Pathy's Principles and Practice of Geriatric Medicine. Группа авторов

Figure 11.3 Three common clinical scenarios where delirium, incontinence, and falls occur in different sequences.

A summary of common adverse events in older people is shown in Box 11.1.

      Preventable functional decline as an adverse event

      Functional decline, defined as a decrement in physical and/or cognitive functioning that leads to a reduced ability to perform the activities of daily living (ADLs) that are necessary to live independently, is a common outcome for older people in the hospital, regardless of whether any adverse events or geriatric syndromes occur during their hospital stay. The dangers of believing the misconception that bed rest is good for hospitalized patients was succinctly put by Asher in 1947:³¹

      It is always assumed that the first thing in any illness is to put the patient to bed. Hospital accommodation is always numbered in beds. Illness is measured by the length of time in bed. Doctors are assessed by their bedside manner. Bed is not ordered like a pill or a purge, but is assumed as the basis of all treatment. Yet we should think twice before ordering our patients to bed and realize that beneath the comfort of the blankets there lurks a host of formidable dangers …. Teach us to live that we may dread unnecessary time in bed. Get people up and we may save our patients from an early grave.

      Unfortunately, older patients are still often confined to bed more than is necessary, and functional decline remains an extremely common problem in more modern times; in one study, one‐third of elderly patients had lost at least one ADL by the time they left the hospital.³²

      Functional decline that occurs during hospitalization can impact the older person (and the healthcare system) in several ways: it can lead to loss of independence necessitating increased care requirements (and even institutionalization), depression, and reduced quality of life. Like the other geriatric syndromes, many cases of functional decline are avoidable during a hospital admission if proper measures are taken to prevent them. One consequence of the diminished reserves associated with frailty and age is that when functional decline occurs, it may be irreversible or require a prolonged period of rehabilitation to achieve partial or complete reversal. When functional decline occurs, the often prolonged hospital stays required for rehabilitation after a serious illness, although often unavoidable, bring further risks.

      Adverse drug events in older people

      The term adverse drug event covers a wide range of medication‐related problems encompassing the following: errors in prescription, preparation, or administration; adverse drug reactions (which may be further subclassified into Type A, predictable, or Type B, bizarre),³³ or problems with concordance. These may occur due to appropriate or ‘inappropriate’ (under‐, over‐, or mis‐) prescribing.

Box 11.1 Adverse events in older people.

      The geriatric syndromes, which could be considered preventable adverse events if they arise de novo in older people in the hospital and are not related solely to the progression of disease:

      Other common adverse events in older people:

As with other adverse events in the hospital, at first glance, the incidence of adverse drug events seems to increase with age, but there is some evidence that they are directly related to complexity and comorbidity rather than age alone. Recent studies have estimated the incidence of adverse drug events in older people in the hospital to be between 31.9 and 37%.³⁴ As with all estimates of hospital‐associated risks, this figure depends very much on the definitions and methodologies used. Nevertheless, even when relatively strict definitions are used, adverse drug events are the most common adverse events to affect hospitalized patients of all ages.³⁵

      People over 60 are the highest users of medications, receiving 59% of dispensed prescriptions in the UK.³⁶ Polypharmacy is an important issue – one‐fifth of people age 70 years take five or more medications.³⁷ Virtually all older patients who are admitted to the hospital are given drug treatment of some description. It would be unusual for an older patient not to have been taking any medications prior to admission or for these not to have changed in some way by the time of discharge.

Adverse drug events are also a significant cause of hospital admission in older people (estimated at 6.5% of admissions, with a median length of stay of 8 days³⁸). Furthermore, patients admitted because of an adverse drug event have a significant chance (17.7%³⁹) of subsequent readmission due to further adverse drug events. Box 11.2 shows the common types of medication‐related problems that may occur at different stages of the hospital admission process in an older person.

      Outside the hospital, the highest users of medications are care home residents. A recent study in the UK showed that the incidence of medication errors in nursing home residents was as high as 69.5%.⁴⁰ The categories of error found were similar to those in Box 11.2 – they included prescribing, monitoring, dispensing, and administration errors. The underlying causes of the errors in both hospitals and care homes relate to common underlying patient safety themes: system failures, individual errors, communication problems within and between healthcare teams and the patient, and assessment or diagnostic skills and procedures not tailored to the individual.

      Certain categories of drugs are more problematic than others for older people, notably anticoagulants, opiates, and other centrally acting medications. Several efforts have been made to identify groups of medications that pose a particular risk so that they can be more easily avoided in this population,

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