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Prevention of Iatrogenic Complications in the Elderly

by James T. Pacala, MD, MS

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.

Risk Factors

The first step in prevention is to identify patients at high risk. Risk factors include the following.

Multiple chronic diseases

The greater the number of chronic diseases, the greater the risk that treatment of one disease will exacerbate others. For example, treatment of arthritis with an NSAID may exacerbate heart failure, coronary artery disease, or chronic gastritis.


Multiple physicians

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.


Multiple drugs (polypharmacy) and inappropriate drugs

Taking multiple drugs concurrently and having multiple chronic diseases markedly increase risk of adverse drug-drug or drug-disease interactions (see Drug-Related Problems in the Elderly). 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 ( Drug Categories of Concern in the Elderly).


Hospitalization

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.

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.


Prevention

Interventions that can prevent iatrogenic complications include the following.

Care management

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.


Geriatric interdisciplinary team

A geriatric interdisciplinary team (see Geriatric Interdisciplinary Teams) 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.


Pharmacist consultation

A pharmacist can help prevent potential complications caused by polypharmacy and inappropriate drug use.


Acute Care for the Elderly (ACE) units

These units are hospital wards with protocols to ensure that elderly patients are thoroughly evaluated for potential iatrogenic problems before problems occur and that such problems are identified and appropriately managed.


Advance directives

Patients are encouraged to prepare advance directives, including designation of a proxy to make medical decisions (see Advance Directives). These documents can help prevent unwanted treatment for critically ill patients who cannot speak for themselves.


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