Perspectives on Safety

Patient Safety in Frail Older Patients

Background

Older patients are at a particular risk of experiencing a patient safety event. Studies in the inpatient setting that have assessed the effect of age on the rate of safety events have consistently concluded that older patients experience more adverse events than younger patients.1 As individuals age, the likelihood increases that they have a chronic medical condition that necessitates higher utilization of the healthcare system, including hospital stays.2 The presence of multiple chronic conditions increases this exposure further and introduces the potential for complications associated with polypharmacy.3 Further, the natural progression of usual aging, including decreasing bone density, decreasing muscle strength, and increasingly fragile skin, predisposes older patients to be less resilient to the side effects of procedures and medications, such as infections or delirium.4 As a highly medically complex population, older patients can be incredibly difficult and complex to manage without causing unintended harms.  

Increased frailty among a subset of older patients can complicate management of risk further. An individual’s frailty status can have a dramatic impact on their healthcare utilization and the outcomes they experience.5-6 Frail older patients are defined as those patients meeting three out of five criteria that indicate compromised energetics: low grip strength, low energy, slowed waking speed, low physical activity, and/or unintentional weight loss. In frail individuals, the physiological decline typically seen in aging is accelerated.2, 7-8 While generally more common among individuals 80 years and older, frailty status is linked to functional status rather than age.

Given these factors, older patients, particularly frail older patients, are often the first to suffer the effects of unsafe healthcare conditions. This makes it necessary to have patient safety practices directed specifically at prevention in these patients.

Patient Safety Considerations in Frail Older Patients

The hazards of hospitalization and overtreatment are well known to geriatricians. Bed rest, hospitalization, and the testing and treatment patients receive come with a number of risks for older adults that can result in an adverse event.4 Additionally, the Centers for Disease Control and Prevention (CDC) estimates that older adults visit the emergency department as a result of an adverse drug event more than twice as often as those under 65 and are nearly seven times more likely to be hospitalized following an emergency visit.9

Medication overtreatment is a critical patient safety risk for frail older patients in both inpatient and outpatient care.10-11 Certain medications may predispose an individual to delirium or reduced cognitive function, increasing their risk of falls, malnutrition, and limiting their participation in their care.3, 10-11  These patients are also at an increased likelihood of adverse events when not taking their medications as prescribed.3 Finally, patients may experience poor outcomes as a result of receiving pharmacological management to achieve certain physiological targets that may not be appropriate given the patient’s functional status.3 For example, attempting to maintain rigid, low HbA1c targets via pharmacological management may expose frail patients to the risk of hypoglycemic events.

Older adults are at an increased risk of experiencing a hospital acquired condition (HAC) or safety event.2 For example, prolonged bed rest can lead to muscle wasting and the increased likelihood of a fall.12 However, the magnitude of risk to older adults and the ability of the individual to recover can be closely tied to their status prior to the event. Individuals who are frail are much more vulnerable to physiological and psychological stressors, putting them at an increased risk of experiencing poor health outcomes and safety events, including incident disability, hospitalization, and mortality.6, 13-14 In the case of prolonged bed rest, in an individual who is already frail additional muscle wasting could have a much more deleterious effect. Coupled with limited mobility and low bone density associated with frailty, there is the heightened risk of not only experiencing a fall, but also the associated cascading events such as a bone fracture, longer hospital stay, and further physiological decline. In frail adults, a HAC can easily be the intermediary event before long-term functional decline, disability, and mortality.4   

Considerations When Treating Frail Older Patients

Given the magnified patient safety risk frail older patients experience, clinicians and other providers should consider their unique status when approaching evaluation and treatment, particularly during inpatient care. A multi-phase approach to the care of these patients may help providers minimize the risk that the patient experiences a harm event.

  • Identification of frail patients

Evidence has demonstrated that identification of frail patients can help ensure that providers are making treatment decisions that are better aligned with the unique care needs of this population.13-14 Identification of frailty in older patients can help prevent ongoing decline and proactively avoid placing patients at an unnecessary risk of adverse events. Several tools and questionnaires exist to help providers identify frailty, including the Groningen Frailty Indicator, the Tilburg Frailty Indicator, the timed-up-and-go-test (TUGT), and the Edmonton Frail Scale.6

  • Consider a horizontal approach

The typical approach for preventing HACs on a condition by condition basis has been very successful, with continuous and steady declines in the rate of HACs over the past decade. However, many risk factors overlap with multiple HACs that have the potential for serious cascading events in frail older patients. Given this, providers may wish to consider a horizontal approach. A horizontal approach strives to address risk factors in the context of lowering overall facility-wide safety events. It focuses on how interventions can prevent multiple types of harm at once and may provide a more comprehensive approach for patients at serious risk.4

  • Risk assessment of treatment

Frail older patients are at risk of unintended consequences from procedures and treatments. Before initiating care providers should determine what the risk of harm is, whether the proposed approach is appropriate given the patient’s functional status, and whether there are alternative approaches that would put the patient at less risk.3, 6 For example, deprescribing may be an effective approach for patients where the negative medication side effects outweigh the benefit the patient is receiving.3    

  • Patient engagement

Engaging in long-term care planning with the patient and/or family can reduce patient exposure to unnecessary risks and ensure a patient-centered approach to care decision-making. This may be particularly important when caring for frail older patients. A patient’s desire to prioritize maintaining functional status and quality of life may change the objectives and approach for care.

Conclusion

The heightened risk for adverse events in the care of frail older patients is one that necessitates a mindful approach to patient treatment and ongoing management. Care providers should consider both the risks of the proposed treatment and the long-term care goals of the patient. As the population continues to age and life expectancy grows, this balance will become increasingly critical not just for maintaining the quality of life of the patient, but also for the healthcare community’s efforts to curb over utilization.

Heidi Wald, MD, MSPH
Chief Quality and Safety Officer
SCL Health
Denver, CO

Kendall K. Hall, MD, MS
Managing Director, IMPAQ Health
IMPAQ International
Columbia, MD

Eleanor Fitall, MPH
Research Associate, IMPAQ Health
IMPAQ International
Washington, DC

References

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3. Lavan AH, Gallaher P. Predicting risk of adverse drug reactions in older adults. Ther Adv Drug Saf. 2016;7(1):11-22.

4. Wald HL. The geometry of patient safety: Horizontal and vertical approaches to the hazards of hospitalization. J Am Geriatr Soc. 2017;65(12):2559-2561.

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8. Torpy JM, Lynm C, Glass RM. Frailty in older adults. JAMA. 2006;296(18):2280.

9. Adverse Drug Events in Adults. cdc.gov. https://www.cdc.gov/medicationsafety/adult_adversedrugevents.html. Accessed November 8, 2019.  

10. Kouladjian L, Gnjidic D, Chen TF, Mangoni AA, Hilmer SN. Drug Burden Index in older adults: Theoretical and practical issues. Clin Interv Aging. 2014;9:1503-15.

11. Ailabouni N, Mangin D, Nishtala PS. DEFEAT-polypharmacy: Deprescribing Anticholinergic and Sedative Medicines Feasibility Trial in residential aged care facilities. Int J Clin Pharm. 2019;41(1):167-178.

12. Wald HL, Ramaswamy R, Perskin MH, et al. The case for mobility assessment in hospitalized older adults: American Geriatrics Society white paper Executive Summary. J Am Geriatr Soc. 2019;67(1):11-16.

13. Xue QL. The frailty syndrome: Definition and natural history. Clin Geriatr Med. 2011;27(1):1-15.

14. Theou O, Squires E, Mallery K., et al. What do we know about frailty in the acute care setting? A scoping review. BMC Geriatrics. 2018;18(139).