Is paracetamol prescribed appropriately in elderly patients admitted for a fall?

Abstract

Background

Paracetamol is a commonly used analgesic among older adults. There have been reports of adverse events with chronic paracetamol use even at therapeutic doses. The objective of this clinical audit is twofold – 1. To evaluate the prevalence of inappropriate paracetamol prescription in the elderly admitted for falls; 2. To introduce strategies to reduce the rate of inappropriate paracetamol prescription in this population.

Methods

A clinical audit was performed on 100 patients aged 75 years and older who were admitted to the Geriatric Medicine department of a tertiary hospital between July 2019 and October 2019 with a primary diagnosis of a fall. Data collected included demographic data, relevant medical history of cirrhosis, cognitive impairment, alcohol use and weight <50 kg, prescription pattern of paracetamol on day 1 or two of admission and on discharge as well as clinical data on the documented indications for paracetamol use.

Results

Paracetamol was prescribed in 84 patients. Out of these 84 patients, 56 were prescribed round-the-clock paracetamol with a median duration of 9 (IQR = 10) days. In this group, paracetamol use was inappropriate in 32 (57%) of them and 32 (57%) patients were discharged with round-the-clock paracetamol for a median duration of 17.5 (IQR = 46) days.

Conclusion

This clinical audit revealed a high prevalence of round-the-clock and inappropriate paracetamol prescription in elderly patients admitted for a fall. Moving forward, we hope that the implementation of a paracetamol prescribing algorithm may reduce the rates of inappropriate paracetamol prescribing in this population.

Keywords

Aged acetaminophen geriatric paracetamol safety

Introduction

Paracetamol is a commonly used analgesic in older adults.¹ Prior studies report paracetamol use in approximately 90% of older adults at an average dose of 3–4g per day.¹ Even when prescribed at therapeutic doses, paracetamol use has been associated with acute liver injury and acute liver failure.² There have also been reports of metabolic acidosis due to the accumulation of endogenous organic pyroglutamate as well as analgesia-related nephropathy associated with long-term paracetamol use.^2,3

Due to altered pharmacokinetics and pharmacodynamics, the presence of multiple co-morbidities and polypharmacy, the elderly are more prone to adverse outcomes including the use of commonly prescribed medications.^3,4 In frail elderly patients, it has been reported that clearance to paracetamol glucuronide was markedly reduced as compared to elderly who were fit.⁵ Risk factors for paracetamol toxicity include older age, frailty, weight of ≤50 kg, malnourishment, presence of renal or liver impairment and hepatotoxic factors such as ethanol.^6,7

Keeping the above in mind, there is a need to rationalise the use of paracetamol in older adults and dose adjustments may be necessary. Existing guidelines do not have specific dosing recommendations on the use of paracetamol in the elderly. However, some literatures caution the use of paracetamol in those who are malnourished or who weigh ≤50 kg.⁷ Existing literature recommends a maximum dose of 60 mg/kg/day or 3000 mg/day in individuals <50 kg.⁷ In individuals with cirrhosis and those who consume regular alcohol, a maximum daily dose of 2–3g per day has been considered safe.^6,7 For individuals with severe renal impairment (creatinine clearance<30 mL/min), a dosing interval of at least 6 h is recommended.⁷

There have been minimal studies to date on the use of paracetamol in elderly patients admitted for a fall. Pain from soft tissue injuries, fractures and dislocations are not uncommon and pain is often under-recognised in older adults⁸ especially in those with dementia.⁹ Older adults often underreport pain unless asked due to factors such as stigma associated with reporting pain, underlying cognitive impairment, impaired pain recognition and differing perceptions of pain.¹⁰ Suboptimal pain control is associated with greater functional decline, social isolation, depression, poor sleep, and recurrent falls.⁸ The objective of this clinical audit was to evaluate the prevalence of inappropriate paracetamol prescribing in the elderly admitted for falls and to introduce strategies to reduce the rate of inappropriate paracetamol prescribing in this population.

Methods

A clinical audit against locally developed criteria for inappropriate prescribing of paracetamol based upon available literature was conducted (Figure 1). Clinical charts of 100 patients aged ≥75 years old, admitted under the Geriatric Medicine department of a tertiary hospital with a primary diagnosis of a fall between July 2019 and October 2019 were reviewed. Demographic data collected included age, sex, and race. Medical history collected included a history of cirrhosis, cognitive impairment and its severity, alcohol use and whether the patient weighed <50 kg. Clinical charts were reviewed for the prescription patterns of paracetamol, including whether paracetamol was prescribed round-the-clock on admission and on day 2 of admission, the dose and duration of paracetamol prescribed round-the-clock during admission and on discharge, indications for paracetamol use, the ability of patients to give a coherent history or indicate pain and the presence of any agitation or restlessness documented by the doctors or nurses. Clinical data on the other types of analgesics prescribed together with round-the-clock paracetamol was also collected.

Figure 1.

Flow diagram for clinical audit.

Figure 2.

Algorithm for paracetamol prescription in elderly patients admitted for a fall.

Inappropriate use of paracetamol in this study was defined as one out of the following three criteria: (1) Dose of paracetamol not adjusted according to body weight, renal or liver impairment and alcohol use; (2) Patients given a lower dose of paracetamol than what he or she should have received; (3) Patients who were prescribed round-the-clock paracetamol when there was no indication stated. For patients weighing <50 kg and those with underlying cirrhosis or consume regular alcohol, the maximum dose of paracetamol is 3 g/day.⁷

Results

Table 1 provides a summary of the demographics and medical background of the patients. Paracetamol was prescribed in 84 patients. Fifty-six patients were prescribed round-the-clock paracetamol for a median duration of 9 (IQR = 10) days and 28 patients were prescribed paracetamol pro re nata (PRN) on as needed basis. The mean age of the patients was 85.8 (SD = 5) and 86.6 (SD = 5) years old for the group who were prescribed round-the-clock paracetamol and for the group who were prescribed paracetamol PRN respectively. In the group prescribed with round-the-clock paracetamol, 25 (45%) of them had a history of cognitive impairment as compared to 7 (25%) patients who had paracetamol prescribed PRN.

Table 1.

Summary of the demographics and medical history.

	Patients prescribed round the clock paracetamol on D1 or D2 of admission	Patients prescribed paracetamol PRN on D1 or D2 of admission
Number of patients, n	56	28
Female sex, n (%)	40 (71)	15 (54)
Age in years, mean (SD)	85.8 (5)	86.6 (5)

Race/ethnicity, n (%)
Chinese	48 (86)	24 (86)
Malay	5 (8)	3 (11)
Indian	2 (3)	0
Others	2 (3)	1 (3)

History of cirrhosis, n (%)	0	0
History of cognitive impairment, n (%)	25 (45)	7 (25)
Current alcohol use, n (%)	3 (5)	0
Weight <50 kg, n (%)	30 (54)	12 (43)

Abbreviations: D1 = day 1, D2 = day 2, PRN = pro re nata, SD = standard deviation.

The prescription pattern of paracetamol is shown in Table 2. In the group prescribed with round-the-clock paracetamol, paracetamol was inappropriately used in 32 (57%) of them. The reasons for inappropriate use were (1) no dose reduction for patients with a body weight of <50 kg (11 out of 32 patients), (2) a higher dose of paracetamol could have been given based on their medical history and body weight (15 out of 32 patients) and (3) patients prescribed round the clock paracetamol when there was no indication written (12 out of 32 patients). Thirty two out of 56 (57%) patients prescribed round-the-clock paracetamol on day 1 or day 2 of admission were discharged with round-the-clock paracetamol for a median of 17.5 (IQR = 46) days. Out of 28 patients who were prescribed with PRN paracetamol on day 1 or day 2 of admission, one (4%) was discharged with round-the-clock paracetamol.

Table 2.

Prescription pattern of paracetamol.

	Patients prescribed round the clock paracetamol on D1 or D2 of admission (n=56)	Patients prescribed PRN paracetamol on D1 or D2 of admission (n=28)
Maximum dose of paracetamol, n (%)
2g per day	1 (2)	0
3g per day	33 (59)	16 (57)
4g per day	22 (39)	11 (39)
Other doses	0	1 (4)
Inappropriate use of paracetamol, n (%)	32 (57%)	–
No dose reduction for patients with a body weight of <50kg, n (%)	11 (34%)	–
A higher dose of paracetamol could have been given based on their medical history and body weight, n (%)	15 (47%)	–
Patients prescribed round the clock paracetamol when there was no indication written, n (%)	12 (38%)	–
Number of days paracetamol was prescribed round the clock, median (IQR)	9 (10)	–
Paracetamol started round the clock on admission before being seen by a Geriatric Medicine consultant, n (%)	30 (54)	–
Paracetamol continued round the clock after being seen by a Geriatric Medicine consultant, n (%)	29 (97)	–
On discharge,
Round the clock paracetamol prescribed, n (%)	32 (57)	1 (4)
Inappropriate dose of paracetamol in patients prescribed round the clock paracetamol, n (%)	5 (16%)	0
Number of days paracetamol was prescribed round the clock, median (IQR)	17.5 (46)	14

Abbreviations: D1 = Day 1, D2 = Day 2, PRN = Pro re nata, SD = Standard deviation.

In the group prescribed with round-the-clock paracetamol, 54 (96%) of them could indicate pain. This was based on clinical charts indicating patients verbalising pain or the ability of the patient to give a coherent history. The indication for round-the-clock paracetamol was not charted in 12 (27%) of the patients and 9 (82%) of them could indicate pain. The median number of other types of analgesics prescribed was 2 (IQR = 2).

Discussion

A thorough pain assessment is important for effective pain management. Components of pain assessment include the site and intensity of pain, effect of pain on affect, behaviour and function as well as the level of cognition affecting pain assessment.¹¹ An individual’s self-report on pain in the form of an interview or the use of standardised forms is the gold standard in pain assessment.¹¹

This clinical audit revealed a high prevalence of round-the-clock and inappropriate doses of paracetamol prescribed in elderly patients admitted for a fall. In addition, more than half of the patients who were prescribed round-the-clock paracetamol were discharged with round-the-clock paracetamol for a median duration of more than 2 weeks. Although paracetamol is recommended as a first-choice analgesic in various guidelines,¹² its use is not without the risk of adverse events especially in the elderly. Hence, it is prudent for paracetamol to be prescribed at the appropriate dose when indicated and to deprescribe whenever appropriate.

We propose an algorithm Figure 2 to reduce the rates of inappropriate prescription of paracetamol in older patients admitted for a fall. The first step of the algorithm is to assess the etiology of the fall and determine if pain contributed to the fall. Thereafter, an assessment of fall-related injuries should be undertaken. The second step of the algorithm is a thorough pain assessment via history taking and physical examination. In the history taking component, we recommend the use of open-ended questions to elicit more pain information¹² followed by targeted questions using the SOCRATES mnemonic (Box 1) which provides a structured approach to the assessment of pain.¹³ If an individual is unable to communicate their pain experience effectively, observations for potential indicators of pain like facial expressions, body movements, altered interpersonal interactions, mental status changes¹⁴ or observational pain scales like the Pain Assessment in Advanced Dementia (PAINAD) scale are recommended.¹³

Box 1.

SOCRATES mnemonic for pain assessment.

S	Site – Where is the pain?
O	Onset – When did the pain start?
C	Character – How would you describe the pain?
R	Radiation – Does the pain go anywhere else?
A	Associated symptoms – Are there any symptoms associated with the pain? E.g., nausea, vomiting, numbness etc.
T	Timing – How long does the pain last for? At what time of the day is the pain worse?
E	Exacerbating or relieving factors – Does anything make the pain better?
S	Severity – How bad is the pain?

If pain is assessed to be continuously present, round-the-clock paracetamol should be prescribed for pain with additional analgesic as appropriate based on the World Health Organisation (WHO) pain ladder. If pain is intermittent, paracetamol can be prescribed PRN.¹⁵ In patients with an underlying cognitive impairment affecting their ability to request medications appropriately,¹⁵ clinical judgement needs to be exercised in determining if round-the-clock paracetamol is indicated. Indications for round-the-clock paracetamol should be reviewed daily and paracetamol should be deprescribed whenever appropriate. Other considerations include weight, alcohol use, and the presence of kidney or liver impairment. On discharge, patients should be reassessed for pain again to determine if round-the-clock paracetamol is indicated.

This clinical audit highlights the prevalence of inappropriate paracetamol prescription in elderly patients admitted for a fall. It also emphasises the importance of judicious prescription of this commonly used analgesic considering the possible adverse events associated with its use, especially in the elderly. To our knowledge, this is the first article that proposes an algorithm to reduce the rates of inappropriate prescriptions of paracetamol in the elderly admitted for a fall. A limitation of this audit was the reliance on clinical documentation to ascertain whether prescription of paracetamol round the clock was indicated. Also, there were no patients with a history of cirrhosis or alcohol use in this clinical audit. As such, we were not able to glean insights to the prescribing pattern in this group of patients.

Conclusion

This clinical audit revealed a high prevalence of round the clock paracetamol prescribed and inappropriate doses of round the clock paracetamol prescribed in elderly patients admitted for a fall. Moving forward, we hope that with the implementation of this algorithm in our clinical setting, the rates of inappropriate paracetamol prescriptions in elderly patients admitted for a fall will be reduced. Other than serving as a reminder to clinicians of the need to be judicious in paracetamol prescription, it is also an opportunity to educate the junior doctors about the adverse events associated with paracetamol use and encourage good paracetamol prescribing habits.

Footnotes

Author contributions

AFY conceived and designed the programme, collected and analysed the data and wrote the manuscript. TKD conceived and designed the programme and edited the manuscript. SDV conceived and designed the programme and edited the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Availability of data

The datasets analysed during the current study are available from AFY.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Angela Frances Hui Wen Yap

Trishpal Kaur Dhaliwal

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Is paracetamol prescribed appropriately in elderly patients admitted for a fall? – A Geriatrician’s perspective

Abstract

Background

Methods

Results

Conclusion

Keywords

Introduction

Methods

Results

Discussion

Conclusion

Footnotes

Author contributions

Declaration of conflicting interests

Availability of data

Funding

ORCID iDs

References