iatrogenesis in elder care

ASSISTED LIVING COLUMN

ndty, E

ric syndromes and the evidence-based tools that

ted living residents provides the context for therisk of iatrogenesis among this population, be-cause it not only describes frailty but speaks tothe importance of knowing a residents baselineso that even subtle changes can be identified.

heimers disease; and 14% have severe dementia

medications on a daily basis. Approximately 80%of residents need assistance with their medica-tion management, from ordering and maintainingan adequate supply of the proper medication tophysical administration of the medication by368 Geriatric Nursing, Volume 31, Number 5ALCnurses canuse toassess the resident to reducethe risk of an iatrogenic event or be better able torecognize one that occurs. A brief profile of assis-

or late-stage Alzheimers disease.1

An assisted living resident takes approximately7.6 prescriptions and 2.3 over-the-counter (OTC)

1Iatrogenesis, Frailty, aEthel Mit

Older adults are at risk for iatrogenesis, espe-cially if they are frail and have 1 or more geri-atric syndromes. Iatrogenic events do notoccur only in acute care; in nursing homesthey affect 65% of residents annually. It istherefore likely that they are occurring in as-sisted living communities, though perhapscalled by another name. Most commonly, ia-trogenesis is an adverse drug event or reac-tion. Knowing more about the characteristicsof frailty and the contributing factors to geriat-ric syndrome(s), assisted living nurses can bebetter prepared to monitor, detect, describe,and communicate an iatrogenic event or out-come. This article describes the signs andsymptoms of atypical presentation of illnessthat canmask or are associatedwith iatrogen-esis. Evidence-basedassessment instrumentsare suggested for each geriatric syndrome.(Geriatr Nurs 2010;31:368-374)

Most iatrogenic events occur in acute care andoverwhelmingly to those who are frail, have 1 ormore geriatric syndromes, and who, by virtue oftheir old age, present illness atypically. Hospital-ized older adults who have experienced an iatro-genic event are much like the older adults whoreside in assisted living communities (ALC):many are frail, have geriatric syndrome(s), andpresent illness atypically! This makes them primecandidates for iatrogenesis. The purpose of this ar-ticle is to describe iatrogenesis, frailty, and geriat-Geriatric SyndromesdD, RN

Clinical Picture of ALC Residents

Almost 30% of residents are admitted from anacute care or rehabilitation hospital or froma skilled nursing facility.1 In 2009, more than40%ofALC residentswere evaluated (and treated,in many cases) in an emergency room, and an-other 35% had a hospital stay of 1 night or more.On average, an ALC resident requires assistancewith 1.6 activities of daily living (ADLs), rangingfrom supervision or limited assistance to exten-sive assistance and total dependence on staff. As-sistance ismost frequently needed for bathing andleast frequently for eating and transferring. Ap-proximately 23% of residents ambulate indepen-dently; 22% use a wheelchair all or some of thetime; and 54% use some kind of supportive or as-sistive device (e.g., cane, walker). By gender,more female than male residents are bladderand bowel continent. However, almost 30%of male and females are not consistently bladdercontinent; only about 15% are generally bowelcontinent.1

The most common medical diagnosis is hyper-tension (66%), followed by arthritis/rheumatoidarthritis (42%), osteoporosis (27%), clinical de-pression (30%), coronary heart disease (33%),macular degeneration/glaucoma (19%), diabetes(17%), stroke (14%), cancer (13%), chronic ob-structive pulmonary disease (13%), and kidneydisease (10%).1 Almost 37% of residents havemild dementia; 47% have early-to mid-stage Alz-

Ethel Mitty

most common cause of iatrogenesis and ac-

points to the need for robust medication manage-counts for 15% of hospitalization of older adults(compared with 6% for younger adults.2 It isestimated that as many as 195,000 hospitalizedMedicare patients die as a result of medicalerrordthat is, iatrogenesis.2 The Centers forDisease Control (CDC) suggest thatmedical errorcould be ranked as the sixth major cause ofdeath.2 Cognitive impairment, falls, impaired bal-ance, and urinary incontinence are common se-quelae of ADE/R.5 High-risk and contraindicatedmedications for older adultsdwhere the risksstaff. Most residents (97%) have a formal func-tional/physical assessment on admission and atleast annually thereafter.1 Slightly fewer resi-dents (89%) have a formal cognitive assessment,although it is unclear how often it is reviewed orrevised. Virtually all residents have a formal writ-ten service or care plan based on (pre)admissionassessment data that is reviewed annually or aftera significant change in condition. The definition offrailty (see below) provides the surround thatsets up the older adult for iatrogenesis.

At-Risk for Iatrogenesis

Iatrogenesis is a state of ill health or an adverseevent that is caused by, or is the result of, a well-intended health care intervention.2 Nevertheless,it is an untoward consequence. Cascade iatro-genesis is a series of adverse events or effectscaused by a medical or nursing intervention thatwas initially used to solve a prior symptom orcondition. It occurs most frequently to olderadults who are significantly functionally impairedand already suffering from a high severity of ill-ness burden. This unintended cascade of declineis almost always associated with poor prognosisafter hospital discharge.2,3 A common exampleis the use of Haldol for delirium caused bydehydration caused by reduced fluid intake (orby laxatives or diuretics), and so on.4

Among the predisposing factors for iatrogene-sis among older adults, the most likely culpritsare the number of prescribed medicationsand polypharmacy (as well as OTC and use ofherbal remedies), atypical presentation of illness,and more comorbid chronic illnesses.2 Impairedcognitive and functional capacity, reduced phys-iologic reserve, and altered compensatory mech-anisms add to the risk.An adverse drug event/reaction (ADE/R) is theGeriatric Nursing, Volume 31, Number 5ment that includes monitoring resident safety inself-administration of medications and medica-tion adherence practices.6 (See the AmericanMedical Directors Association and Center forExcellence in Assisted Livingmaterials in Recom-mended Reading list.) Periodic review of resi-dents medication regimens should seek tominimize polypharmacy and reduce the use ofhigh-risk medications to the extent possible.The ALC should have precise instructions orguidelines on handling of lab data, particularlywith regard to Coumadin (warfarin sodium)administration.

Frailty

Most older adults who live to an advanced agewill become frail. Not really a disease, frailty isa combination of age-related changes and assortedmedical problems. Eluding precise definition, theFried framework suggests that an individual hav-ing 3 ormore of the following conditions should beconsidered frail: exhaustion, unintentional weightloss of more than 10 pounds in 1 year, muscleweakness, walking slowly, and low physicalactivity level.7,8 Research indicates that frailty isa reliable indicator of imminent decline inhealth status and includes falls, reduced mobility,low functional reserve, easy tiring, and highsusceptibility to disease. Certain diseases andmedical conditions are associated with frailty,including anorexia, sarcopenia, atherosclerosis,outweigh the benefitsdconstitute the Beers Cri-teria and should guide prescribing aswell asmon-itoring (see the Molony article in theRecommended Reading list at the end of this arti-cle). Iatrogenesis can also be caused by adversereaction to a diagnostic procedure (e.g., drop inblood pressure) or therapeutic/surgical interven-tion that used local anesthetic, hospital-acquired(nosocomial) infection, and falls. Hospitalizedolder adults are more likely to experience com-plications associated with a diagnostic workup,adverse reaction to a medication, and falls com-pared with younger patients.2

Nursing homedata indicate that asmany as 65%of residents experience an ADE/R annually.2

There is no ADE/R data for assisted living, butgiven similar population characteristics withnursing home residents, one might assume thatADE/Rs are happening in ALCs as well. This369

incontinence.

this section, even though it is not a geriatricAlmost 95% of persons with dementia have atleast 1 other chronic medical condition.5 De-pression might coexist with anxiety, and bothmight be masked by dementia.2 Cognitive im-pairment can be an outcome of depression,which, if treated properly, will eliminate the ad-verse cognitive changes. It is important to assessolder adults who present with somatic com-plaints, an atypical presentation of depression(also common in poststroke older adults). Exac-erbation or onset of a new illness or conditionmight be completely maskeddand misseddunless the normal or baseline behavior, activity,and responsiveness of the resident is docu-mented and known to ALC staff. Assumingthe appearance of a new sign or symptomimpaired balance,mooddisturbance (depression),and cognitive impairment.8

Early recognition of frailty can improve ormaintain the quality of life desired by and impor-tant to older adults. The assessment tools andtests to be performed should be person-specificand ordered by the residents primary healthcare provider (in consultation with the relevantspecialist, e.g., physiatrist, pain management spe-cialist, etc.). Managing frailty can be framed bythe frailty mnemonic: Food intake maintained;Resistance exercises; Atherosclerosis preven-tion; Isolation avoidance; Limit pain; Tai Chi orother balance exercises; Yearly check for testos-terone deficiency (associated with chronic un-dernutrition in males).8,p.3

Atypical Presentation of Illness

The atypical presentation of illness in olderadults means that the presentation itself is vague,altered, or not presented at all.5 In some cases,the signs of 1 disease might be hidden by thesigns of another. Conditions in which atypicalpresentation is common are infections, falls, uri-nary incontinence, myocardial infarct, and con-gestive heart failure. Signs and symptoms ofatypical presentation include acute confusion(delirium), inability to eat or drink (anorexia), ab-sence of temperature elevation or fever evenwithan elevated white blood count (leukocytosis), nocomplaint of pain with a disease/conditionknown to cause pain (e.g., gastric ulcer), reducedmobility and overall functional decline, general-ized weakness and fatigue, falls, and urinary370syndrome.Knowledge of normal age-related changes and

how each geriatric syndrome might present in anolder adult can facilitate amore rapid and person-centered response to changes in status. Each ge-riatric syndrome and how it can be assessed isnow discussed.(e.g., incontinence, cognitive change, falling, de-lirium) or behavior, before adding a new medica-tion or treatment, the question must be asked:Could this be an outcome of a previous inter-vention? If the answer is yes, could it be an ad-verse drug reaction? Could it be an iatrogenicevent or process?

Geriatric Syndromes

Geriatric syndromes can be an outcome of ia-trogenesis and frailty. They have an impact onmorbidity and mortality. The term refers toa sign or symptom, or a group of specific signsand symptoms, that occur more often in olderadults than in younger adults. It is not possibleto predict or even be fully knowledgeableabout the multiple etiological and pathologicalpathways of some of the geriatric syndromes.Contributing factors include multiple chronicdiseases, normal age-related changes, polyphar-macy, multiple providers, and the adverseeffect of therapeutic or diagnostic interventions.The Fulmer SPICES, an acronym for the geriatricsyndromes, is an efficient and effective way toconduct assessment of them.9 Although psycho-metric testing of SPICES validity and reliabilityhas not been conducted, widespread utilizationindicates its significant usefulness:

S: Sleep Disorders P: Problems with Eating or Feeding I: Incontinence C: Confusion E: Evidence of Falls S: Skin Breakdown9

Some clinicians add another P or substitutePain for problems with eating or feeding. As-sessment for potential and actual pain shouldbe a standard component of the clinical assess-ment of patients of all ages, not just older adults.Pain is not a unique feature of aging, nor is it anaccepted age-related change. Could pain be iatro-genic in origin? Yes. Hence, it is discussed later inGeriatric Nursing, Volume 31, Number 5

with regard to possible causes of transient UI.13Sleep Disorders

It is important to know (and perhaps to reas-sure the resident) that although the amount ofsleep in 24 hours is unchanged, there are changesin sleep pattern and quality. Impaired sleep canbe related to diseases (e.g., restless leg syn-drome), medications, or an environment thatdoes not promote good sleep (e.g., room temper-ature, mattress, noise, roommate habits, etc.).Sleep assessment includes getting a thoroughsleep history from the resident and past use ofany medications or routines (e.g., exercise) to in-duce sleep and restfulness. The Pittsburgh SleepQuality Index (PSQI) is a self-rated instrumentthat measures sleep quality.10 The EpworthSleepiness Scale (ESS) is another self-rated in-strument that measures excessive daytime sleep-iness.11 Both the PSQI and ESS can be used tomeasure the effectiveness of interventions. Day-time sleepiness is more than a simple need fora daytime nap; it could be iatrogenesis. (See theMitty and Flores article in the RecommendedReading list.)

Problems with Eating or Feeding

Most nutritional issues are associated witha disease or illness, but other causes include die-tary restrictions, oral cavity and denture issues,medications, reduced sense of smell and taste,and inability to carry food and fluid to themouth.12 Many eating or feeding problems inolder adults can be severe. Nutritional assess-ment includes diet(ary) history (e.g., previous in-terventions that were successful as well asunsuccessful) and oral cavity examination. Indi-viduals who are overweight (i.e., body mass in-dex [BMI] . 25) are as at risk for malnutritionas those who are underweight (i.e., BMI\ 19).12

Both can have loss of muscle mass and a compro-mised immune system. The Mini Nutritional As-sessment can identify older adults at risk formalnutrition.12 Information about the olderadults culture, food preferences, and social cus-toms with regard to eating, as well as lab workand a 72-hour food diary, should be part of theassessment.12

Incontinence

Urinary incontinence (UI) can occur secondaryto age-related physiological changes, iatrogene-sis, frailty, or disease.5 Urinary incontinence isGeriatric Nursing, Volume 31, Number 5The Urinary Incontinence Assessment in OlderAdults, Part IIdEstablished Urinary Inconti-nence instrument contains the Urogenital Dis-tress Inventory that addresses frequency ofurination, leakage, and discomfort when uri-nating.14 It also contains the Impact Question-naire, which addresses the extent to whichUI or leakage has affected the individualsability to perform household tasks and engagein recreational and social activities, as well ashis or her emotional well-being (e.g., feelingdepressed).Fecal incontinence, almost as common as UI, is

frequently a result of fecal impaction. Not sur-prisingly, constipation and fecal impaction areassociated with chronic use of laxatives, consti-pating medications (e.g., opioids, iron, calciumchannel blockers), limited mobility, malnutrition,reduced fluid intake, and the 3 Ds: delirium, de-mentia, depression.2 Think of cascading iatrogen-esis that started with just a couple of days ofbedrest after a bad fall (or a URI) that ends upas intestinal obstruction requiring major surgery.

Confusion

It is necessary to differentiate among demen-tia, delirium, and depression (3-Ds), although as-pects (symptoms) of all 3 can be present at thesame time in an individual. Space limitations pre-clude discussion of each condition.Several evidence-based assessment instru-

ments for the 3-Ds are as follows (each consti-tutes a basic assessment and can point to theneed for further evaluation):

Dementia. Mini-COG: consists of a 3-item re-call and the Clock Drawing Test; used tonot a normal age-related change or consequenceof aging. There are 4 types of urinary inconti-nence: urge, stress, overflow, and functional.Each has different characteristics, and all presentpsychological, physical, and social challenges toquality of life.13 A 3-day self-recorded bladder di-ary is recommended, although a 7-day calendarelicits more reliable information. For the residentwith dementia, it would be necessary for some-one else to record the incontinent events. TheUrinary Incontinence Assessment in OlderAdults, Part IdTransient Urinary Incontinenceinstrument contains 2 mnemonicsdDIAPPERSand TOILETEDdthat frame the assessment371

at risk for skin breakdown or pressure ulcer.

cial interaction and activities, pain is the fifth vitalidentify dementia; takes approximately 3-5minutes to administer. Aspects of cognitiontested: recall, registration, and executive func-tion. Unlike the Mini-Mental Status Examina-tion, education level, culture, or languagehave no effect on the Mini-COG score.15 Olderadults who were administered the Mini-COGdid not appear stressed or otherwise discom-fited by the examination.

Dementia. Brief Evaluation of Executive Dys-function: recommended for 4 conditions:1) when an older adult after hospitalizationseems not quite like his former self; 2) theMini-COG fails to reveal the presence of cogni-tive impairment (i.e., dementia); 3) deliriumhas been ruled out; and 4) the older adult stillhas memory/recall and language ability.16

Language and education level can yield false-positive results because a portion of the exam-ination includes word association.16

Delirium. Commonly thought of as a hospital-related event, delirium can occur in the ALC, aswell. Risk factors include infection, dehydra-tion, fracture, and use of psychotropic medica-tion. The Confusion Assessment Method(CAM) identifies the presence or absence of de-lirium but not does indicate severity.17 TheCAM consists of 4 factors: 1) acute onset orfluctuating course of mental changes or behav-ior; 2) inattention; 3) disorganized thinking;and 4) altered level of consciousness. Factors1 and 2 and either 3 or 4 must be present forthe diagnosis of delirium.17

Depression. Contrary to myth, depression isnot a normal part of aging, can delay recov-ery from a medical illness, and is treatable.The short-form (15-item) Geriatric Depres-sion Scale (GDS) is a valid and reliable as-sessment instrument that can differentiatebetween depressed and nondepressed olderadults. It takes approximately 5-7 minutesto administer and score but is not a substi-tute for a clinical interview, nor does it iden-tify suicide risk.18

Evidence of Falls

Data on falls are sobering: 5% of falls result infractures, but about 25%, on average, result ininjury. Most falls (85%) occur in the home.What are the shared characteristics of an ALCwith a traditional home and the hazards of fall-ing? The Hendrich II Fall Risk Model is recom-mended for long-term care residents, although372sign, except that it is self-reported instead of re-corded on some kind of device. There are severalvalid and reliable pain assessment tools for ver-bal as well as nonverbal older adults, includingthose who lack the visual acuity to see a scaleand those with dementia. Research indicatesthat the Numeric Rating Scale (NRS) is preferredby cognitively intact older adults, whereas theFaces Pain Scale (FPS) is preferred (i.e., the pa-tients were better able to report) by cognitivelyimpaired individuals.21 For those with dementia,The Braden Scale has been extensively testedfor its validity and reliability in predicting devel-opment of a pressure ulcer. It consists of 6 com-ponents that are applicable for a wheelchairbound as well as a bedbound resident: sensoryperception of discomfort related to pressure ona bony prominence; exposure of skin to moisture(e.g., perspiration, urine); amount of physical ac-tivity (chairfast, walking); mobility (i.e., the abil-ity to change body position); customary foodintake; and friction/shear when changing positionin bed or a chair.20 Some clinicians recommendthat the Braden Scale should be administered assoon as an individual is placed on bedrest andevery 24 hours (more frequently, if indicated).

Persistent Pain

Although not included in the SPICES acronymand not unique to older adults, persistent pain af-fects almost 50% of community-residing olderadults. Associated with depression, reduced so-it was originally intended to identify hospital pa-tients at risk for falls. The assessment includesmedications that predispose to fall risk, dizzi-ness, and mental states (e.g., confusion, disori-entation) as well as a get up and go test.19 Itis highly recommended that every ALC includea valid fall risk assessment tool in the (pre)ad-mission examination as well as at subsequenttimes, particularly after a change of condition.A resident with a UTI experiencing a changedvoiding pattern is at risk for fall.

Skin Breakdown

Given that many states permit ALCs to retainresidents who require bedrest for a short period,as well as residents receiving hospice care, it isentirely possible that some residents might beGeriatric Nursing, Volume 31, Number 5

the PAINAD Scale (Pain Assessment in AdvancedDementia) observes quality of breathing, nega-

Preventing Iatrogenesis

geriatric nursing protocols for best practice. 3rd ed. New

York: Springer Publishing Company; 2008. p. 369-90.References

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Zwicker D, Mezey M, Fulmer T, editors. Evidence-basedExpect iatrogenesis among your residents.Identify residents at high risk for iatrogenesisdthat is, older adults who are aged 80 years orolder, are frail, have multiple physical and cogni-tive comorbidities, and have new-onset geriatricsyndromes. Educate the resident and family, tothe extent possible, about where they are atrisk, what is being done to minimize that risk,and the things they need to do to remainhale and hearty. Dispel the myths of aging amongresidents, family, and staff. Develop a proactiveapproach to prevention and recognition of iatro-genesis, recognizing that the early warning signsmay be fragmented. Monitor and communicateunexplained signs, symptoms, and complaints.5

Develop, foster, and maintain a blame-free cul-ture of safety so that when an iatrogenic eventdoes occur, its origin and resolution can be betterunderstood and managed.tive vocalization or groaning, facial expression,body language, and consolability. It is a reliableand valid assessment tool but requires trainingfor proper interpretation (even though it takesonly a few minutes to administer).22 If adminis-tration of a treatment or a specific kind of activity(e.g., toilet transfer) elicits expression of pain innondemented individuals, then the assumptionhas to be made that those with dementiawho cannot express themselves are likely to ex-perience pain as well. (See the Horgas article inthe Recommended Reading list.)Geriatric Nursing, Volume 31, Number 55. Mezey M. (2010). Iatrogenesis and frailty. Presentation at

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somnolence. Geriatr Nurs 2009;30:53-60.

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Columbia, MD: AMDA; 2010.

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MD: AMDA; 2010.

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ETHEL MITTY, EdD, RN, is an Adjunct Clinical Professor of

Nursing at the College of Nursing, New York University, and

Consultant in Long Term Care at the John A. Hartford

Institute for Geriatric Nursing, College of Nursing, New

York University, New York, NY.

0197-4572/$ - see front matter

2010 Mosby, Inc. All rights reserved.doi:10.1016/j.gerinurse.2010.08.004374 Geriatric Nursing, Volume 31, Number 5

Iatrogenesis, Frailty, and Geriatric SyndromesClinical Picture of ALC ResidentsAt-Risk for IatrogenesisFrailtyAtypical Presentation of IllnessGeriatric SyndromesSleep DisordersProblems with Eating or FeedingIncontinenceConfusionEvidence of FallsSkin BreakdownPersistent Pain

Preventing IatrogenesisReferencesRecommended Reading

iatrogenesis in elder care

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