decision making
et al16 2006 (Akron, OH) older adults aged ≤65 years management of older adults and the role at point of care
of clinical nurse specialists (CNS) within More interventions
this context to meet patient needs
Increased use of EBM
practices
Increased IDT
collaboration
Increased provider
satisfaction
Decreased hospital
readmissions
Functional Outcomes
Palmer Literature Review Hospitalized older adults To determine which characteristics contributed Description of ACE
et al5 1994 (Cleveland, OH) aged ≤65 years to improvement of functional decline characteristics
for hospitalized older adults on ACE Description
of ACE model
Landefeld RCT (Cleveland, OH) Hospitalized older adults To determine whether ACE contributed Decreased cost of care
2 et al3 1995 ≤ years
aged 70 to improvement of functional mobility Decreased LOS
2 and at teaching hospital; and performance of activities of daily Decreased NH placement
randomized to living when compared to usual care at discharge
a specialized geriatric unit Decreased functional
versus usual care decline
Palmer Literature Review Hospitalized older adults To determine which standards of care Description of ACE
et al4 1998 (Cleveland, OH) aged 65 plus years. and nurse initiated strategies contribute model of care
to prevention and potential restoration
of functional decline for hospitalized older
adults and develop a model of care
Kresevic Literature Review Hospitalized older adults To determine which standards of care Description of ACE
et al8 1998 (Cleveland, OH) aged ≤65 years and nurse initiated strategies contribute model of care
to prevention and potential restoration
of functional decline for hospitalized older
adults and develop a model of care
Miller17 2002 Case Study ≤ years
Older adults aged 65 To describe an experience of 1 elderly patient Case Study revealed:
(Newark, with multiple hospitalized for pneumonia and transferred Reduced delirium
NJ) comorbid conditions for care to an ACE unit Decreased functional
and acute hospitalization decline
Decreased polypharmacy
Reversed unnecessary NH
placement
Palmer Flaherty Descriptive Study (Cleveland, OH) (Winston-Salem, NC)
et al7 2003 et al19 2003 Interventional Study (Akron, OH)
Allen Edwards
et al13 2003 et al20 2003 Delirium
Observational/
Interventional Study (St.
Pharmacological Outcomes Louis, Missouri)
Non-concurrent cohort study
 Hospitalized older free unit To define and describe an IDT approach to IDT model described
Staffing/Char adults aged 65 years ≤ caring for patients on ACE
acteristics Hospitalized older To determine if the intervention of the SU model described
adults aged 65 years ≤ ACE Stroke Unit (ACE SU) Decreased LOS
and admitted contributed to decreased LOS/mortality, Increased provider
to a stroke and increased functional satisfaction
unit status of acute stroke patients Decreased hospital
versus usual care readmissions

To determine if potentially Decreased use of PIMs

Hospitalized older inappropriate medications Increased incidence
adults aged 65 years ≤ (PIMs) were more or less likely of discontinued PIMs
and admitted to ACE to be prescribed or discontinued
on ACE units

To determine whether the ACE model Description of ACE model

Patients on ACE unit for delirium would promote care of delirium
with mean age of and decrease incidence of delirium Decreased prevalence/
82.6 years admitted for hospitalized older adults at risk duration of delirium
to a 4-bed, restraint- Decreased LOS
Siegler Survey Study (New York) ACE units throughout To determine what staffing Staffing description
et al18 2002 the country and continuous quality on existing ACE units
that care improvement data were
2 for hospitalized, older adults utilized at ACE sites
2 aged ≤65 years
Jayadevappa Survey Study Operational ACE Units (16) To determine both the prevalence Characteristics
et al9 2003 (Philadelphia, PA) since the 1990s and characteristics of ACE units, of existing ACE units
as well as the characteristics
of hospitals that were associated
with these units

CHF, congestive heart failure; EBM, evidence-based medicine; IDT, interdisciplinary teams; LOS, length of stay; NH, nursing home; RCT, randomized controlled trial; UTI, urinary tract infection.
224
Most RCTs included in this review (3 of 5) evaluated the
prevalence of discharges to nursing homes and reported sta-
tistically significant reductions in long-term care placement
among the ACE Unit intervention group. 3,11,15 Landefeld et al
reported a significant reduction in discharges to long-term care
among patients who received ACE Unit intervention versus
usual care (14% versus 22%, respectively). 3
Functional decline
Prevention of functional decline is one of the major
thrusts of ACE units. The majority of studies cited the
intervention group to have significantly less functional
decline in activi- ties of daily living. 2,3,15,17 Landefeld et al
reported statisti- cally significant findings of overall health
status at discharge for patients assigned to the ACE
intervention (P < 0.001), which most notably included
improvement in the ability to perform instrumental
activities of daily living (P ¼ 0.06) and improved
ambulation (P ¼ 0.04).3 Asplund et al determined the ACE
intervention group to have similar or neutral results
compared to general medical care.11
Delirium
The ACE model of care was designed to reduce the risk
of functional decline, delirium, and iatrogenic illness5,6,8–13,16–
18
;
3 studies (ie, 1 RCT, 1 intervention study, 1 case study)
evaluated the effect of ACE on acutely hospitalized older
adults at risk for or diagnosed with delirium. 3,4,13 Asplund et
al reported mixed results of the prevalence of delirium for
patients admitted to acute geriatric wards versus medical
wards. Initially, the prevalence was less in the intervention
group (4.3% versus 5.0%), but later development of
delirium was more prevalent in this group (3.3% versus
1.9%).11 Flaherty et al performed an intervention study to
decrease the prevalence and duration of delirium. Specific
modifica- tions for this intervention included the following:
environ- mental modifications, interdisciplinary team
meetings, focused geriatric principles of care, avoidance of
physical and chemical restraints, and utilization of sitters. 19
This study yielded statistically robust reductions of delirium
prevalence and duration for older adults cared for on ACE
units versus general medicine wards. 19 Miller reported a
positive outcomes case study that demonstrated reversibility
of functional decline, delirium, and a potentially inappro-
priate discharge to long-term care.17
Polypharmacy
Polypharmacy is a well-known contributor to acute hos-
pitalization, functional impairment, and cognitive decline,
but few studies have evaluated the effects of ACE interven-
tion on inpatient pharmacologic practices (eg, prevalence of
potentially inappropriate medications for elders [PIMs],
polypharmacy, prevalence of unnecessary medications). Re-
sults yielded 2 positive outcome studies 17,20 and 2 neutral
studies11,12 that examined the effect of ACE versus usual
care on medicine wards regarding polypharmacy. A
noncohort, retrospective, non-RCT hypothesized that the
ACE model would be less associated with polypharmacy
and more as- sociated with medication reduction and
avoidance of PIMs when compared with usual care;
however, these results were not statistically significant.20
Another study, an RCT, deter-
AHMED AND PEARCE
mined that patients in the intervention group had a lower
mean number of drugs when compared to patients on
medical wards (4.8 versus 5.2 with a 95% CI).19 Though
this was quantitatively a marginal reduction in the number
of prescriptions between groups, this trend persisted up to 3
months post hospital discharge for the intervention group.
Patient/provider satisfaction
Four of the 18 studies included in this review evaluated
patient and provider satisfaction with ACE intervention in-
patient care. Two of 5 RCTs reviewed compared ACE units
to general medical wards and specifically measured patient,
provider, or caregiver satisfaction between groups. 2,12 One
study with strong methodology, by Counsell et al, surveyed
1531 patients who were divided into 2 groups: an interven-
tion group (n ¼ 767) and a usual care group (n ¼ 764).12
The patients who received care on ACE units, as opposed to
general medical units, and participated in surveys 1 month
post hospital discharge reported superior overall satisfaction
with care compared to prior hospitalization experiences
(40% versus 26%, P < 0.001).
Provider surveys also yielded favorable satisfaction
scores for the ACE intervention group versus usual
care.13,15,16 For example, nurses reported being very satisfied
that geriatric patients were receiving needed care (64%
versus 27%).15 Of the 2 descriptive studies, surveys
demonstrated improved provider satisfaction rates for
nurses and physicians in the intervention group versus usual
care.13,16 Surprisingly, 70% of physicians surveyed rated
geriatric care on an ACE Unit to be 4.6 on a Likert scale
(with 5 being ‘‘high satisfaction’’ and 1 being ‘‘low
satisfaction’’).16 Additionally, all included studies that
specified satisfaction scores for patients, caregivers, and
families identified ACE as superior compared to usual
care.4,13,15,17
Discussion
In this review of the literature, we attempted to ascertain
an estimate of the prospective value of expansion and
further implementation of the ACE paradigm of care. The
results of studies of the ACE model have been primarily
positive, with a few neutral global outcomes (Table 2). All
studies reported reduced total costs of care for patients who
received inter- ventional care.2,3,11,14,15 Lengths of stay were
not reported to increase 14,15,19 and were more often reduced
for hospitalized older adults compared to general medical
care.2,3,11–13 Despite decreased costs of care and LOS,
readmissions to acute care hospitals did not increase;
readmissions were
TABLE 2. OVERALL SUMMARY of STUDIES: ACUTE CARE
for the ELDERLY (ACE) VERSUS USUAL-CARE
Outcome Variables Increased Decreased Neutral
Cost* 2,14 11,15 11,15
Length of stay 2,3,11–13 12
Hospital readmission 12,13 3,11
Nursing home placement 2,3,11,14,15,17
Functional decline 2–4,15,17 11
Delirium 13,19 3
*Increased initial costs were offset by decreased LOS, resulting in
decreased total cost of care
ACE UNITS
predominantly lower for patients discharged from ACE
units.3,11–14
Most studies report reduced functional decline for acutely
ill patients discharged from the intervention group, and this
is increasingly important in the wake of the new methodol-
ogy of paying for performance based on quality measures
defined by Medicare. Frail elders cost hospitals more, have
extended LOS, and are more likely to require more frequent
hospital readmissions if their global needs are not addressed
prior to discharge. The traditional approach to acute care is
inadequate to support these needs; although patients may
recover from illnesses that precipitate hospitalization, they
are often less functionally independent and require a higher
level of care upon discharge.
There were mixed results concerning the reduction and
prevalence of delirium: 4,11,19 only 1 study was designed to
specifically address delirium as a primary outcome vari-
able,19 and neither of the 2 remaining studies focused on
delirium as a primary outcome variable of interest. 4,11
Nonetheless, existing evidence suggests that the ACE model
contributes to reductions in polypharmacy. 11,12,17,20 Finally,
satisfaction scores for patients, providers, and caregivers
serve as a reflection of quality care that is potentially unbi-
ased by researcher opinion or statistical analysis. All studies
that reported satisfaction survey results reported superior
evaluations for the ACE intervention group compared to the
usual care group.4,12,16,17
Limitations of this study include the scarcity in
duplicated results and homogeneity in operational
definitions and out- come variables associated with this
relatively new model of care. This underscores the need for
replication in future re- search to confirm or dispel
significant findings. Additionally, publication bias is
another potential weakness of literature reviews, as neutral
results are less likely to be published in journals than
impressive positive or negative outcome stud- ies. More
studies are needed to delineate prescribing practices on
ACE units and to identify how these practices contribute to
the functional prognosis of acutely ill older adults.
Author Disclosure Statement
Dr. Ahmed and Ms. Pearce disclosed no financial
conflicts of interest. Dr. Ahmed’s salary is supported by a
Geriatric Academic Career Award (GACA grant).
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Address correspondence to:
Nasiya N. Ahmed, M.D.
Department of Internal
Medicine
Division of Geriatric and Palliative
Medicine University of Texas Health Science Center
—Houston
6431 Fannin, MSB 5.120
Houston, TX
77030 E-mail:
Nasiya.Ahmed@uth.tmc.edu