Breve analisi storica delle principali norme sui MSNA

If sedation is required, then the initial dose of haloperidol should be kept low (1 mg initially); if necessary, a further dose can be given 20–30 min later. Follow-on medication should be given only if necessary, and in this situation should be low dose (0.5 mg twice a day). Treatment should not be continued beyond 3 days and should never be continued indefinitely. If the patient has pre-existing parkinsonism, a small dose of lorazepam 0.5–1 mg can be considered as an alternative.

CASE 6.14 –  An 86-year-old woman who is a nursing home resident has become more drowsy than usual.

A1: What iatrogenic illness may result from the given intervention?

There is a high risk of C. difficile colitis if antibiotics are used in this setting. Bowel colonization with C. difficile is not uncommon in residents of care homes (around 25 per cent of residents). Further disturbance of the normal large bowel bacterial flora by broad-spectrum antibiotics (especially ciprofloxacin) carries a high risk of precipitating C. difficile infection.

A2: What risk factors for iatrogenic illness are present in this case?

Age, comorbid illnesses, care-home settings and recent use of broad-spectrum antibiotics all increase the risk of C. difficile infection.

A3: Suggest some alternative management strategies.

In this scenario, there is no definite evidence of UTI. The abnormal urine dipstick result may be caused by (i) diabetic/hypertensive kidney disease, (ii) bladder irritation due to the urinary catheter or (iii) asymptomatic bacteriuria (present in up to 40–50 per cent of residents of care homes). The patient has hypoactive delirium, most likely caused by dehydration and hyperglycaemia. The dehydration should be corrected by giving regular oral fluids. Renal function, plasma electrolytes and capillary glucose should be checked and corrective action taken as necessary. The patient should be monitored regularly by the nursing staff, including charting of fluid balance and temperature. Resolution of the current symptoms and signs over the next 24 h will confirm that the management plan is working and that antibiotic treatment is not required.

A4: How can these complications be minimized?

If fever develops and there is no likely source of infection other than urine, then treatment for UTI must be considered. An elevated plasma white cell count or CRP will provide further support for UTI. Keeping the antibiotic course short (3–5 days) and using a narrow-spectrum agent (trimethoprim v. ciprofloxacin) where possible will minimize the risk of C. difficile colitis. A discussion with the patient and the nursing staff regarding removal of the urinary catheter and managing continence by other means (e.g. regular toileting, pads) will substantially reduce the risk of UTI in this setting.

CASE 6.15 –  A 92-year-old woman is feeling dizzy and nauseated and is not her usual self.

A1: What iatrogenic illness may result from the given intervention?

A1: Digoxin toxicity, hypotension and renal failure may all result. Hypotension and renal failure are related to treatment with diuretics and ramipril. Hyperkalaemia is related to treatment with

spironolactone (an aldosterone antagonist) and ramipril. The dizziness is multifactorial – digoxin toxicity, cardiac arrhythmia and hypotension are all possible causes.

A2: What risk factors for iatrogenic illness are present in this case?

Chronic renal failure – either disease- or age-associated – will cause digoxin accumulation as the drug is excreted via the kidneys and has a long half-life (36 h with normal renal function). A recent increase in diuretic dose can result in excessive diuresis, which will further compromise kidney function due to volume depletion. Nausea due to digoxin toxicity will reduce fluid intake and exacerbate the situation.

Spironolactone is contraindicated in the presence of kidney disease because of the risk of hyperkalaemia, a situation aggravated by ACE inhibition.

A3: Suggest some alternative management strategies.

Adjustments in diuretic dose require close monitoring in this situation, ideally with serial weight, blood pressure and kidney function tests. Regular home assessments by a nurse specialist in cardiac failure are a valuable means of monitoring such treatment in frail older patients, rather than relying on frequent visits to the surgery or outpatient department.

A4: How can these complications be minimized?

Renal function declines progressively with age. The severity can be underestimated in frail older patients, as plasma creatinine is often lower than expected because of reduced muscle mass (estimated glomerular flow rate is a better guide to renal function in this situation). The digoxin dose should be reduced accordingly (62.5 mg/day or on alternate days in this scenario), and clinical effects and the digoxin level should be monitored carefully if events supervene that further compromise kidney function.

Iatrogenic illness in frail older patients 181

Spironolactone should be avoided in chronic kidney disease because hyperkalaemia is a predictable complication. ACE inhibition requires caution, as this medication can compromise renal perfusion.

CASE 6.16 –  An 84-year-old woman with dementia is admitted from a residential home because she has had some falls.

A1: What iatrogenic illness may result from the given intervention?

Head injury and intracranial bleeding are a substantial risk because of the patient’s frailty, confusion and risk of further falls. Low-dose enoxaparin will substantially increase this risk. The distress caused by subcutaneous injections may exacerbate the patient’s delirium. There may be cutaneous bruising at injection sites and elsewhere due to the patient’s restlessness and agitation and resulting minor trauma.

A2: What risk factors for iatrogenic illness are present in this case?

Fall-related head injury carries a higher than normal risk of intracranial bleeding, particularly subdural haemorrhage, because of age- and dementia-associated cerebral atrophy.

A3: Suggest some alternative management strategies.

The patient could be assessed for anti-thromboembolic stockings if peripheral circulation is satisfactory.

Rehydration, treatment of respiratory infection and supervised mobilization will reduce the risk of VTE.

A4: How can these complications be minimized?

The risk of VTE has to be balanced against the substantial risk (in this case) of harm from increased bleeding. A supportive nursing environment and medical management aiming to reverse treatable conditions and resolve delirium are important. If the patient is judged not to have capacity to

participate in treatment-related decisions, then the medical team should act in her best interests. Timely involvement of family members or any legally appointed representative (lasting power of attorney) is imperative.

CASE 6.17 –  A frail 92-year-old woman has fallen at home. The ambulance service has conveyed her to the local A&E department for further assessment.

A1: What iatrogenic illness may result from the given intervention?

This a common scenario. The patient is frail and will be at substantial risk from hospital admission-related complications such as delirium, further falls, health-care-associated infection, deconditioning due to reduced activity and loss of functional skills. Local support networks will be destabilized by her admission. These risks have to be balanced against the hazards of returning to a potentially unsafe environment and occult illness.

A2: What risk factors for iatrogenic illness are present in this case?

The presence of frailty, cognitive impairment and sensory impairments substantially increases the risk of delirium and falls within the hospital environment. Any subsequent ward moves with unfamiliar routines and interventions will add to this risk.

A3: Suggest some alternative management strategies.

Assessment by a rapid-response therapy and nursing team skilled in the assessment of frail older people is essential in this A&E setting. The patient should have a supported discharge home with reinstatement

of her existing care plan, supplemented by short-term additional social and therapy support as necessary.

There should be further early review at home or attendance at a community or day hospital-based falls clinic (depending on local availability of services) for further comprehensive geriatric assessment. This will identify modifiable conditions and implement treatment and support to enhance care at home and reduce risk of further falls.

A4: How can these complications be minimized?

Safe alternatives to hospital admission should always be considered in frail older people. A working knowledge of local services and community teams is essential. Close liaison and reassurance to the patient’s family and carers are also important. The medical role in A&E is to quickly exclude life-threatening or serious illness, and this will provide focus to the rapid-response nursing/therapy team to permit early supported discharge. Many such teams are supported by elderly-care physicians who are able to give further confidence with respect to medical stability, immediate changes to medication and follow-up plans.

 One-third of people aged over 65 years fall in a year, often repeatedly. Falls resulting in injury are a leading cause of death in older people, accounting for two-thirds of injury-related deaths in people aged 85 years and over.

 Falls in elderly people may be related to one or more underlying medical conditions, including aortic stenosis, cardiac arrhythmia, silent MI, postural hypotension, vasovagal episode, and hindbrain TIA.

 Osteomalacia (vitamin D deficiency) may occur due to lack of exposure to sunlight, poor diet if socially isolated or in poor health, and enhanced metabolism of vitamin D as a result of treatment with phenytoin (a liver enzyme inducer). Diseases causing malabsorption and chronic renal failure can also predispose to osteomalacia.

 There are many common causes of difficulty in walking in elderly people, including stroke,

osteoarthritis, parkinsonism, dementia, visual impairment, chronic cardiorespiratory disease, injuries and complications of falling, and problems with feet and footwear.

 Acute confusion is more prevalent in elderly people. Common causes include metabolic and electrolyte problems, infection, medication and cerebrovascular disease.

 Drug toxicity (e.g. digoxin, phenytoin) is more common in elderly people due to polypharmacy and chronic renal and hepatic impairment.

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