were included.29 Besides age, important causative factors were found to be comorbidity, clinical complexity, severity of illness, functional status, and poor quality of care. As might be expected, data from these studies show that older people in the hospital tend to experience different types of adverse events than their younger counterparts, such as falls, hospital‐acquired infections, and drug errors, rather than complications related to invasive procedures. In general, it seems that it is controversial as to whether adverse events are more preventable in elderly than in younger patients.
Data from reporting systems
Another way of estimating the incidence of hospital‐related harm in older people is to analyse data from local and national reporting systems. The incidents most commonly reported to the NRLS in acute hospitals are patient‐related accidents, which in older people are most likely to be falls. These are followed closely by problems related to medication. Such data sources are very useful in terms of allowing us to prioritize areas for intervention. However, it is important to bear in mind that many problems go unreported, particularly those that may not be as obvious as falls or drug errors, so the scale and nature of adverse events may not be truly reflected in this way.
Types of adverse events experienced by older people in the hospital
The geriatric syndromes
During a hospital stay, older people are of course vulnerable to the same adverse events as their younger counterparts, such as hospital‐acquired infections, adverse drug events, deep vein thrombosis, and procedure‐related complications. As described above, there is evidence that the incidence of these types of adverse events is greater in older patients and their consequences are more severe. However, the process and effects of hospitalization in older people, particularly those who are frail and have multiple comorbidities, are different from those in younger people; it therefore follows that any analysis of patient safety and adverse events in this vulnerable population should be undertaken in this context. Figure 11.2 illustrates this in a proposed scheme for the effects of hospitalization in frail older people.
Older people may be admitted to the hospital because of an acute illness, acute exacerbation of a chronic disease process, side effects of treatment for these conditions, or the development of a new geriatric syndrome. These are similar to the geriatric giants first coined by Isaacs in 1965 (immobility and instability, incontinence, and impaired intellect) and are now understood to include delirium, falls, incontinence, pressure sores, depression, undernutrition, constipation, and functional decline. Older patients very commonly have one or more of these conditions at the time they are admitted to the hospital, but there is a strong argument that if any of these truly occur de novo during the inpatient stay and are not related solely to the progression of disease, each should be considered an adverse event because of their association with increased mortality and morbidity and the strong evidence that they are largely preventable.30 The geriatric syndromes rarely occur in isolation – during the complex, lengthy hospital admissions often experienced by older people, they are often interlinked and may contribute to downward spirals in progress and outcome. They can each contribute to or be an outcome of each other; this is illustrated in Figure 11.3, which shows three common clinical scenarios where delirium, incontinence, and falls occur in different sequences.
Figure 11.2 A proposed scheme for the effects of hospitalization on frail older people.
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:
Functional decline
Loss of mobility
Urinary or faecal incontinence
Delirium
Severe constipation
Pressure sores
Falls
Malnutrition and/or dehydration
Depression