Preventing Adverse Drug Reactions

Approximately 700,000 emergency department visits and 120,000 hospitalizations are due to adverse drug reactions (ADRs) annually. The risk of ADRs increases with the number of prescriptions, with the use of two medications conferring a 15% risk, compared with an 82% risk when seven or more medications are used. In the long-term care (LTC) setting, patients receive an average of seven medications, placing them at high risk of ADRs. In addition, age-related changes affect the ability of older persons to metabolize these medications, further increasing the risk. Despite these challenges, many ADRs are preventable. The American Geriatrics Society (AGS) 2012 Updated Beers criteria suggest that up to 42% of ADRs in LTC settings can be prevented. In this issue of Annals of Long-Term Care: Clinical Care and Aging^® (ALTC), we consider two important strategies that can reduce the risk of ADRs: (1) cautious use of inappropriate and high-risk drugs; and (2) careful consideration of a patient’s comorbid conditions, particularly renal function, before prescribing any medications.

In our first article, “When Should Antipsychotics for the Management of Behavioral and Psychological Symptoms of Dementia be Discontinued?”, Michael Gordon, MD, discusses the role of antipsychotics for treating the behavioral and psychological symptoms of dementia (BPSD). The use of these agents in the LTC setting is controversial, and the AGS Beers criteria recommend against their use as a treatment for BPSD unless nonpharmacological interventions have failed and the patient poses a threat to himself/herself or to others. Over the decades, numerous measures have been taken to try to reduce the use of these potentially inappropriate agents in LTC; however, as Dr. Gordon’s article demonstrates, antipsychotics are sometimes needed to calm agitated/aggressive behaviors and should not always be viewed negatively. When an antipsychotic successfully curbs untoward behaviors, there may be reluctance to wean patients from these agents, fearing their agitated/aggressive behaviors will return, but as two of the case scenarios presented by Dr. Gordon demonstrate, a short treatment course may be all that is needed. In these cases, while the antipsychotics curbed the BPSD, they also contributed to impairments in speech, gait, posture, and facial expression. Once the antipsychotics were discontinued, these impairments noticeably improved and the patients’ agitation/aggression did not return. On the other hand, if a patient’s agitation/ aggression worsens during the weaning process, as shown by a third case scenario in the article, then these agents may be needed longer term.

In our second article, “Fluoroquinolone-Induced Hypoglycemia in an Overweight Nonagenarian With Acute Kidney Injury and Not on Glucose-Lowering Therapy”, Amit Bhargava, MD, and Maura Brennan, MD, report the case of a patient with impaired renal function who developed hypoglycemia after being treated with two commonly prescribed fluoroquinolones following a urinary tract infection. Although hypoglycemia has been previously reported with fluoroquinolone use, most cases have involved patients on glucose-lowering therapy. Drs. Bhargava and Brennan speculate that their patient’s impaired renal function inhibited his ability to excrete the fluoroquinolones, as these agents primarily have a renal route of elimination. As this case report shows, considering a patient’s renal function and other comorbidities is important before prescribing any agents. In addition, although fluoroquinolones are not considered a potentially inappropriate medication for older adults, there is some indication that they are being overprescribed. In general, these agents should be reserved for more serious systemic infections. The authors provide a useful table that outlines the indications for each of the six fluoroquinolones approved for use in the United States.

In this issue, you will also find an Ask the Expert article in which Vanessa Hinson, MD, PhD, discusses the challenges of treating movement disorders in elderly persons residing in LTC settings. In addition, I encourage you to download a valuable resource from the AGS: “A Guide to the Management of Atrial Fibrillation in Older Adults.” This resource was previously published as a pocketcard.

Last but not least, we are delighted to announce that Michael Gordon, MD, has joined our editorial advisory board. Dr. Gordon practices palliative care at the Baycrest Geriatric Healthcare System in Toronto and has been a loyal contributor to ALTC. You can read Dr. Gordon's blog posts on our website here>>

Thank you for reading!