Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 305

During a hospital stay, older people are of course vulnerable to the same adverse events as their younger counterparts, such as hospital‐acquired infections, adverse drug events, deep vein thrombosis, and procedure‐related complications. As described above, there is evidence that the incidence of these types of adverse events is greater in older patients and their consequences are more severe. However, the process and effects of hospitalization in older people, particularly those who are frail and have multiple comorbidities, are different from those in younger people; it therefore follows that any analysis of patient safety and adverse events in this vulnerable population should be undertaken in this context. Figure 11.2 illustrates this in a proposed scheme for the effects of hospitalization in frail older people.

Older people may be admitted to the hospital because of an acute illness, acute exacerbation of a chronic disease process, side effects of treatment for these conditions, or the development of a new geriatric syndrome. These are similar to the geriatric giants first coined by Isaacs in 1965 (immobility and instability, incontinence, and impaired intellect) and are now understood to include delirium, falls, incontinence, pressure sores, depression, undernutrition, constipation, and functional decline. Older patients very commonly have one or more of these conditions at the time they are admitted to the hospital, but there is a strong argument that if any of these truly occur de novo during the inpatient stay and are not related solely to the progression of disease, each should be considered an adverse event because of their association with increased mortality and morbidity and the strong evidence that they are largely preventable.³⁰ The geriatric syndromes rarely occur in isolation – during the complex, lengthy hospital admissions often experienced by older people, they are often interlinked and may contribute to downward spirals in progress and outcome. They can each contribute to or be an outcome of each other; this is illustrated in Figure 11.3, which shows three common clinical scenarios where delirium, incontinence, and falls occur in different sequences.

Figure 11.2 A proposed scheme for the effects of hospitalization on frail older people.

Figure 11.3 Three common clinical scenarios where delirium, incontinence, and falls occur in different sequences.

A summary of common adverse events in older people is shown in Box 11.1.