The custodial approach to care found in many state hospitals is an added burden for geriatric patients. Their medical and psychiatric problems are complex, and their susceptibility to iatrogenic complications is greater than that of the general patient population. Rather than requiring less treatment, geriatric patients need a more intensive clinical approach. State hospitals often are not prepared to meet these needs because they lack adequate facilities, appropriate programs, or the necessary specialized services. Notwithstanding these barriers, recognition of some common age-related problems and understanding of the elderly's basic clinical needs may lead to an improved level of care in many state hospitals.