Prevention of Iatrogenic Complications in the Elderly
Iatrogenic complications are more common and often more severe among the elderly than among younger patients. These complications include adverse drug effects (eg, interactions), falls, nosocomial infections, pressure ulcers, delirium, and complications related to surgery. Prevention is often possible.
The first step in prevention is to identify patients at high risk. Risk factors include the following.
Having multiple physicians can result in uncoordinated care and polypharmacy. Consultation among multiple physicians every time one of them sees a common patient is difficult. As a result, a patient’s therapeutic regimen is frequently changed without the input of the patient’s other physicians, thereby increasing risk of iatrogenic complications.
Taking multiple drugs concurrently and having multiple chronic diseases markedly increase risk of adverse drug-drug or drug-disease interactions. Risk of such interactions is particularly high among patients who are undernourished or who have renal failure. Also, certain drugs have an especially high risk of adverse effects in the elderly, due to changes in body composition and drug metabolism. Specific examples include anticholinergics such as diphenydramine, benzodiazepines and other sleep aids (eg, zolpidem), opioids, antipsychotics, anticoagulants, and NSAIDs (see Beers criteria).
Risks due to hospitalization include hospital-acquired infection, polypharmacy, and transfusion reactions. Hospitalized patients who have dementia or who are immobilized (eg, after surgery) are at high risk of iatrogenic complications (eg, pressure sores, deep venous thrombosis, urinary retention, delirium).
Medical technology may contribute to iatrogenic complications, including sudden death or MI after valvular replacement surgery, stroke after carotid endarterectomy, fluid overload after transfusions and infusions, unwanted prolongation of life via artificial life support, and hypoxic encephalopathy after potentially life-prolonging CPR.
Interventions that can prevent iatrogenic complications include the following.
Care managers facilitate communication among health care practitioners, ensure that needed services are provided, and prevent duplication of services. Care managers may be employed by physician groups, health plans, or community or governmental organizations. The frail elderly benefit the most from case management.
A geriatric interdisciplinary team evaluates all of the patient’s needs, develops a coordinated care plan, and manages (or, along with the primary care physician, co-manages) care. Because this intervention is resource-intensive, it is best reserved for very complex cases.
Patients are encouraged to prepare advance directives, including designation of a proxy to make medical decisions. These documents can help prevent unwanted treatment for critically ill patients who cannot speak for themselves.