HUMAN FACTORS IN GERIATRIC SAFETY (abbreviated version posted to rgpc.ca) Why bad things happen to good (older) people C.Patterson McMaster Fall Symposium 2006

Why bad things happen to good (older) people System factors Factors affecting the individual older person

Adverse Event “An unintended injury or complication which results in disability, death or prolonged hospital stay and is caused by health care management” Wilson R et al Med J Aus 1995;163:458

Adverse events affecting older people Iatrogenic events (complications of investigations; adverse drug events; complications of procedures) Hospitalization (injuries; nosocomial infections) Undertreatment

Why are older people more vulnerable to adverse events? Aging process Presence of chronic diseases Cultural factors More frequent exposures

Aging process Changes in vision, hearing, attention, gait Reduced physiological reserves Changes in pharmacokinetics, pharmacodynamics

Presence of chronic diseases Musculoskeletal disorders Renal impairment Cardiac failure Cognitive impairment/Dementia

Cultural factors “It is just my age…” Beliefs “Whatever you say, doctor…”

More frequent exposures More transitions (hospital admissions & discharges; to & from long term care; on & off home care) Longer hospital lengths of stay More prescribed (and OTC) medications More procedures

Adverse Events in Hospital (Weingart BMJ 2000;320:774; Baker & Norton CMAJ 2004;170:1678) Incidence in hospital % Meta analysis of incidence 6.7% Canadian Adverse Events 7.5% Adverse drug events 50% Operative complications 30% Nosocomial infections 20% Preventable 30-60%

Incidence of Preventable AEs (Thomas & Brennan BMJ 2000;320:741) Event typeIncidence ages Incidence age >65 Diagnostic Operative Procedure * Drug * Fall *

Adverse events after Hospital (Forster A et al CMAJ 2004;170:345) At least one adverse event 23% Adverse drug event 72% Therapeutic errors 16% Nosocomial infections 11% Temporary disability 25%; permanent 3%; death 3% Preventable 12%

Common adverse events in older people Medication adverse events Injuries (falls, thermal) Dehydration Deconditioning Undertreatment Delirium Malnutrition Decubitus ulcers

Medication adverse events More medications (greater opportunity for interactions) Pharmacokinetics (slower excretion of some drugs; slower metabolism) Pharmacodynamics (greater effect of equivalent dose) High risk groups (>85; malnourished; renal, cardiac, hepatic disease; multiple medications) Adherence poorer

Poor adherence to medications Complicated drug regimens Visual changes Memory impairment Hand function and childproof containers

Injuries Falls (floors; stairs; lighting; mobile furniture) Thermal (baths; showers) Medication effects (especially long acting sedatives)

Consequences of falls: Canada

Mortality rate from falls: Canada

Dehydration Total body water (absolute and proportion) is less in old age Thirst sensation and response to water deprivation is reduced Renal concentrating ability is reduced

Dehydration Total body water (absolute and proportion) is less in old age Thirst sensation and response to water deprivation is reduced Renal concentrating ability is reduced These 3 factors conspire to render the older person more susceptible to dehydration and its consequences

Deconditioning

Bedrest or immobility leads to a 3-5% daily loss of maximal muscle contraction (strength) Many older people are close to the threshold of mobility After several days of “rest” an older person can become permanently chairbound

Delirium (acute confusion) 10-40% on admission to hospital 25-60% incidence during hospitalization Increased mortality Prolonged length of hospital stay Harbinger of future problems 20% annual incidence of dementia

Delirium: predisposing factors Older people (>75 years) Preexisting cognitive changes (especially dementia) Poor functional status Electrolyte imbalance (Na, K, Glu) Poor vision, hearing Alcohol abuse

Undertreatment (Grymonpre & Patterson CPS 2006) Medication classPercent of optimal ASA in ischemic heart disease 50 Beta blockers after MI 50 Hypertension 50 Warfarin for atrial fibrillation Antidepressants Osteoporosis after hip # 10

How can we reduce the incidence of adverse events?

Reducing adverse events Systematic approach Individual approach

Reducing injuries (after Tsilimingras et al J Gerontol 2003;58A:813) Identify those at high risk Address common risk factors Avoid restraints Avoid sedatives (e.g. long acting benzodiazepines) Low beds, alarms Consider hip protectors Regulate water temperature

Reducing medication adverse events Accurate diagnosis Set therapeutic target Careful selection of treatment: non drug option? Review response Review again Avoid high risk drugs “Start low, go slow…”

Reducing Procedure related adverse events Will test change management? Consider cascade Careful preoperative assessment Volume vs. quality

Prevention of delirium (by 40%) (S Inouye et al N Eng J Med 1999;340:669) The HELP program Early mobilization Adequate hydration and nutrition Vision aids Hearing Orientation Non pharmacological sleep measures

Conclusions Older individuals are at higher risk of many adverse events System based approach is essential At individual level: Risk assessment Targeting risk factors Thoughtful investigating, careful prescribing Multicomponent interventions e.g.HELP

No conflicts of interest Abbreviated presentation will be available on Regional Geriatric Program of Central Ontario website: rgpc.ca