Medication-related Harm: A Geriatric Syndrome

Jennifer M. Stevenson; J. Graham Davies; Finbarr C. Martin

Disclosures

Age Ageing. 2020;49(1):7-11. 

In This Article

Abstract and Introduction

Abstract

The WHO Global Patient Safety Challenge: Medication Without Harm recognises medication-related harm (MRH) as a global public health issue. Increased life-expectancy coupled with multimorbidity and polypharmacy leads to an increased incidence of MRH, especially in older adults: at a cost of approximately £400 million to the National Health Service (NHS) in England. Harm from medicines has long been recognised by geriatricians, and strategies have been developed to mitigate harm. In general, these have focused on the challenges of polypharmacy and appropriateness of medicines, but impact on the quality of life, clinical and economic outcomes has been variable and often disappointing. The problem of MRH in older adults will continue to grow unless a new approach is adopted. Emerging evidence suggests that we need to take a broader approach as described in our conceptual model, where well-recognised physiological changes are incorporated, as well as other rarely considered psychosocial issues that influences MRH. Parallels may be drawn between this approach and the management of geriatric syndromes. We propose there must be a greater emphasis on MRH, and it, of itself, should be considered as a geriatric syndrome, to bring the spotlight onto the problem and to send a clear signal from geriatric experts that this is an important issue that needs to be addressed using a co-ordinated and tailored approach across health and social care boundaries. This requires a more proactive approach to monitor and review the medicines of older adults in response to their changing need.

Introduction

Harm from medicines is on the rise,[1] especially in older adults. Increased life expectancy coupled with multimorbidity frequently leads to polypharmacy and an increased risk of medication-related harm (MRH).[2,3] To this, add frailty, multiagency care within and across health and social care, and MRH seems almost inevitable. Strategies to mitigate MRH have considered these drivers so that polypharmacy and age-related alterations in drug handling are the focus of potentially inappropriate medicines (PIMs) criteria[4,5] and risk prediction models,[2] while transitions of care are addressed by medicines reconciliation and review. However, the impact on the quality of life, clinical and economic outcomes of such interventions is variable and often disappointing.[6,7] The scale of MRH suggests that it should now be thought of as a global public health issue.[8]

Geriatricians have long recognised the scale and importance of MRH in older adults:[9] latrogenesis was added as a 5th pillar to Isaacs' Geriatric Giants. A modern equivalent, the Geriatric 5Ms recognises medicines as a priority point of geriatric expertise and details some important considerations: polypharmacy, deprescribing, optimal prescribing, adverse medication effects and medication burden.[10] While this is helpful, MRH remains problematic. An increasing older population means an increasing number of patients at the risk of MRH and potentially resulting in more hospital admissions and GP visits, costing the NHS in England an estimated £400 million annually.[11] More importantly, the healthcare burden on these individuals is tangible, and reduces the quality of life of those approaching the end of life.

Emerging evidence reminds us that in frail older adults, even 'appropriate' medicines can present as a situational challenge and be harmful due to multiple reserve deficits impairing mechanisms to deal with even a minor side-effect.[12,13] Existing systems employed to reduce MRH fail to recognise this vulnerability, and the instability of an individual. It is now time to place a greater emphasis on MRH, and we propose that it should, of itself, be considered as a geriatric syndrome, to bring the spotlight onto this problem and to send a clear signal from geriatric experts that this is an important issue that needs to be addressed using a coordinated and tailored approach across health and social care boundaries. This requires a more proactive approach to monitor and review the medicines of older adults, in accordance with the patient journey.

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