Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department

doi:10.1067/mem.2001.119456

Annals of Emergency Medicine

Volume 38, Issue 6, December 2001, Pages 666-671

Presented at the Canadian Emergency Physician (CAEP) meeting, Quebec City, Quebec, Canada, October 1999.

https://doi.org/10.1067/mem.2001.119456 Get rights and content

Abstract

Study Objectives: We sought to document the degree of polypharmacy, the frequency of adverse drug-related events (ADREs) leading to emergency department presentation that were recognized by emergency physicians, and the frequency of potential adverse drug interactions (PADIs) in medication regimens of elderly patients in the ED. Methods: We conducted a retrospective chart review on 300 randomly selected ED visits made by patients 65 years of age and older between January 1 and December 31, 1998. ADREs were defined according to a standardized algorithm. PADIs were identified by using the drug interaction database PharmVigilance. Results: After excluding 17 patient visits with inadequate documentation, 283 were left for review. Of these, 257 (90.8%) patients were taking 1 or more medications (prescribed or over the counter). The number of medications consumed ranged from 0 to 17 and averaged 4.2 (SD±3.1) drugs per patient. ADREs accounted for 10.6% of all ED visits in our patient group. The most frequently implicated classes of medications were nonsteroidal anti-inflammatory drugs, antibiotics, anticoagulants, diuretics, hypoglycemics, β-blockers, calcium-channel blockers, and chemotherapeutic agents. Thirty-one percent of all patients in our group had at least 1 PADI in their medication list. Among patients who presented because of an ADRE, 50% had at least 1 PADI in their medication list that was unrelated to the ADRE with which they presented. Conclusion: ADREs are an important cause of ED presentation in the elderly. PADIs are found in a significant proportion of medication lists. Emergency physicians must be vigilant in monitoring elderly patients for medication-related problems. [Hohl CM, Dankoff J, Colacone A, Afilalo M. Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department. Ann Emerg Med. December 2001;38:666-671.]

Introduction

Adverse drug-related events (ADREs) present a challenging and expensive public health problem. They account for 3% to 23% of hospital admissions, prolong hospital stays, and increase morbidity and mortality.1, 2 In the hospital environment, physicians and nurses have been estimated to detect only between 5% and 15% of ongoing ADREs when systematic computer-surveillance tools or dedicated personnel are not available.2, 3 An emergency department–based study found that emergency physicians underappreciate the frequency and significance of ADREs. They did not routinely screen for ADREs and medication interactions but added 1 or more new medications to preexisting regimens in 47% of visits and were not more careful in prescribing to high-risk patients.⁴

We found 4 studies examining the frequency of drug-related illness as a cause of ED presentation.5, 6, 7, 8 These studies report ADREs in 0.86% to 4.3% of all adults presenting to the ED. None of the studies focused on the elderly or other high-risk patient groups, one omitted important causes of ADREs,⁶ and another did not use a standardized approach for ADRE detection.⁸ The purpose of this study was to describe the degree of polypharmacy and the frequency of recognized ADREs and PADIs by using standardized detection tools in a population of elderly patients presenting to the ED.

Section snippets

Materials and methods

A retrospective chart review was performed at Sir Mortimer B. Davis-Jewish General Hospital in Montreal, Quebec, Canada. This is a 637-bed university adult teaching hospital with an annual ED census of 55,000 patient visits. We randomly selected 300 visits from a register of all visits to our ED between January 1 and December 31, 1998, made by patients 65 years of age and older. This was a pilot study to set the groundwork for a larger prospective study, and as such, the selection of 300

Results

Of the 300 selected patient visits, 8 were excluded because none of the medications could be identified, 5 because the patients left before evaluation by the ED physician, 3 because the charts could not be found by medical records, and 1 because the ED diagnosis was missing. This left 283 patient visits for analysis. In 20 of the remaining 283 charts, 1 or 2 of the medications could not be identified. Either the compound name could not be found in the Compendium of Pharmaceuticals and

Discussion

We report high rates of medication use consistent with those found by previous investigators. In our sample, 90.8% of patients were taking daily prescription or over-the-counter medication. This is slightly higher than rates previously reported for community-dwelling ambulatory elderly patients.12, 13 The average number of medications consumed daily by our patients was 4.2. This is higher than previous estimates for the community-dwelling elderly population (ie, 2 to 3) but lower than rates for

Acknowledgements

Author contributions: All authors participated actively in the conception of this project. The study was designed by CMH with significant input from JD, MA, and AC. The study proposal was drafted by CMH and reviewed by JD, MA, and AC. Data were acquired and processed by CMH under the supervision of JD. Statistical analysis was performed by AC and CMH. All authors were involved in the interpretation of the study results. CMH drafted the article. It was revised for intellectual content by JD, MA,

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^*: Author contributions are provided at the end of this article.

^**: Supported by the Emergency Department of the Sir Mortimer B. Davis-Jewish General Hospital.

^*: Address for reprints: Corinne Mich`ele Hohl, MD, c/o Dr. Afilalo's office, Sir Mortimer B. Davis-Jewish General Hospital, 3755 Cote Ste. Catherine, Montreal, Quebec, Canada, H3T 1E2; 514-340-8222 ext. 4579; E-mail [email protected].

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ToxicologyPolypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department*,**,*

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

Drug-related hospital admissions

Ann Pharmacother

Adverse drug events in hospitalized patients

JAMA

Incidence of adverse drug events and potential adverse drug events

JAMA

Potential adverse drug interactions in the emergency room. An issue in the quality of care

Ann Intern Med

Drug-related illness in the emergency department patients

Am J Health Syst Pharm

Adverse drug reaction surveillance in an emergency room

Am J Hosp Pharm

Medication misadventures resulting in emergency department visits at an HMO medical center

Am J Health Syst Pharm

Suspected adverse drug events requiring emergency department visits or hospital admissions

Eur J Clin Pharmacol

Toxicology
Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department*,**,*