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Secondary Prevention: Preventing Disability
Through Chronic Disease Management
(September 15, 2006)
In individuals who are already significantly impaired by the effects
of illness and aging, such as the residents of nursing homes,
preventive interventions must be realistic and pertinent. The
emphasis should be on a few simple measures that enhance
quality of life while trying to minimize painful and costly
complications.
For example, many dietary interventions that can help prevent
serious chronic diseases such as arteriosclerotic cardiovascular
disease in younger, relatively healthy individuals have very limited
proven effectiveness in frail elderly nursing home residents who
already have significant end-organ complications such as heart
and kidney disease. Event he benefits of lowering cholesterol in
individuals over the age of 85 have been challenged. For nursing
home residents, who are typically at considerable nutritional risk,
it may make more sense just to let them eat what they want and
to try to encourage as much activity as possible, within the limits
of their physical and functional impairments.
Nursing home residents may be less able to exercise vigorously,
but any kind of physical activity–however simple–may benefit
their psychosocial well-being and quality of life.
Similarly, treating high blood pressure aggressively is a good
thing in younger, healthier individuals or in those who have
suffered major organ damage such as multiple strokes or heart
attacks. But in frail older individuals or those over the age of 85,
overly aggressive blood pressure control may lead to undesirable
complications including increased fall risk, dizziness, and other
unpleasant side effects of treatment without necessarily improving
the results.
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In this second of two programs, we consider some key preventive
measures that often can help reduce risk and complications in
nursing home residents. These include injury prevention, reducing
complications from medical treatments including attention to
adverse medication consequences, minimizing hospitalization,
trying to reduce acquired infections, preventing pressure ulcers,
and improving the quality and consistency of evidence-based care
and practices in nursing homes.
Injury prevention
Injuries are a major cause of disability and death in elderly
individuals.
For example, more than one-third of adults aged 65 or older
fall each year, and of those who fall, 20%B30% suffer moderate
to severe injuries that ultimately reduce mobility and
independence.
Injuries associated with hospitalization
These are more common and may be more severe in older
(65 years) than in younger individuals (<65 years). They are
often preventable.
The development of adverse events or disability during
hospitalization in older patients is strongly related to a poorer
prognosis following hospital discharge.
The Hospital Outcomes Project for the Elderly found that,
following discharge from hospitalization, a third of elderly patients
declined in at least one of their activities of daily living.
Causes of functional decline include the effects of illness,
treatment, adverse events, and deconditioning. These individuals
have a greater risk of subsequent falls, rehospitalization,
institutionalization, and dying.
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Six major categories of injuries in the hospitalized elderly
Unintentional medical injuries are a serious public health
problemBand not a new problem, at all. For example, a 1962
study of 500 consecutive admissions of elderly indigent patients
admitted to a single medical service found that 29% had
complications as a result of hospitalization.
The Harvard Medical Practice Study defined an adverse event
as an unintended injury caused by medical management that
resulted in measurable disability. Such events occurred in nearly
4% of hospitalized patients. More than two thirds of these
iatrogenic injuries were due to errors and were, therefore,
potentially preventable. Adverse events were more common in
patients aged 65 years and older, even after adjusting for
comorbidities.
The hospitalized elderly are most often injured by adverse
drug events, falls, nosocomial infections, pressure sores, delirium,
and surgical and perioperative complications. [Source: Rothschild
JM, Bates DW, Leape LL. Preventable medical injuries in older
patients. Arch Intern Med. 2000;160:2717-2728.]
Older individuals are at higher risk for all of these
complications in any setting, including the nursing home. For
example, there is as much as a 10-fold increase in falls risk
compared to younger individuals. Older individuals are at special
risk, have special problems, and may require special measures to
achieve acceptable levels of safety in health care.
Although the main cause of these increased risks appears to
be the diminished physiological reserve of elderly individuals, age
alone is a less important predictor of adverse events than
comorbidities and functional status.
Many injury prevention strategies are applicable to those of
all ages, while others are specifically beneficial in older patients.
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The success of intervention varies by type of complications.
For example, various interventions have been successful in
reducing medication-related injuries, and fall prevention programs
have been demonstrated to be effective in the nursing home and
home.
Among nursing home patients, Gurwitz et al found 3890
reported events in a 1-year study in a 700-bed long-term care
facility. The most common events were falls, non-fall-related
injuries, and adverse drug events (ADEs).
Adverse Drug Events
Adverse drug events (defined as injuries resulting from the
medical use of a drug) have been identified as the most common
type of adverse event in hospitalized patients, including patients
aged 65 years or older.
Adverse drug events include preventable (those due to
errors) and nonpreventable ADEs, also called adverse drug
reactions.
Studies have identified an incidence of ADEs among
hospitalized older patients ranging from 2.0 to 14.8%.
In addition to these ADEs that occur during hospitalization,
these events are also an important reason for older individuals
being admitted to the hospital. In 1969, Hurwitz found that ADEs
contributed to the need for hospitalization in 15% of individuals
aged 60 years or older, which was 2.5 times the rate in younger
patients.
Adverse drug events are also common in nursing homes. In
one study over a 4-year period, 217 (65.4%) of 332 nursing
home residents had 444 ADEs. A different, 18-month study of
veterans admitted to a nursing home found that 32% had ADEs.
In the outpatient setting, studies have found that 7.5% to
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23.5% of individuals receive inappropriate or contraindicated
drugs.
Of great importance, newly revised surveyor guidance on
Unnecessary Drugs is to be released in the latter part of 2006.
This guidance provides considerable clarity and detail about the
scope of medication-related concerns in nursing home residents,
and identifies many ways in which facilities and practitioners can
reduce medication-related risks and identify actual adverse
consequences related to medications.
Early Recognition
It has been known for some time that physicians often fail to
recognize ADEs, leading to continuing injury and unnecessary
additional therapy and tests. When an ADE is misinterpreted as a
newly acquired illness, physicians often prescribe additional
therapy, which fails to resolve the underlying cause and places the
individual at risk for additional harm from the additional drugs. An
example is extrapyramidal symptoms developing after initiating
metoclopramide therapy, which can result in drug therapy for
(erroneously) presumed parkinsonism.
Strategies for Reducing Medication-Related Injury
One approach is to use safer medications and
nonpharmacological alternatives; for example, to manage pain or
improve sleep. Pharmacists can offer safeguards for older
individuals in hospitals and nursing homes. Their roles should be
expanded to other settings.
Falls and Restraints
Falls are a major source of injury, decline, and death in older
individuals. Age, female sex, and living alone are all associated
with increased rates of falling.
Among nursing home residents, approximately half fall each
year, and 9% sustain serious injury.
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The 1-year incidence of falls among elderly patients living in
the community is 32%, with resultant serious injuries in 24% of
those who fall.
An estimated 250,000 fall-related hip fractures occur
annually, a figure that could double by the year 2040.
Individuals at risk for falling pose management challenges.
Restraints are of limited value in reducing falls or preventing
injury, and are increasingly controversial. Restraints in
hospitalized patients have been associated with increased
mortality rates, longer lengths of stays, pressure sore
development, increased incidence of nosocomial infections, and
emotional distress.
Environmental factors are more important causes of falling
for younger elderly patients, while host-related factors (decreased
mobility, visual impairment, dizziness, and neurologic or
cardiovascular disease) are more prominent in older and frailer
elderly individuals.
Nonenvironmental risk factors most associated with falling in
long-term care facilities include a history of falling, the ability to
walk, dementia, and medications, especially sedative-hypnotics,
vasodilators, antidepressants (including newer psychotropics), and
diuretics.
Successful fall prevention programs target high-risk patients
and are cost-effective. Fall consultation services have been shown
to help reduce nursing home falls and fall-related injuries. Studies
have identified marked reductions in fall rates by use of a
multifactorial intervention program including medication review,
education, training in gait and transfer skills, changes in
environmental hazards, strengthening exercises, and behavioral
modifications.
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Other Factors
In addition to an increased rate of complications from
medical care, older individuals have iatrogenic injuries from
inappropriate care.
For example, congestive heart failure is the most common
reason for hospitalization of elderly individuals, responsible for
more than 500,000 admissions per year. One study identified 7%
of admissions for congestive heart failure to result from improper
treatment, including fluid overload, procedures, and misuse of
drugs. These individuals were also much more likely to die while
hospitalized.
Underdiagnosis and delayed diagnosis of illnesses are more
common in elderly individuals. Examples of factors associated with
underdiagnosis include patient-related causes, such as symptom
denial and symptom attribution to old age; systems-related
causes, such as inadequate medical access and reimbursement
that is inadequate for the time needed to care for complex older
individuals; and physician-related causes. Older individuals often
present with nonspecific or atypical symptoms; for example, that
relate to an organ system other than the one that is involved with
the immediate problem, or that are different from the
presentation in healthier or younger individuals.
Underdiagnosis in older patients appears more common
when a nongeriatric physician is involved. For example, providers
who are not trained in geriatrics may be deficient in diagnosing
gait disturbances, metabolic problems, early cancers, the
presence of untreated infections, and reversible causes of
incontinence and dementia.
Nosocomial Infections
Nosocomial infections (those that are acquired while in a
healthcare facility are common and often dangerous to older
individuals. For example, pneumonia among hospital inpatients
occurs twice as often in older patients and is associated with
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poorer outcomes. Pneumonia and urinary tract infections account
for approximately half of nosocomial infections in long-term care
facilities.
Risk factors responsible for nosocomial infections include
urinary catheterization, fecal and urinary incontinence, recent
antibiotic use, intravenous lines, nasogastric tubes, and
corticosteroid use. Older individuals are predisposed to pneumonia
because of decreased lung capacity, cough reflex, and immunity.
Other risk factors include poor nutritional status, neuromuscular
disease, and witnessed aspiration events.
Approaches to preventing nosocomial infections in older
individuals include following basic principles that are applicable to
all ages, including frequent hand washing, appropriate wound and
skin care, immunization, and isolation of contagious individuals.
Decreasing prolonged use of broad-spectrum antibiotics or
invasive devices (endotracheal tubes, nasogastric tubes,
indwelling urinary catheters, and central venous catheters) can
also reduce infections.
Pressure Ulcers
Pressure ulcers are an important source of complications and
death in elderly individuals. Older individuals at greatest risk for
pressure sores are bedridden or chair bound. Risk factors include
fecal incontinence, long lengths of hospital stay, traumatic
injuries, neuromuscular diseases, malnutrition, lymphopenia,
decreased body weight, dry skin, and an altered level of
consciousness.
Skin breakdown develops in the setting of moisture, friction,
shearing forces, and pressure.
Pressure sore prevention begins with early risk assessment
to identify individuals who are likely to benefit from prevention
strategies. In hospitals, staff education has been shown to reduce
hospital-acquired pressure sores significantly. Other preventive
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measures include reduction of mechanical loading due to
immobility, appropriate support surfaces, careful skin care,
reduction of excess moisture, addressing modifiable causes of
incontinence, providing basic nutrition support, earlier clinical
recognition, improved wound care, and education.
Delirium
Delirium refers to acute change in mental status and level of
consciousness, and is a medical emergency that often presents
with psychiatric symptoms.
Common causes for delirium include medications, infections,
fluid and electrolyte imbalance or other metabolic abnormalities,
and alcohol or drug withdrawal.
Predisposing factors include age, comorbid conditions, and
preexisting cognitive or functional impairment.
External influences include insufficient social support, sleep
deprivation, unfamiliar environments, pain, and stimuli reduction.
Physicians fail to diagnose 30% to 50% of delirious patients.
Reasons for this include poor patient-physician communication,
inadequate provision of information by nursing and other staff of
the details of symptoms, misdiagnosis as dementia or depression,
overlooking delirium while managing other diseases, and
mistakenly attributing the behavior to normal aging.
Delirium is often predictable and preventable, especially in
high-risk elderly individuals. One study identified a one-third
reduction in delirium for hospitalized older patients who undergo a
multifactorial intervention to reduce risk factors.
Surgical and Perioperative Complications
Age alone is not an important risk factor for many types of
surgery. Even the oldest individuals with few comorbid conditions
and nonemergency operations have outcomes comparable to
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younger age groups.
Important factors in predicting postoperative outcomes
include complexity scores, functional status, emergency nature of
cases, or the preoperative anesthesia risk assessment scores. The
rates of surgical complications increase with age, with 3 to 4 times
as many of the oldest individuals having more than one
complication.
After surgery, iatrogenic injury involving the lungs, kidneys,
and cardiovascular system increased several-fold with aging.
Postponing surgery until a condition becomes more
complicated or an emergency may increase risk of complications
during and after surgery.
Effective preventive measures include stabilizing active
medical problems before surgery, and trying to minimize
postoperative complications due to bed rest, pain management,
and several predictable physiologic responses. For example,
letting an elderly individual use patient-controlled analgesia can
complications.
An approach to preventive efforts in the nursing home
Preventive efforts in the nursing home should reflect a
coordinated, widespread initiative of all disciplines who provide or
support care.
The facility should emphasize appropriate primary,
secondary, and tertiary preventive measures that are most likely
to improve function, reduce pain and discomfort, enhance
autonomy, reduce preventable complications, prevent the spread
of communicable illnesses, reduce subsequent need for more
costly and prolonged medical care, or support a more comfortable
death.
Physicians should help identify appropriate preventive and
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screening measures.
Goals related to prevention in the nursing home include the
following:
1. Residents have a lower incidence of preventable illnesses
or complications, within the limits of their underlying conditions.
2. Preventive and screening measures are relevant to the
condition, prognosis, and wishes of individual residents / patients.
3. The facility complies with related laws and regulations; for
example, those related to immunization.
The following represents a proposed approach to prevention
and screening:
1. Where medically indicated and not declined by the
resident / patient or substitute decision maker, the attending
physician and staff should identify an individualized screening
approach and primary preventive measures. Examples include:
 immunizations
 injury prevention
 reduction of drug doses to address or prevent side
effects
 measures to maintain adequate nutritional status
 prevention of pressure sores
 measures to try to maintain continence
 measures to maintain mobility
 prophylaxis of osteoporosis
Primary prevention is aimed at reducing the incidence of a
disease or condition by preventing its onset.
2. Where medically indicated and not declined by the
resident / patient or substitute decision maker, the staff and
attending physician should identify secondary and tertiary
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preventive measures for individual residents / patients, such as:
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control hypertension
identify and treat dental disease
manage diabetes and diabetic complications
compensate for significant sensory impairments,
including vision and hearing
manage medication complications
reduce risk factors for delirium
address treatable causes of incontinence
screen for depression
provide restorative services
prevent complications of osteoporosis
reduce risk factors for gastrointestinal bleeding
prevent stroke
Secondary prevention targets early identification of a disease
or condition to limit its course and complications. Tertiary
prevention focuses on prevention of additional problems,
complications, and functional impairments that might
otherwise result from a disease or disability that is not fully
preventable or correctable.
3. The physician should order diagnostic or screening tests
that are relevant to monitoring the individual=s medication
regimen or identifying modifiable risks and complications.
Most routine annual or other periodic laboratory screening
has not been demonstrated to be clinically valuable or costeffective, unless targeted specifically to a patient's
conditions, risks, or medication regimen.
4. The staff and physician should address ethical issues to
identify situations where residents / patients don=t want, or are
unlikely to benefit from aggressive medical interventions,
screening, or preventive interventions (see policies on managing
Ethical Issues).
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Application of Common Lessons To Preventing Injury
Nursing homes should incorporate proven approaches to
injury prevention from industry and elsewhere. Principles of total
quality management, including interdisciplinary approaches, are
important for preventing errors in the care of elderly individuals.
For example, high-reliability organizations (such as aviation)
emphasize management of workflow and schedules to prevent
fatigue and stress and provide extensive training in teamwork and
individual responsibility for safety.
Key concepts to reduce medical errors have been identified
and should be incorporated into every nursing home=s systems,
including simplify, standardize, improve communication,
encourage the reporting of errors in a nonpunitive environment,
reduce reliance on memory, provide pertinent training, and use
redundancy to intercept inevitable errors.
Reducing Variability in the Treatment of Older Patients
There is considerable room for prevention through greater
standardization of treatment and better use of evidence-based
guidelines and protocols.
Older individuals often benefit greatly from interventions,
even though their risk is higher. Inappropriate care of older
patients is associated with underuse, overuse, and misuse of
medical services, including procedures and medications.
Risk assessment
Assessing the risk profile of older individuals at the time of
admission to a nursing home can identify individuals at risk for
functional decline and injury. Improved communication between
nursing homes and hospitals, improved transfer and discharge
planning, and greater attention to detail in accepting patients for
admission from hospitals can help identify individuals at risk and
those who need additional follow-up because of complications.