Hospital-Initiated Guardianship for Older Adults: A Retrospective Analysis

Guardianship is a legal process by which a court-appointed individual assumes decision-making authority over a person deemed to be incapacitated. Despite granting significant authority over vulnerable individuals, guardianship remains poorly regulated and understudied. Social determinants of health (SDOH) may influence guardianship outcomes, yet data are limited. This study characterizes guardianship petitions filed by a large academic healthcare system and examines the role of SDOH in petition outcomes.

We identified adults aged 60 years or older for whom our healthcare system filed guardianship petitions using publicly available county probate court records from January 2019 through September 2024. Petition outcomes, demographics, and hospitalization data were abstracted from court records and the electronic medical record. Logistic regression models were used to identify demographic factors associated with guardian type (known entity vs. professional) and guardianship scope (full vs. limited).

Among 236 unique individuals, 215 (91.1%) petitions resulted in the appointment of a guardian. Nineteen petitions were not heard by the court for various reasons. Of the remaining 217 petitions heard in court, 215 (99.0%) resulted in guardianship assignment. Medicaid recipients had lower odds of being assigned to a guardian with whom they had a prior, personal relationship (p = 0.04). Lower educational attainment was associated with full guardianship (p = 0.02). More restrictive forms of guardianship were associated with decreased likelihood of being discharged home. There were variations in ethics, palliative care, and psychiatry consults and the relationship of the assigned guardian.

SDOH, including socioeconomic status and educational attainment, correlated with guardianship outcomes. Guardianship type and scope appear to impact care delivery and discharge destination. Policy reform and community-based interventions are needed to protect vulnerable older adults while preserving autonomy.