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In Brief: The Nature and Extent of Medical Injury in Older Patients

This "In Brief" summarizes the findings of the AARP Public Policy Institute Issue Paper, The Nature and Extent of Medical Injuries in Older Patients, by Jeffrey M. Rothschild, MD, and Lucian L. Leape, MD, MPH. The Institute of Medicine estimated in 1999 that medical errors result in 44,000 to 98,000 deaths among patients of all ages and cost $17 to $29 billion annually. Two population-based studies of medical error and injury reveal that preventable medical injury is a particularly significant problem for patients age 65 and older, who are injured at a substantially higher rate than younger patients are.

The Issue Paper provides a comprehensive overview of the nature and extent of medical injury among older patients, explains why they are at greater risk of suffering iatrogenic injury (injury due to medical treatment) than younger patients are, and presents a number of recommendations on how to lower rates of medical injury in the older patient population.

Key Findings: The Extent of Medical Injury in Older Patients

Medical injuries occur among patients in all age groups, but are substantially more common in older patients. At least 6 percent of hospitalized patients age 65 and older suffer a treatment-caused injury serious enough to result in a measurable disability or to prolong their hospital stay. That is approximately twice the rate of injury in younger patients. Iatrogenic injury in other care settings, such as nursing homes, is also quite widespread. The risk of accidental medical injury increases with advancing age, particularly for falls and surgical complications. About two-thirds of iatrogenic injuries are potentially preventable.

Older patients are particularly susceptible to adverse drug eventsfallsnosocomial (hospital-acquired) infectionspressure soresdelirium, and surgical complications.

Adverse drug events (ADEs) are the most common cause of preventable injury among hospitalized older patients. They are a particular problem in nursing homes and occur frequently in outpatient settings as well. Older patients are at greater risk for ADEs due to (1) the normal effects of aging on the body's handling of, and response to, certain pharmaceutical agents; (2) multiple drug use, including the direct effect of using many drugs and the difficulties older patients experience in correctly complying with often complex regimens; (3) inappropriate prescribing by physicians; and (4) age bias by physicians that can lead to a form of inappropriate care unique to this age group: underprescribing.

Falls occur frequently in the nursing home setting; they are less common in hospitalized patients. On average, half of older patients residing in nursing homes suffer falls each year. Progressive instability and difficulty in walking, use of psychotropic medications, visual or neurologic impairment, and dementia make older patients especially vulnerable to falls.

Nosocomial infections occur in 6-17 percent of hospitalized patients, and they are probably equally common in nursing homes. Older patients are particularly at risk for contracting these infections due to declines in their physiologic reserves and declining immunity, and because they commonly have longer hospital stays and multiple treatments.

Pressure sores are a hazard for those who are bedridden or chairbound, as are many older patients in hospitals and nursing homes. Pressure sores are observed in 1.7 million patients annually, mostly in older nursing home patients. Those who suffer from neurologic injury, malnutrition, fecal incontinence, and orthopedic injuries are particularly susceptible.

Delirium is a common affliction in older patients, complicating the course of treatment in 2.3 million patients (mostly older) annually, at a cost of $4 billion. Many cases of delirium are precipitated by surgical procedures and drug therapy. Delirium in older patients is frequently and mistakenly attributed to aging and dementia.

Finally, surgical complications are twice as common in older patients as in their younger counterparts. Half of all surgical complications and three-quarters of operative deaths occur in patients age 65 and older. Older patients are at increased risk of injury due to impaired organ function and multiple chronic diseases, but they are also endangered by delays in needed surgery.

Recommendations: Ways to Avoid Many Older-Patient Injuries

Injuries due to ADEs may be reduced through physician education in geriatric pharmacology, teaching them how to recognize ADEs and distinguish them from "new illnesses," and teaching nonpharmacologic treatment alternatives for conditions such as anxiety and sleep disorders. In addition, ADEs may be reduced through increased pharmacist involvement in medication management, geriatric drug labeling, redesign of hospital medication safety systems, and the use of new technology, such as computerized physician order entry.

The number of injuries due to falls can be reduced by implementing comprehensive programs to identify patients at risk and provide safeguards. Nosocomial infection rates can be reduced by more rigorous application of well-known principles of infection control. Long-established principles of nursing care, if followed, would prevent pressure sores. Such care requires large commitments of staff time. Prevention of delirium begins with identifying patients at risk and promptly instituting preventive measures, such as ensuring effective pain control. Finally, many post-operative complications could be avoided if surgeons, geriatric specialists, and anesthesiologists worked together to establish optimal pre-operative preparation and post-operative care.

In addition to the injury-specific approaches to preventing injury, four general strategies hold promise for reducing the number of medical injuries in all patients, particularly older ones. These strategies include (1) applying error-prevention strategies from other industries, using human factors principles such as standardization, simplification, improved information access, and teamwork training; (2) reducing variability in medical care, through the dissemination of guidelines and the enforcement of standards; (3) enhancing the roles of geriatric specialists; and (4) using riskprofiling and discharge planning, assessing and identifying older patients at risk for iatrogenic complications when they are admitted to the hospital and when they are discharged.

Footnote

  1. AARP Public Policy Institute Issue Paper #2000-17 (September 2000)

Written by Andrew H. Smith AARP Public Policy Institute
September 2000
©2000 AARP
May be copied only for noncommercial purposes and with attribution; permission required for all other purposes.
Public Policy Institute, AARP, 601 E Street, NW, Washington, DC 20049

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