ASSISTED LIVING COLUMN

Ethel Mitty

Iatrogenesis, Frailty, and Geriatric Syndromes

Ethel Mitty, EdD, RN
Older adults are at risk for iatrogenesis, especially if they are frail and have 1 or more geriatric syndromes. Iatrogenic events do not
occur only in acute care; in nursing homes
they affect 65% of residents annually. It is
therefore likely that they are occurring in assisted living communities, though perhaps
called by another name. Most commonly, iatrogenesis is an adverse drug event or reaction. Knowing more about the characteristics
of frailty and the contributing factors to geriatric syndrome(s), assisted living nurses can be
better prepared to monitor, detect, describe,
and communicate an iatrogenic event or outcome. This article describes the signs and
symptoms of atypical presentation of illness
that can mask or are associated with iatrogenesis. Evidence-based assessment instruments
are suggested for each geriatric syndrome.
(Geriatr Nurs 2010;31:368-374)
Most iatrogenic events occur in acute care and
overwhelmingly to those who are frail, have 1 or
more geriatric syndromes, and who, by virtue of
their old age, present illness atypically. Hospitalized older adults who have experienced an iatrogenic event are much like the older adults who
reside in assisted living communities (ALC):
many are frail, have geriatric syndrome(s), and
present illness atypically! This makes them prime
candidates for iatrogenesis. The purpose of this article is to describe iatrogenesis, frailty, and geriatric syndromes and the evidence-based tools that
ALC nurses can use to assess the resident to reduce
the risk of an iatrogenic event or be better able to
recognize one that occurs. A brief profile of assisted living residents provides the context for the
risk of iatrogenesis among this population, because it not only describes frailty but speaks to
the importance of knowing a residents baseline
so that even subtle changes can be identified.

368

Clinical Picture of ALC Residents

Almost 30% of residents are admitted from an
acute care or rehabilitation hospital or from
a skilled nursing facility.1 In 2009, more than
40% of ALC residents were evaluated (and treated,
in many cases) in an emergency room, and another 35% had a hospital stay of 1 night or more.
On average, an ALC resident requires assistance
with 1.6 activities of daily living (ADLs), ranging
from supervision or limited assistance to extensive assistance and total dependence on staff. Assistance is most frequently needed for bathing and
least frequently for eating and transferring. Approximately 23% of residents ambulate independently; 22% use a wheelchair all or some of the
time; and 54% use some kind of supportive or assistive device (e.g., cane, walker). By gender,
more female than male residents are bladder
and bowel continent. However, almost 30%
of male and females are not consistently bladder
continent; only about 15% are generally bowel
continent.1
The most common medical diagnosis is hypertension (66%), followed by arthritis/rheumatoid
arthritis (42%), osteoporosis (27%), clinical depression (30%), coronary heart disease (33%),
macular degeneration/glaucoma (19%), diabetes
(17%), stroke (14%), cancer (13%), chronic obstructive pulmonary disease (13%), and kidney
disease (10%).1 Almost 37% of residents have
mild dementia; 47% have early-to mid-stage Alzheimers disease; and 14% have severe dementia
or late-stage Alzheimers disease.1
An assisted living resident takes approximately
7.6 prescriptions and 2.3 over-the-counter (OTC)
medications on a daily basis.1 Approximately 80%
of residents need assistance with their medication management, from ordering and maintaining
an adequate supply of the proper medication to
physical administration of the medication by

Geriatric Nursing, Volume 31, Number 5

staff. Most residents (97%) have a formal functional/physical assessment on admission and at
least annually thereafter.1 Slightly fewer residents (89%) have a formal cognitive assessment,
although it is unclear how often it is reviewed or
revised. Virtually all residents have a formal written service or care plan based on (pre)admission
assessment data that is reviewed annually or after
a significant change in condition. The definition of
frailty (see below) provides the surround that
sets up the older adult for iatrogenesis.

At-Risk for Iatrogenesis

Iatrogenesis is a state of ill health or an adverse
event that is caused by, or is the result of, a wellintended health care intervention.2 Nevertheless,
it is an untoward consequence. Cascade iatrogenesis is a series of adverse events or effects
caused by a medical or nursing intervention that
was initially used to solve a prior symptom or
condition. It occurs most frequently to older
adults who are significantly functionally impaired
and already suffering from a high severity of illness burden. This unintended cascade of decline
is almost always associated with poor prognosis
after hospital discharge.2,3 A common example
is the use of Haldol for delirium caused by
dehydration caused by reduced fluid intake (or
by laxatives or diuretics), and so on.4
Among the predisposing factors for iatrogenesis among older adults, the most likely culprits
are the number of prescribed medications
and polypharmacy (as well as OTC and use of
herbal remedies), atypical presentation of illness,
and more comorbid chronic illnesses.2 Impaired
cognitive and functional capacity, reduced physiologic reserve, and altered compensatory mechanisms add to the risk.
An adverse drug event/reaction (ADE/R) is the
most common cause of iatrogenesis and accounts for 15% of hospitalization of older adults
(compared with 6% for younger adults.2 It is
estimated that as many as 195,000 hospitalized
Medicare patients die as a result of medical
errordthat is, iatrogenesis.2 The Centers for
Disease Control (CDC) suggest that medical error
could be ranked as the sixth major cause of
death.2 Cognitive impairment, falls, impaired balance, and urinary incontinence are common sequelae of ADE/R.5 High-risk and contraindicated
medications for older adultsdwhere the risks
Geriatric Nursing, Volume 31, Number 5

outweigh the benefitsdconstitute the Beers Criteria and should guide prescribing as well as monitoring (see the Molony article in the
Recommended Reading list at the end of this article). Iatrogenesis can also be caused by adverse
reaction to a diagnostic procedure (e.g., drop in
blood pressure) or therapeutic/surgical intervention that used local anesthetic, hospital-acquired
(nosocomial) infection, and falls. Hospitalized
older adults are more likely to experience complications associated with a diagnostic workup,
adverse reaction to a medication, and falls compared with younger patients.2
Nursing home data indicate that as many as 65%
of residents experience an ADE/R annually.2
There is no ADE/R data for assisted living, but
given similar population characteristics with
nursing home residents, one might assume that
ADE/Rs are happening in ALCs as well. This
points to the need for robust medication management that includes monitoring resident safety in
self-administration of medications and medication adherence practices.6 (See the American
Medical Directors Association and Center for
Excellence in Assisted Living materials in Recommended Reading list.) Periodic review of residents medication regimens should seek to
minimize polypharmacy and reduce the use of
high-risk medications to the extent possible.
The ALC should have precise instructions or
guidelines on handling of lab data, particularly
with regard to Coumadin (warfarin sodium)
administration.

Frailty
Most older adults who live to an advanced age
will become frail. Not really a disease, frailty is
a combination of age-related changes and assorted
medical problems. Eluding precise definition, the
Fried framework suggests that an individual having 3 or more of the following conditions should be
considered frail: exhaustion, unintentional weight
loss of more than 10 pounds in 1 year, muscle
weakness, walking slowly, and low physical
activity level.7,8 Research indicates that frailty is
a reliable indicator of imminent decline in
health status and includes falls, reduced mobility,
low functional reserve, easy tiring, and high
susceptibility to disease. Certain diseases and
medical conditions are associated with frailty,
including anorexia, sarcopenia, atherosclerosis,
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impaired balance, mood disturbance (depression),

and cognitive impairment.8
Early recognition of frailty can improve or
maintain the quality of life desired by and important to older adults. The assessment tools and
tests to be performed should be person-specific
and ordered by the residents primary health
care provider (in consultation with the relevant
specialist, e.g., physiatrist, pain management specialist, etc.). Managing frailty can be framed by
the frailty mnemonic: Food intake maintained;
Resistance exercises; Atherosclerosis prevention; Isolation avoidance; Limit pain; Tai Chi or
other balance exercises; Yearly check for testosterone deficiency (associated with chronic undernutrition in males).8,p.3

Atypical Presentation of Illness

The atypical presentation of illness in older
adults means that the presentation itself is vague,
altered, or not presented at all.5 In some cases,
the signs of 1 disease might be hidden by the
signs of another. Conditions in which atypical
presentation is common are infections, falls, urinary incontinence, myocardial infarct, and congestive heart failure. Signs and symptoms of
atypical presentation include acute confusion
(delirium), inability to eat or drink (anorexia), absence of temperature elevation or fever even with
an elevated white blood count (leukocytosis), no
complaint of pain with a disease/condition
known to cause pain (e.g., gastric ulcer), reduced
mobility and overall functional decline, generalized weakness and fatigue, falls, and urinary
incontinence.
Almost 95% of persons with dementia have at
least 1 other chronic medical condition.5 Depression might coexist with anxiety, and both
might be masked by dementia.2 Cognitive impairment can be an outcome of depression,
which, if treated properly, will eliminate the adverse cognitive changes. It is important to assess
older adults who present with somatic complaints, an atypical presentation of depression
(also common in poststroke older adults). Exacerbation or onset of a new illness or condition
might be completely maskeddand missedd
unless the normal or baseline behavior, activity,
and responsiveness of the resident is documented and known to ALC staff. Assuming
the appearance of a new sign or symptom
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(e.g., incontinence, cognitive change, falling, delirium) or behavior, before adding a new medication or treatment, the question must be asked:
Could this be an outcome of a previous intervention? If the answer is yes, could it be an adverse drug reaction? Could it be an iatrogenic
event or process?

Geriatric Syndromes
Geriatric syndromes can be an outcome of iatrogenesis and frailty. They have an impact on
morbidity and mortality. The term refers to
a sign or symptom, or a group of specific signs
and symptoms, that occur more often in older
adults than in younger adults. It is not possible
to predict or even be fully knowledgeable
about the multiple etiological and pathological
pathways of some of the geriatric syndromes.
Contributing factors include multiple chronic
diseases, normal age-related changes, polypharmacy, multiple providers, and the adverse
effect of therapeutic or diagnostic interventions.
The Fulmer SPICES, an acronym for the geriatric
syndromes, is an efficient and effective way to
conduct assessment of them.9 Although psychometric testing of SPICES validity and reliability
has not been conducted, widespread utilization
indicates its significant usefulness:







S: Sleep Disorders
P: Problems with Eating or Feeding
I: Incontinence
C: Confusion
E: Evidence of Falls
S: Skin Breakdown9

Some clinicians add another P or substitute

Pain for problems with eating or feeding. Assessment for potential and actual pain should
be a standard component of the clinical assessment of patients of all ages, not just older adults.
Pain is not a unique feature of aging, nor is it an
accepted age-related change. Could pain be iatrogenic in origin? Yes. Hence, it is discussed later in
this section, even though it is not a geriatric
syndrome.
Knowledge of normal age-related changes and
how each geriatric syndrome might present in an
older adult can facilitate a more rapid and personcentered response to changes in status. Each geriatric syndrome and how it can be assessed is
now discussed.
Geriatric Nursing, Volume 31, Number 5

Sleep Disorders
It is important to know (and perhaps to reassure the resident) that although the amount of
sleep in 24 hours is unchanged, there are changes
in sleep pattern and quality. Impaired sleep can
be related to diseases (e.g., restless leg syndrome), medications, or an environment that
does not promote good sleep (e.g., room temperature, mattress, noise, roommate habits, etc.).
Sleep assessment includes getting a thorough
sleep history from the resident and past use of
any medications or routines (e.g., exercise) to induce sleep and restfulness. The Pittsburgh Sleep
Quality Index (PSQI) is a self-rated instrument
that measures sleep quality.10 The Epworth
Sleepiness Scale (ESS) is another self-rated instrument that measures excessive daytime sleepiness.11 Both the PSQI and ESS can be used to
measure the effectiveness of interventions. Daytime sleepiness is more than a simple need for
a daytime nap; it could be iatrogenesis. (See the
Mitty and Flores article in the Recommended
Reading list.)
Problems with Eating or Feeding
Most nutritional issues are associated with
a disease or illness, but other causes include dietary restrictions, oral cavity and denture issues,
medications, reduced sense of smell and taste,
and inability to carry food and fluid to the
mouth.12 Many eating or feeding problems in
older adults can be severe. Nutritional assessment includes diet(ary) history (e.g., previous interventions that were successful as well as
unsuccessful) and oral cavity examination. Individuals who are overweight (i.e., body mass index [BMI] . 25) are as at risk for malnutrition
as those who are underweight (i.e., BMI \ 19).12
Both can have loss of muscle mass and a compromised immune system. The Mini Nutritional Assessment can identify older adults at risk for
malnutrition.12 Information about the older
adults culture, food preferences, and social customs with regard to eating, as well as lab work
and a 72-hour food diary, should be part of the
assessment.12
Incontinence
Urinary incontinence (UI) can occur secondary
to age-related physiological changes, iatrogenesis, frailty, or disease.5 Urinary incontinence is
Geriatric Nursing, Volume 31, Number 5

not a normal age-related change or consequence

of aging. There are 4 types of urinary incontinence: urge, stress, overflow, and functional.
Each has different characteristics, and all present
psychological, physical, and social challenges to
quality of life.13 A 3-day self-recorded bladder diary is recommended, although a 7-day calendar
elicits more reliable information. For the resident
with dementia, it would be necessary for someone else to record the incontinent events. The
Urinary Incontinence Assessment in Older
Adults, Part IdTransient Urinary Incontinence
instrument contains 2 mnemonicsdDIAPPERS
and TOILETEDdthat frame the assessment
with regard to possible causes of transient UI.13
The Urinary Incontinence Assessment in Older
Adults, Part IIdEstablished Urinary Incontinence instrument contains the Urogenital Distress Inventory that addresses frequency of
urination, leakage, and discomfort when urinating.14 It also contains the Impact Questionnaire, which addresses the extent to which
UI or leakage has affected the individuals
ability to perform household tasks and engage
in recreational and social activities, as well as
his or her emotional well-being (e.g., feeling
depressed).
Fecal incontinence, almost as common as UI, is
frequently a result of fecal impaction. Not surprisingly, constipation and fecal impaction are
associated with chronic use of laxatives, constipating medications (e.g., opioids, iron, calcium
channel blockers), limited mobility, malnutrition,
reduced fluid intake, and the 3 Ds: delirium, dementia, depression.2 Think of cascading iatrogenesis that started with just a couple of days of
bedrest after a bad fall (or a URI) that ends up
as intestinal obstruction requiring major surgery.

Confusion
It is necessary to differentiate among dementia, delirium, and depression (3-Ds), although aspects (symptoms) of all 3 can be present at the
same time in an individual. Space limitations preclude discussion of each condition.
Several evidence-based assessment instruments for the 3-Ds are as follows (each constitutes a basic assessment and can point to the
need for further evaluation):
 Dementia. Mini-COG: consists of a 3-item recall and the Clock Drawing Test; used to
371

identify dementia; takes approximately 3-5

minutes to administer. Aspects of cognition
tested: recall, registration, and executive function. Unlike the Mini-Mental Status Examination, education level, culture, or language
have no effect on the Mini-COG score.15 Older
adults who were administered the Mini-COG
did not appear stressed or otherwise discomfited by the examination.
 Dementia. Brief Evaluation of Executive Dysfunction: recommended for 4 conditions:
1) when an older adult after hospitalization
seems not quite like his former self; 2) the
Mini-COG fails to reveal the presence of cognitive impairment (i.e., dementia); 3) delirium
has been ruled out; and 4) the older adult still
has memory/recall and language ability.16
Language and education level can yield falsepositive results because a portion of the examination includes word association.16
 Delirium. Commonly thought of as a hospitalrelated event, delirium can occur in the ALC, as
well. Risk factors include infection, dehydration, fracture, and use of psychotropic medication. The Confusion Assessment Method
(CAM) identifies the presence or absence of delirium but not does indicate severity.17 The
CAM consists of 4 factors: 1) acute onset or
fluctuating course of mental changes or behavior; 2) inattention; 3) disorganized thinking;
and 4) altered level of consciousness. Factors
1 and 2 and either 3 or 4 must be present for
the diagnosis of delirium.17
 Depression. Contrary to myth, depression is
not a normal part of aging, can delay recovery from a medical illness, and is treatable.
The short-form (15-item) Geriatric Depression Scale (GDS) is a valid and reliable assessment instrument that can differentiate
between depressed and nondepressed older
adults. It takes approximately 5-7 minutes
to administer and score but is not a substitute for a clinical interview, nor does it identify suicide risk.18
Evidence of Falls
Data on falls are sobering: 5% of falls result in
fractures, but about 25%, on average, result in
injury. Most falls (85%) occur in the home.
What are the shared characteristics of an ALC
with a traditional home and the hazards of falling? The Hendrich II Fall Risk Model is recommended for long-term care residents, although
372

it was originally intended to identify hospital patients at risk for falls. The assessment includes
medications that predispose to fall risk, dizziness, and mental states (e.g., confusion, disorientation) as well as a get up and go test.19 It
is highly recommended that every ALC include
a valid fall risk assessment tool in the (pre)admission examination as well as at subsequent
times, particularly after a change of condition.
A resident with a UTI experiencing a changed
voiding pattern is at risk for fall.
Skin Breakdown
Given that many states permit ALCs to retain
residents who require bedrest for a short period,
as well as residents receiving hospice care, it is
entirely possible that some residents might be
at risk for skin breakdown or pressure ulcer.
The Braden Scale has been extensively tested
for its validity and reliability in predicting development of a pressure ulcer. It consists of 6 components that are applicable for a wheelchair
bound as well as a bedbound resident: sensory
perception of discomfort related to pressure on
a bony prominence; exposure of skin to moisture
(e.g., perspiration, urine); amount of physical activity (chairfast, walking); mobility (i.e., the ability to change body position); customary food
intake; and friction/shear when changing position
in bed or a chair.20 Some clinicians recommend
that the Braden Scale should be administered as
soon as an individual is placed on bedrest and
every 24 hours (more frequently, if indicated).
Persistent Pain
Although not included in the SPICES acronym
and not unique to older adults, persistent pain affects almost 50% of community-residing older
adults. Associated with depression, reduced social interaction and activities, pain is the fifth vital
sign, except that it is self-reported instead of recorded on some kind of device. There are several
valid and reliable pain assessment tools for verbal as well as nonverbal older adults, including
those who lack the visual acuity to see a scale
and those with dementia. Research indicates
that the Numeric Rating Scale (NRS) is preferred
by cognitively intact older adults, whereas the
Faces Pain Scale (FPS) is preferred (i.e., the patients were better able to report) by cognitively
impaired individuals.21 For those with dementia,
Geriatric Nursing, Volume 31, Number 5

the PAINAD Scale (Pain Assessment in Advanced

Dementia) observes quality of breathing, negative vocalization or groaning, facial expression,
body language, and consolability. It is a reliable
and valid assessment tool but requires training
for proper interpretation (even though it takes
only a few minutes to administer).22 If administration of a treatment or a specific kind of activity
(e.g., toilet transfer) elicits expression of pain in
nondemented individuals, then the assumption
has to be made that those with dementia
who cannot express themselves are likely to experience pain as well. (See the Horgas article in
the Recommended Reading list.)

5.

6.

7.

8.

9.

Preventing Iatrogenesis
Expect iatrogenesis among your residents.
Identify residents at high risk for iatrogenesisd
that is, older adults who are aged 80 years or
older, are frail, have multiple physical and cognitive comorbidities, and have new-onset geriatric
syndromes. Educate the resident and family, to
the extent possible, about where they are at
risk, what is being done to minimize that risk,
and the things they need to do to remain
hale and hearty. Dispel the myths of aging among
residents, family, and staff. Develop a proactive
approach to prevention and recognition of iatrogenesis, recognizing that the early warning signs
may be fragmented. Monitor and communicate
unexplained signs, symptoms, and complaints.5
Develop, foster, and maintain a blame-free culture of safety so that when an iatrogenic event
does occur, its origin and resolution can be better
understood and managed.

10.

11.

12.

13.

14.

References
15.
1. National Center for Assisted Living. 2009 overview of
assisted living. Washington, DC: National Center for
Assisted Living; 2010.
2. Francis DC. Want to know more: Iatrogenesis. New York:
Hartford Institute for Geriatric Nursing; 2005. Available
at http://consultgerirn.org/topics/iatrogenesis/
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3. Thornlow DK, Anderson R, Oddone E. Cascade
iatrogenesis: factors leading to the development of
adverse events in hospitalized older adults. Int J Nurs
Stud 2009;46:1528-35.
4. Mentes JC. Managing oral hydration. In: Capezuti E,
Zwicker D, Mezey M, Fulmer T, editors. Evidence-based

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17.

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Mezey M. (2010). Iatrogenesis and frailty. Presentation at
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Morley JE. (n.d.). Frailty: management and treatment.
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York: The Hartford Institute for Geriatric Nursing,
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Smyth C. The Pittsburgh Sleep Quality Scale (PSQI). Try
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Dowling-Castronovo A. Urinary incontinence
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Institute for Geriatric Nursing, New York University,
College of Nursing; 2007. Available at http://
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Dowling-Castronovo A. Urinary incontinence
assessment in older adults. Part Idestablished urinary
incontinence. Try This No. 11.2. New York: The Hartford
Institute for Geriatric Nursing, New York University,
College of Nursing; 2008. Available at http://
ConsultGeriRN.org. Accessed July 1, 2010.
Doerflinger DMC. Mental status assessment of older
adults: the Mini-COG. Try This No. 3. New York: The
Hartford Institute for Geriatric Nursing, New York
University, College of Nursing; 2007. Available at http://
ConsultGeriRN.org. Accessed July 1, 2010.
Kennedy G. Brief Evaluation of Executive Function: an
essential refinement in the assessment of cognitive
impairment. Try This No. D3. New York: The Hartford
Institute for Geriatric Nursing, New York University,
College of Nursing; 2007. Available at http://
ConsultGeriRN.org. Accessed July 1, 2010.
Waszynski C. The Confusion Assessment Method
(CAM). Try This No. 13. New York: The Hartford
Institute for Geriatric Nursing, New York University,

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College of Nursing; 2007. Available at http://

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Gray-Miceli D. Fall risk assessment for older adults: The
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Ayello EA. Predicting pressure ulcer risk. Try This No. 5.
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Warden V, Hurley AC, Volicer L. Development and
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Recommended Reading
Horgas AL, Yoon SL. Pain management. In: Capezuti E,
Zwicker D, Mezey M, Fulmer T, editors. Evidence-based
geriatric nursing protocols for best practice. 3rd ed. New
York: Springer Publishing Company; 2008. p. 199-222.

374

Mitty E, Flores S. Sleepiness or excessive daytime

somnolence. Geriatr Nurs 2009;30:53-60.
American Medical Directors Association. Assisted living.
Management of medications. A manual for caregivers.
Columbia, MD: AMDA; 2010.
American Medical Directors Association. Assisted living.
Medication management manual: operations level. Columbia
MD: AMDA; 2010.
Center for Excellance in Assisted Living with American
Society of Consultant Pharmacists. (2009). Medication
administration pocket guide for assisted living and nursing
home medication technicians. Available from MED-PASS at
www.med-pass.com. Accessed July 1, 2010.
Molony S. Beers Criteria for potentially inappropriate
medication use in older adults. Part I: 2002 Criteria
independent of diagnoses or conditions. Part II: 2002 Criteria
dependent on diagnoses or conditions. Try This Nos. 16 and
16a. New York: The Hartford Institute for Geriatric Nursing.
New York University, College of Nursing; 2008. Available at
http://ConsultGeriRN.org. Accessed July 1, 2010.

ETHEL MITTY, EdD, RN, is an Adjunct Clinical Professor of

Nursing at the College of Nursing, New York University, and
Consultant in Long Term Care at the John A. Hartford
Institute for Geriatric Nursing, College of Nursing, New
York University, New York, NY.
0197-4572/$ - see front matter
2010 Mosby, Inc. All rights reserved.
doi:10.1016/j.gerinurse.2010.08.004

Geriatric Nursing, Volume 31, Number 5