April 09, 2019 10:05 am Chris Crawford – New research shows that less than 40% of older adult patients reported adverse drug events (ADEs) they experienced to their family physicians. And even when they did, the study said their physicians didn't always include that information in the health record.
That's according to research published in the March/April 2019 issue of Annals of Family Medicine, which found that the patients who did not report their ADEs said they thought the symptoms were due to old age and didn't want to bother their physicians.
In a retrospective cohort study that evaluated 859 community-dwelling patients ages 70 and older who had multimorbidity and were being treated at 15 primary care practices affiliated with the Royal College of Surgeons in Ireland and Trinity College Dublin, researchers used a patient-reported instrument to identify ADEs in these older adults.
Specifically, the patients were asked whether they had experienced any of a list of 74 symptoms during the previous six months and, if so, whether
Self-reported symptoms were independently reviewed by two clinicians who determined the likelihood that the symptom was an ADE. Family physician medical records were also reviewed for any report of ADEs.
The ADE instrument the researchers used was found to have an accuracy of 75% in differentiating ADEs from non-ADEs, as well as a sensitivity of 29% and a specificity of 93%.
Among participating patients, 78% (n=674) were classified as having had at least one ADE during the study period.
Lead author Caitriona Cahir, Ph.D., research fellow in the population health sciences division of the Royal College of Surgeons in Ireland in Dublin, told AAFP News she and her colleagues chose to examine this topic because older people have a greater risk of ADEs.
"We were surprised that only 39% of patients reported adverse drug events to their family physician," she said. "Also, only a small proportion of patient-reported adverse drug events were documented in their family physician record."
According to the study, family physicians only documented ADEs from the previous six months in the medical records for 10 percent of the patients studied.
"Older patients do not report all symptoms they suspect to be adverse drug events to their family physician," said Cahir, "and family physicians do not record all adverse drug-related symptoms that may be reported to them."
The median age of the cohort analyzed was 77, and 55% of participants were female. Forty-one percent of patients had five or more chronic conditions and were dispensed, on average, six or more different drug classes, the study found. The most common conditions treated were hyperlipidemia, cerebrovascular disease and heart disease.
Antithrombotic agents were most frequently associated with ADEs; 86% of patients prescribed aspirin and warfarin reported bruising, bleeding and indigestion.
Additionally, cardiovascular drugs associated with mild ADEs included diuretics, beta-blocking agents, calcium channel blockers, agents acting on the renin-angiotensin system and serum lipid-reducing agents.
As for the types of ADEs these older adults experienced, they most frequently reported being bothered by muscle pain and weakness (75%), followed by dizziness or lightheadedness (61%), cough (53%) and unsteadiness while standing (52%), but they didn't associate these symptoms with their medication.
Notably, patients were less bothered by the more prevalent ADEs: 21% of patients were bothered by bruising and 26% by minor hemorrhages; of those patients, 28% and 22%, respectively, reported their symptoms to the family physician.
Cahir said that given the complexity of identifying ADEs in older people who have various comorbidities and are taking several medications, patients may have difficulty distinguishing effectively between symptoms attributable to their individual medications or their underlying medical conditions.
She added that family physicians face obstacles of their own.
"Family physicians are often unable to evaluate the risk/benefit in terms of the time available for making decisions and have been shown to preserve the doctor-patient relationship ahead of medication rationalization," Cahir said.
Techniques need to be developed that facilitate communication with patients on their potential options for treatment, she said, and provide family physicians opportunities for collaborative decision-making and treatment planning.
"Patients could be provided with concise information resources that describe the purpose of their medication and help them anticipate and recognize adverse drug events and seek appropriate treatment," Cahir said. "Adverse drug event interviews with a nurse or pharmacist could be incorporated into patient medication reviews as part of a patient's ongoing pharmacologic care."
Enabling health care professionals and patients to consider drugs as a possible cause of adverse effects, and to differentiate them from symptoms of chronic disease or frailty, may ultimately help in enhancing monitoring and discontinuation of drugs, she said.
"This approach may also help in avoiding unnecessary, more serious adverse drug events that cause death or disability," Cahir added.
Cahir's research team is doing further work in this area, investigating quality and safety in prescribing medications to older populations as part of a Health Research Board (HRB) Research Leaders Award and the HRB Centre for Primary Care Research.
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