Non-conveyance of older adult patients and association with subsequent clinical and adverse events after initial assessment by ambulance clinicians: a cohort analysis

Abstract Background Older adults (age ≥ 65 years) represent a significant proportion of all patients who are not transported to hospital after assessment by ambulance clinicians (non-conveyed patients). This study aimed to fill the knowledge gap in the understanding of the prevalence of older adult non-conveyed patients and investigate their characteristics and risk factors for subsequent and adverse events with those of younger non-conveyed patients comparatively. Methods This population-based retrospective cohort study included all adult non-conveyed patients who availed the ambulance service of Region Stockholm, Sweden in 2015; they were age-stratified into two groups: 18–64 and ≥ 65 years. Inter-group differences in short-term outcomes (i.e. emergency department visits, hospitalisations, and mortality within 7 days following non-conveyance) were assessed using multivariate regression analyses. Results Older adult patients comprised 48% of the 17,809 non-conveyed patients. Dispatch priority levels were generally lower among older non-conveyed patients than among younger patients. Non-conveyance among older patients occurred more often during daytime, and they were more frequently assessed by ambulance clinicians with nonspecific presenting symptoms. Approximately one in five older adults was hospitalised within 7 days following non-conveyance. Patients presenting with infectious symptoms had the highest mortality risk following non-conveyance. Oxygen saturation level < 95% or systolic blood pressure > 160 mmHg had significantly higher associations with hospitalisation within 7 days following non-conveyance in older adult patients. Conclusions Older adult patients have an increased risk for adverse events following non-conveyance. In combination with a complex and variating presentation of symptoms and vital signs proved difficult for dispatch operators and ambulance clinicians to identify and assess, the identified risks raise questions on the patient safety of older adult non-conveyed patients. The results indicate a system failure that need to be managed within the ambulance service organisation to achieve higher levels of patient safety for older non-conveyed patients.

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Non-conveyance of older adult patients and association with subsequent clinical and adverse events after initial assessment by ambulance clinicians: A cohort analysis

10.21203/rs.3.rs-53328/v1 ◽

2020 ◽

Author(s):

Jakob Lederman ◽

Veronica Lindström ◽

Carina Elmqvist ◽

Caroline Löfvenmark ◽

Gunnar Ljunggren ◽

...

Keyword(s):

Older Adults ◽

Adverse Events ◽

Older Adult ◽

Cohort Analysis ◽

Significant Proportion ◽

Emergency Department Visits ◽

Adult Patients ◽

Oxygen Saturation Level ◽

Presenting Symptoms ◽

Increased Risk

Abstract Background: Older adults (age ≥65 years) represent a significant proportion of all patients who are not transported to hospital after assessment by ambulance clinicians (non-conveyed patients). This study aimed to fill the knowledge gap in the understanding of the prevalence of older adult non-conveyed patients and investigate their characteristics and risk factors for subsequent and adverse events with those of younger non-conveyed patients comparatively.Methods: This population-based retrospective cohort study included all adult non-conveyed patients who availed the ambulance service of Region Stockholm, Sweden in 2015; they were age-stratified into two groups: 18–64 and ≥65 years. Inter-group differences in short-term outcomes (i.e. emergency department visits, hospitalisations, and mortality within 7 days following non-conveyance) were assessed using multivariate regression analyses.Results: Older adult patients comprised 48% of the 17,809 non-conveyed patients. Dispatch priority levels were generally lower among older non-conveyed patients than among younger patients. Non-conveyance among older patients occurred more often during daytime, and they were more frequently assessed by ambulance clinicians with nonspecific presenting symptoms. Approximately one in five older adults was hospitalised within 7 days following non-conveyance. Patients presenting with infectious symptoms had the highest mortality risk following non-conveyance. Oxygen saturation level <95% or systolic blood pressure >160 mmHg had significantly higher associations with hospitalisation within 7 days following non-conveyance in older adult patients.Conclusions: Older adult patients have an increased risk for adverse events following non-conveyance. In combination with a complex symptom presentation which proves difficult for dispatch operators and ambulance clinicians to identify, this risk raises questions on the patient safety of older adult non-conveyed patients.

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Safety and Efficacy Considerations of Gabapentin as Adjunctive Therapy to Opioids in the Perioperative Setting for Older Adults

The Senior Care Pharmacist ◽

10.4140/tcp.n.2020.436. ◽

2020 ◽

Vol 35 (10) ◽

pp. 436-438

Author(s):

Edgar Garcia ◽

Justin P. Reinert ◽

Michael Veronin

Keyword(s):

Older Adults ◽

Chronic Pain ◽

Pain Management ◽

Adverse Effects ◽

Older Adult ◽

Adjunctive Therapy ◽

Adult Patients ◽

Opioid Epidemic ◽

Safety And Efficacy ◽

Initial Choice

While opioids have historically been the initial choice of analgesic for both acute and chronic pain, legislative and deprescribing trends as a result of the opioid epidemic have demonstrated an increase in the use of adjunctive therapies. These adjunctive agents are being utilized with increased frequency, especially in older adult patients, as a mechanism to mitigate any likelihood of dependency and in an effort to provide multimodal pain management. As this patient population can be more challenging because of comorbidities, the presence of polypharmacy, pharmacokinetic, and pharmacodynamic changes, it is important to evaluate the risk of any relevant adverse effects for opioids and adjuncts that can lead to higher risk of opioid toxicities. Gabapentin is one of the most commonly added adjunctive medications; however, its safety and efficacy in conjunction with opioids has not been exclusively considered in older adult patients in the perioperative setting. This report will summarize available evidence for gabapentin as an adjunctive therapy to opioids in older adult patients undergoing surgery.

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Antipsychotic Polypharmacy in Older Adult Asian Patients With Schizophrenia: Research on Asian Psychotropic Prescription Pattern

Journal of Geriatric Psychiatry and Neurology ◽

10.1177/0891988719862636 ◽

2019 ◽

Vol 32 (6) ◽

pp. 304-311 ◽

Cited By ~ 2

Author(s):

Min Dong ◽

Liang-Nan Zeng ◽

Qinge Zhang ◽

Shu-Yu Yang ◽

Lian-Yu Chen ◽

...

Keyword(s):

Older Adults ◽

Older Adult ◽

Multiple Logistic Regression Analysis ◽

Mainland China ◽

Careful Consideration ◽

Drug Induced ◽

Prescription Pattern ◽

Asian Patients ◽

Increased Risk ◽

Collection Form

Background and Objective: Antipsychotic polypharmacy (APP) is a controversial topic in the treatment of older adults with schizophrenia. The objective of this study was to examine the use of APP in older adult Asian patients with schizophrenia and its associated demographic and clinical factors. Methods: This study was based on the fourth survey of the consortium known as the Research on Asian Psychotropic Prescription Pattern for Antipsychotics. Fifteen Asian countries/territories participated in this survey, including Bangladesh, Mainland China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, Myanmar, Pakistan, Singapore, Sri Lanka, Taiwan, Thailand, and Vietnam. Basic demographic and clinical characteristics were collected using a standardized data collection form. Results: Among the 879 older adults with schizophrenia included in the survey, the rate of APP was 40.5%. Multiple logistic regression analysis revealed that higher antipsychotic doses ( P < .001, odds ratio [OR] = 1.003, 95% confidence interval [CI]: 1.002-1.003), longer duration of illness ( P = .02, OR = 1.845, 95% CI: 1.087-3.132), and the prescription of anticholinergics ( P < .001, OR = 1.871, 95% CI: 1.329-2.635), second-generation antipsychotics ( P = .001, OR = 2.264, 95% CI: 1.453-3.529), and first-generation antipsychotics ( P < .001, OR = 3.344, 95% CI: 2.307-4.847) were significantly associated with APP. Conclusion: Antipsychotic polypharmacy was common in older adult Asian patients with schizophrenia. Compared to the results of previous surveys, the use of APP showed a declining trend over time. Considering the general poor health status of older patients with schizophrenia and their increased risk of drug-induced adverse events, the use of APP in this population needs careful consideration.

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Atypical presentations in the hospitalised older adult testing positive for SARS-CoV-2: a retrospective observational study in Glasgow, Scotland

Scottish Medical Journal ◽

10.1177/0036933020962891 ◽

2020 ◽

pp. 003693302096289

Author(s):

Peter Davis ◽

Rory Gibson ◽

Emily Wright ◽

Amy Bryan ◽

Jamie Ingram ◽

...

Keyword(s):

Older Adults ◽

Older Adult ◽

Respiratory Symptoms ◽

The Elderly ◽

Mortality Rates ◽

Rt Pcr ◽

Contributing Factors ◽

Prognostic Features ◽

Presenting Symptoms ◽

Atypical Presentations

Introduction: Understanding of how SARS-CoV-2 manifests itself in older adults was unknown at the outset of the pandemic. We undertook a retrospective observational analysis of all patients admitted to older people’s services with confirmed COVID-19 in one of the largest hospitals in Europe. We detail presenting symptoms, prognostic features and vulnerability to nosocomial spread. Methods: We retrospectively collected data for each patient with a positive SARSCoV-2 RT PCR between 18th March and the 20th April 2020 in a department of medicine for the elderly in Glasgow. Results: 222 patients were included in our analysis. Age ranged from 56 to 99 years (mean = 82) and 148 were female (67%). 119 patients had a positive swab for SARS-CoV-2 within the first 14 days of admission, only 32% of these patients presented with primarily a respiratory type illness. 103 patients (46%) tested positive after 14 days of admission – this was felt to represent likely nosocomial infection. 95 patients (43%) died by day 30 after diagnosis. Discussion: This data indicates that older people were more likely to present with non-respiratory symptoms. High clinical frailty scores, severe lymphopenia and cumulative comorbidities were associated with higher mortality rates. Several contributing factors will have led to nosocomial transmission.

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0173 Spring Forward, Fall Back: Increased Patient Safety-Related Adverse Events Following the Spring Time Change

SLEEP ◽

10.1093/sleep/zsaa056.171 ◽

2020 ◽

Vol 43 (Supplement_1) ◽

pp. A69-A69

Author(s):

B Kolla ◽

B J Coombes ◽

T I Morgenthaler ◽

M P Mansukhani

Keyword(s):

Patient Safety ◽

Adverse Events ◽

Human Error ◽

Negative Binomial ◽

Random Effect ◽

Time Change ◽

Healthcare Organizations ◽

Human Errors ◽

Fall Time ◽

Increased Risk

Abstract Introduction “Spring forward,” the start of daylight savings time (DST) reduces sleep opportunity by an hour. The resulting sleep deprivation in healthcare workers can increase the potential for medical errors. We examined the change in patient safety-related adverse events (AEs) following the time change in both spring and fall. Methods Self-reported AEs that occurred 7 days prior to and following the spring and fall time changes for years 2010–2017 in a large healthcare organization were ascertained. AEs likely resulting from human errors were identified. The change in the number of AEs (all AEs or restricted to those resulting from human error) following the spring and fall time change were modeled using negative binomial mixed models using a random effect to correct for non-independent observations in consecutive. Results Over the 8 year period, there were more AEs (all and human) in the 7 days following the change in time both in spring (All: 2812 V. 2699; Human: 1902 V. 1625) and fall (All: 3207 V. 3007; Human: 2189 V. 2087). However, the only statistically significant increase was for the estimated 18% increase in human errors following time change in spring (95% CI: 6% to 34%; p = 0.004). The 18% AE increase in spring was also significantly greater than the 5% increase in AE in fall (p = 0.018). Conclusion There is a significant increase in human error related AEs following the “spring forward” clock change which can jeopardize patient safety. Based on safety considerations, DST might best be eliminated; alternatively, policy makers and healthcare organizations should evaluate measures to mitigate the increased risk during this period. Support NA

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How to manage bleeding disorders in aging patients needing surgery

Hematology ◽

10.1182/hematology.2021000288 ◽

2021 ◽

Vol 2021 (1) ◽

pp. 529-535

Author(s):

Mouhamed Yazan Abou-Ismail ◽

Nathan T. Connell

Keyword(s):

Older Adult ◽

Volume Overload ◽

Von Willebrand Disease ◽

Adult Patients ◽

Bleeding Disorders ◽

Age Related ◽

Increased Risk ◽

Individualized Approach ◽

Underlying Disorder ◽

Guidelines And Recommendations

Abstract With improvements in medical care, the life expectancy of patients with bleeding disorders is approaching that of the general population. A growing population of older adult patients with bleeding disorders is at risk of age-related comorbidities and in need of various elective and emergent age-related procedures. The increased risk of thrombosis and volume overload in older adults complicates perioperative hemostatic management. Furthermore, antithrombotic treatment such as antiplatelet or anticoagulant therapy, which is frequently required for various cardiovascular interventions, requires a meticulous individualized approach. Evidence-based guidelines for the management of aging patients with bleeding disorders are lacking, largely due to the underrepresentation of older adult patients in clinical trials as well as the rarity of many such bleeding disorders. We discuss the current guidelines and recommendations in the perioperative hemostatic management of older adult patients with hemophilia and von Willebrand disease as well as other rare bleeding disorders. The optimal management of these patients is often complex and requires a thorough multidisciplinary and individualized approach involving hematologists, surgeons, anesthesiologists, and the specialists treating the underlying disorder.

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A Systematic Review Examining the Efficacy of Epidural Analgesia on Mortality in Older Adult Patients with Rib Fractures

10.28971/532019ce132 ◽

2019 ◽

Author(s):

Erin Casimiro

Keyword(s):

Systematic Review ◽

Older Adults ◽

Epidural Analgesia ◽

Older Adult ◽

Patient Population ◽

Effective Means ◽

Pulmonary Complications ◽

Rib Fractures ◽

Definitive Treatment ◽

Increased Risk

Rib fractures are a common consequence of blunt force trauma, producing pain and potentially leading to complications such as pneumonia, atelectasis, respiratory failure, and death. Due to physiological changes related to aging, older adults aged 65 and over are at increased risk for developing such complications. Aggressive treatment of pain has been recognized as paramount in preventing such consequences. While there are multiple modalities to treat pain related to rib fractures, epidural analgesia has frequently been recognized as an effective means of preventing pulmonary complications and decreasing mortality in an opioid sparing technique. However, it remains unclear if this therapy would serve as a definitive treatment in the population of older adults. The purpose of this systematic review was to determine the effect of epidural analgesia on decreasing mortality in the older adult patient population. Literature and pertinent randomized controlled trials were searched for inclusion within this review. Six trials were included within this review utilizing the PRISMA checklist and CASP tool to extract and critically appraise data. Cross study analysis was then utilized to determine overarching themes within the data. This systematic review did not find any statistically significant data to suggest that mortality is decreased in older adults by utilizing epidural analgesia after thoracic trauma. Further research is necessary utilizing prospective data focusing on this particular patient population in order to better determine the effectiveness of this treatment.

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Red Blood Cell Adhesion Is Increased in the Young Adult Population with Sickle Cell Disease

Blood ◽

10.1182/blood-2018-99-120175 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 2387-2387

Author(s):

Erina Quinn ◽

Charlotte Yuan ◽

Sargam Kapoor ◽

Karen Ireland ◽

Janine Keenan ◽

...

Keyword(s):

Older Adults ◽

Young Adults ◽

Young Adult ◽

Blood Cell ◽

Older Adult ◽

Sickle Cell ◽

Research Funding ◽

Adult Patients ◽

Cell Disease ◽

Blood Samples

Abstract Background: Sickle cell disease (SCD) is characterized by abnormal cellular adhesion to the endothelium, contributing to progressive vasculopathy and vaso-occlusion. The progression of the underlying pathophysiology in SCD with age is not well understood. We evaluated red blood cell (RBC) adhesion at clinical baseline to laminin (LN) in children and adults with HbSS, using the SCD Biochip.1 The SCD Biochip is a microfluidic device that recapitulates physiologic flow and allows quantitation of RBC adhesion to biological surfaces.1 Methods: This prospective cross-sectional study was conducted at The Children's Hospital at Montefiore in the Bronx, NY and University Hospitals Adult Sickle Cell Clinic in Cleveland, OH between 2014 and 2017. Blood samples were obtained from 29 children 8 to 18 years of age (33 samples, 28 HbSS and 1 HbSS HPFH (hereditary persistence of fetal hemoglobin), 13 males and 16 females), from 61 young adult patients 18 to 40 years of age (117 samples, 53 HbSS and 8 HbSS HPFH, 32 males and 29 females), and from 20 older adult patients >40 years of age (38 samples, 16 HbSS and 4 HbSS HPFH, 9 males and 11 females). All blood samples were obtained at clinical baseline. Of the children, young adult, and older adult populations, 45%, 46%, and 40% were on hydroxyurea treatment, respectively. Adhesion experiments were performed using surplus whole blood passed at physiological flow through LN-immobilized microchannels, and quantified after a wash step via microscope based on published protocols.1 Median values were used for multiple samples from a single individual. Results: Adults had higher, more heterogeneous RBC adhesion (440 ± 654, N=81) than did children (90 ± 193, N=29, not shown, p<0.001). Young adults tended to have higher adhesion than older adults (n.s.), as well as children (P<0.001, Figure 1). Young adults also had higher pain levels (relative to children, P=0.002) and higher reticulocyte counts (relative to older adults, Table 1, p=0.011), despite a higher total Hgb (P=0.012). As expected, children had a higher hemoglobin F level than young adults (Table 1, 11.1 ± 6.74 vs 4.85 ± 6.90, p=0.011). Conclusions: Our data demonstrates that adult patients with SCD have higher and more variable adhesion compared to pediatric patients with SCD, and this may be especially true in young adults. Older adults tended to have lower adhesion (perhaps due to compensatory genetic mutations that allowed them to survive before optimal pediatric care), but this was not statistically significant. Recall, as recently as the 1970s half of all Americans with SCD died before the age of 15 years of age. However, modern children with SCD are being treated aggressively with transfusions or hydroxyurea, and their low overall RBC adhesion reflects either these interventions or an innate low RBC adhesion during childhood. Increased adhesion in RBCs from young adults with SCD is congruent with increased mortality in the transition population2, and strongly suggests that modern treatments, as currently prescribed and taken, are insufficient to completely reverse the abnormal red cell physiology seen in young adults. Young adults have an increased RBC adhesion, possibly reflective of the natural history of SCD, and may benefit the most from anti-adhesive therapies and intensive interventions. Lower adhesion in children with SCD may also reflect an overall improved response to therapeutic interventions in children. References: Alapan Y, Kim C, Adhikari A, Gray KE, Gurkan-Cavusoglu E, Little JA, Gurkan. Transl Res. 2016 Jul;173:74-91.e8. doi: 10.1016/j.trsl.2016.03.008. Epub 2016 Mar 19. Quinn CT, Rogers ZR, McCavit TL, Buchanan GR. Blood. 2010 Apr 29;115(17):3447-52. Disclosures Little: NHLBI: Research Funding; Doris Duke Charitable Foundations: Research Funding; PCORI: Research Funding; Hemex: Patents & Royalties: Patent, no honoraria.

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Older adult females hospitalized with cardiovascular disease outweigh male older adults in receiving Potentially Inappropriate Medication

10.22541/au.161829221.15848128/v1 ◽

2021 ◽

Author(s):

rishabh Sharma ◽

Parveen Bansal ◽

Manik Chhabra ◽

Malika Arora

Keyword(s):

Cardiovascular Disease ◽

Older Adults ◽

Logistic Regression ◽

Older Adult ◽

Tertiary Care ◽

Binary Logistic Regression ◽

Adult Patients ◽

Potentially Inappropriate Medications ◽

Care Hospital ◽

Very High

Introduction: There are a lack of potentially inappropriate medications (PIMs) predictors among the geriatric population with cardiovascular disease (CVD). Objective: This study was focussed on finding out the predictors and prevalence of PIMs use in the older adult patients hospitalized with cardiovascular disease. Methods: This prospective cross-sectional study included 250 older adult patients (mean age 69.03± 5.76 years) with the CVD having age 65 years or more, admitted in the cardiology/medicine department of a tertiary care hospital. PIMs were identified as per Beers criteria 2019. Binary Logistic regression analysis was used to determine the predictors of PIMs use in older adult patients. Results: Results indicate a very high PIM prescription rate of more than 62.4% (n= 156) with Proton pump inhibitor, short acting insulin according to sliding scale, Enoxaparin <30ml/min as the most commonly prescribed PIMs. On Binary logistic regression, important predictors for PIMs use were found to be females (odds ratio [OR] 2.36, 95% confidence interval (CI) 1.36- 4.09, P= 0.002), three diagnosis (OR 4.29, 95% CI 1.31- 14.0, P= 0.016), ≥4 diagnosis (OR 4.8, 95% CI 1.49- 15.44, P= 0.009), 7-9 days of hospital stay (OR 4.74, 95% CI 1.07- 20.96, P= 0.04), ≥ 9 medications per day (OR 0.09, 95% CI 0.01- 0.50, P= 0.006). Conclusion: The prevalence of PIMs in older adults with cardiovascular disease is very high, and females with CVD have emerged as a potential PIM indicator. The study also indicates a lack of awareness towards Beer criteria in health care workers (physicians/pharmacists/nursing staff) leading to PIM.

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The Safety of Benzodiazepines and Opioids in the Geriatric Population: An Analysis of Patient Safety Events Reported by Hospitals and Ambulatory Surgical Facilities

Patient Safety ◽

10.33940/data/2021.12.5 ◽

2021 ◽

pp. 42-49

Author(s):

Elizabeth Kukielka

Keyword(s):

Older Adults ◽

Patient Safety ◽

Motor Vehicle ◽

Reversal Agent ◽

Geriatric Population ◽

Inappropriate Use ◽

Safety Reporting ◽

Pain Medications ◽

Increased Risk ◽

Potential Risks

Benzodiazepines may increase the risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes in patients 65 years and older. The concomitant use of benzodiazepines and opioids may also be inappropriate for older adults due to the increased risk of overdose. We searched the Pennsylvania Patient Safety Reporting System (PA-PSRS) for reports of patient safety events related to the concomitant use of benzodiazepines and opioids in older adults in order to gain a better understanding of the potential risks of using these medications in combination. We identified 80 reports in which a patient may have experienced an adverse drug reaction (ADR) to the combined use of a benzodiazepine and an opioid pain medication. Reports were reviewed to determine the ADR(s) experienced by the patient. Changes in mental status were most common, occurring in more than two-thirds of reports (68.8%; 55 of 80), followed by respiratory reactions (51.3%; 41 of 80) and cardiovascular reactions (25.0%; 20 of 80). In over two-thirds of reports (70.0%; 56 of 80), the patient received a reversal agent, either flumazenil (10.7%; 6 of 56) or naloxone (35.7%; 20 of 56), or both (53.6%; 30 of 56). The inappropriate use of benzodiazepines and opioid pain medications in combination among patients 65 years and older is a growing problem, and an increased awareness may be the first step for providers to begin addressing it.

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