Are you missing adverse drug events in the elderly?
If an elderly man came in complaining of dizziness, would you suspect a connection to a medication the patient is taking?
A new study shows that EDs often miss adverse drug events (ADEs) pertaining to misuse of prescription and over-the-counter medications in elder patients, especially ones unrelated to the patient’s chief complaint.1
If patients report syncope, hypotension, nausea, vomiting, abdominal pain, constipation, diarrhea, or headache, this may be due to improper use of prescription medications, says Steven D. Glow, RN, MSN, FNP, adjunct assistant professor at the College of Nursing at Montana State University-Bozeman in Missoula. "Just look at the list of common adverse effects for several medications, and these will appear as common themes," he says.
To improve assessment of elder patients for ADEs, do the following:
- Ask the right questions at triage.
It may not be clear that a patient’s complaint is related to an ADE, says Shelley Cohen, RN, CEN, an educator for Health Resources Unlimited, a Hohenwald, TN-based consulting company specializing in ED triage and health care leadership. Obtain current accurate information on prescriptions, over-the-counter medications, herbal supplements, and vitamins that the patient claims they are taking, she recommends. Ask patients the following questions, advises Cohen:
- Do you know the names of the medications you are supposed to be taking?
- Which of these are you actually taking now?
- How often do you take them?
- What are the doses of each of these?
- Are you taking any vitamins? If so, what are the names, and how often do you take them? How many at a time do you take?
- Are you taking any herbal agents? If so, which ones, how many, and how often?
If you feel that the patient’s complaint could be related to a medication, ask the following questions:
- How long have you been taking this medication?
- Did you take your dose for today yet?
- Have you had these symptoms before? If yes, how long ago, and did you see a doctor for them?
Encourage elderly patients to bring medications with them to the ED, recommends Glow. "The bottles have much valuable information including prescriber, quantity, and date, which may assist the nurse in screening for ADEs," he says.
- Differentiate side effects from an ADE.
Side effects from a medication are not necessarily an ADE, notes Cohen. For example, if a patient becomes drowsy after taking 25 mg promethazine, this is an expected side effect, not an adverse reaction, she says. "The patient is warned about this common side effect, and the bottle is even labeled with a caution sticker to alert the patient to this," she says.
However, if the same patient takes the same drug and dose and has a dystonic reaction, this is an adverse event because it is unintended, undesirable, and generally unexpected, says Cohen.
If you’re not sure whether a patient’s reaction is truly an ADE, contact pharmacists, she adds. This can be very confusing. "Sometimes the side effect becomes an ADE when it requires discontinuing the medication or specific treatment related to those symptoms," Cohen says. "Anytime we suspect an ADE, even if we are not sure, we report it to our pharmacy. They review the case and determine if it needs to be reported."
Involve the patient’s pharmacist in your assessment process, Glow recommends. "When I am stuck, I ask the patient the name of their pharmacy and call their pharmacist, who is often able to assist in clarifying the patient’s current medication plan," he says.
- Ask patients how they keep track of medications.
"If the patient cannot describe an organized system such as drug boxes, color coding, or calendars for keeping track of their medications, the current problem may be too much or too little of their medication," says Glow.
He points to the Joint Commission’s National Patient Safety Goals requiring you to reconcile a patient’s medications across the continuum of care, including obtaining and documenting a complete list of the patient’s current medications, and communicating a list of the patient’s medications to the next provider of service. "If patients discharged from the ED are referred to a primary care provider, a list must be compiled on discharge," says Glow.
Record this information electronically so it can be accessed during the patient’s next ED visit, Glow recommends. "Providing the patient with a written list of medications at discharge would enhance the continuity of care," he says.
Reference
- Hohl CM, Robitaille C, Lord V, et al. Emergency physician recognition of adverse drug-related events in elder patients presenting to an emergency department. Acad Emerg Med 2005; 12:197-205.
Sources
For more information on adverse drug events in elderly patients, contact:
- Shelley Cohen, RN, CEN, Health Resources Unlimited, 522 Seiber Ridge Road, Hohenwald, TN 38462. Telephone: (888) 654-3363 or (931) 722-7206. Fax: (931) 722-7495. E-mail: [email protected]. Web: www.hru.net.
- Steven D. Glow, RN, MSN, FNP, Adjunct Assistant Professor, College of Nursing, Montana State University-Bozeman, Missoula Campus, 32 Campus Drive, No. 7416, Missoula, MT 59812-7416. Telephone: (406) 243-2536. Fax: (406) 243-5745. E-mail: [email protected].
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