Medical care can be both “a blessing and a curse”. The contributions of medicines to increased human lifespan and falling mortality from the major cardiovascular diseases are undisputed. However, in lockstep with remarkable extension of human lifespan has been increase in the numbers of people living with chronic age related neurodegenerative conditions and frailty. In frail, multi-morbid populations, with limited homeostatic reserve and life expectancy, the balance between the risk and harms of medicines can be in equipoise. In this context the number of older people living with dementia is increasing, and understanding threats to the quality of life of people with dementia is of growing significance. Among the myriad potential causes of harm to older people with dementia, in this issue of the journal Mitchell and colleagues present new Australian data reminding us of the importance of admissions due to both intentional and unintentional poisoning.
In medicine there has long been a fine line between the therapeutic and poisonous effects of substances (Ropper, Reference Ropper2012). Usually “poisoning” is considered to encompass intentional overdose and errors, relating to both medicines and non-medicinal substances. This is in contrast to adverse drug reactions, which occur when a medicine is taken as intended. Consistent with this approach, Mitchell and colleagues have excluded admissions due to adverse effects caused by drugs in correct therapeutic use. Thus, poisoning overlaps with the larger problem of medication related misadventure and harm. Although poisons can include non-medicinal substances, in this study at least, medicinal substances were the large majority of unintentional poisons among people with dementia (94%) and people without dementia (88%). Similarly, medicinal substances were almost always the poison used intentionally by people with dementia (93%) and those without (94%).
Mitchell et al.’s pharmacoepidemiologic study analyzed large samples of admissions in New South Wales (NSW), of people aged 50 and over, with accidental (n = 6,240) and intentional (n = 10,451) poisoning. Although people with dementia were overall a small subgroup (n = 895 [5%]), they were over-represented among admissions for unintentional (n = 581 [9%]), compared to intentional (n = 314 [3%]), poisoning. In fact, for individuals aged over 60 years the age-adjusted hospitalization rate of unintentional poisoning for people with dementia (69.5 per 100,000; 95%CI 60.4–78.6) was more than double that of people without dementia (31.6 per 100,000; 95%CI 30.6–32.6). These rates are for people over the age of sixty as the authors used denominator data from published reports of the number of people with dementia aged 60 years and over living in NSW. Thus, the absolute rates should be interpreted with caution, although relative differences remain informative. Dementia was also associated with higher mortality rates and longer length of stay among people admitted due to unintentional poisoning.
Similarly, intentional poisoning appeared to be much more common among people with dementia (56.4 per 100,000; 95%CI 46.7–66.2), although the magnitude of difference compared to people without dementia (32.5 per 100,000; 95%CI 31.5–33.5) was not quite as large as for unintentional poisoning. Intentional poisoning, in contrast to unintentional poisoning, did not appear to more often be fatal among people with dementia, compared to people without dementia.
The authors highlight how cognitive impairment can lead to confusion, perhaps increasing the risk of poisoning with both medicinal and non-medicinal substances. As would be anticipated, co-morbid mental health conditions were coded much more frequently among people with intentional poisoning. A not insubstantial proportion of unintentional poisonings occurred in aged care facilities (6%; OR 5.44 [95%CI 4.43–6.67]) or health service areas (17%; OR 4.56 [95%CI 4.06–5.13]). The authors show that co-morbidity is more common among people admitted with poisoning who have dementia. Comorbidity is also associated with unintentional poisoning. Thus comorbidity, and associated polypharmacy, may potentially contribute to an increased danger of poisoning among people with dementia, perhaps medicated by increase in the risk of error. Polypharmacy among older people may also contribute to the fact that a diverse range of medicines were frequently intentional and unintentional poisons in the older people in this study. Notwithstanding the diversity of agents, psychotropic medicines were the drugs most commonly implicated in intentional poisoning.
This study uses an administrative dataset and thus interpretation of the findings is necessarily limited. A substantial number (n = 1,513; 8% of the total potential sample) of admissions were excluded because intent was uncertain. Thus the data presented, if anything, likely underestimate the size of the problem. Furthermore, there could potentially be incomplete detection of medication related poisoning contributing to admission, particularly in the case of mild effects of medication error.
“Poisoning” is a loaded word. Mitchell et al.'s analysis highlights that the benefits medicines have achieved for humankind care are tempered by the potential for iatrogenic harm, particularly among people living with dementia. These data serve as an additional call to arms, to both consumers and healthcare workers, for a vigilant focus on safety of older people living with dementia, and a particular focus on safer use of medicines. In addition to the commonly cited high personal risk situations such as driving, accidental fire, falls and becoming lost, safety in relation to medicines, and other poisons needs to be consistently addressed for older people, particularly those with cognitive impairments.
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Medical care can be both “a blessing and a curse”. The contributions of medicines to increased human lifespan and falling mortality from the major cardiovascular diseases are undisputed. However, in lockstep with remarkable extension of human lifespan has been increase in the numbers of people living with chronic age related neurodegenerative conditions and frailty. In frail, multi-morbid populations, with limited homeostatic reserve and life expectancy, the balance between the risk and harms of medicines can be in equipoise. In this context the number of older people living with dementia is increasing, and understanding threats to the quality of life of people with dementia is of growing significance. Among the myriad potential causes of harm to older people with dementia, in this issue of the journal Mitchell and colleagues present new Australian data reminding us of the importance of admissions due to both intentional and unintentional poisoning.
In medicine there has long been a fine line between the therapeutic and poisonous effects of substances (Ropper, Reference Ropper2012). Usually “poisoning” is considered to encompass intentional overdose and errors, relating to both medicines and non-medicinal substances. This is in contrast to adverse drug reactions, which occur when a medicine is taken as intended. Consistent with this approach, Mitchell and colleagues have excluded admissions due to adverse effects caused by drugs in correct therapeutic use. Thus, poisoning overlaps with the larger problem of medication related misadventure and harm. Although poisons can include non-medicinal substances, in this study at least, medicinal substances were the large majority of unintentional poisons among people with dementia (94%) and people without dementia (88%). Similarly, medicinal substances were almost always the poison used intentionally by people with dementia (93%) and those without (94%).
Mitchell et al.’s pharmacoepidemiologic study analyzed large samples of admissions in New South Wales (NSW), of people aged 50 and over, with accidental (n = 6,240) and intentional (n = 10,451) poisoning. Although people with dementia were overall a small subgroup (n = 895 [5%]), they were over-represented among admissions for unintentional (n = 581 [9%]), compared to intentional (n = 314 [3%]), poisoning. In fact, for individuals aged over 60 years the age-adjusted hospitalization rate of unintentional poisoning for people with dementia (69.5 per 100,000; 95%CI 60.4–78.6) was more than double that of people without dementia (31.6 per 100,000; 95%CI 30.6–32.6). These rates are for people over the age of sixty as the authors used denominator data from published reports of the number of people with dementia aged 60 years and over living in NSW. Thus, the absolute rates should be interpreted with caution, although relative differences remain informative. Dementia was also associated with higher mortality rates and longer length of stay among people admitted due to unintentional poisoning.
Similarly, intentional poisoning appeared to be much more common among people with dementia (56.4 per 100,000; 95%CI 46.7–66.2), although the magnitude of difference compared to people without dementia (32.5 per 100,000; 95%CI 31.5–33.5) was not quite as large as for unintentional poisoning. Intentional poisoning, in contrast to unintentional poisoning, did not appear to more often be fatal among people with dementia, compared to people without dementia.
The authors highlight how cognitive impairment can lead to confusion, perhaps increasing the risk of poisoning with both medicinal and non-medicinal substances. As would be anticipated, co-morbid mental health conditions were coded much more frequently among people with intentional poisoning. A not insubstantial proportion of unintentional poisonings occurred in aged care facilities (6%; OR 5.44 [95%CI 4.43–6.67]) or health service areas (17%; OR 4.56 [95%CI 4.06–5.13]). The authors show that co-morbidity is more common among people admitted with poisoning who have dementia. Comorbidity is also associated with unintentional poisoning. Thus comorbidity, and associated polypharmacy, may potentially contribute to an increased danger of poisoning among people with dementia, perhaps medicated by increase in the risk of error. Polypharmacy among older people may also contribute to the fact that a diverse range of medicines were frequently intentional and unintentional poisons in the older people in this study. Notwithstanding the diversity of agents, psychotropic medicines were the drugs most commonly implicated in intentional poisoning.
This study uses an administrative dataset and thus interpretation of the findings is necessarily limited. A substantial number (n = 1,513; 8% of the total potential sample) of admissions were excluded because intent was uncertain. Thus the data presented, if anything, likely underestimate the size of the problem. Furthermore, there could potentially be incomplete detection of medication related poisoning contributing to admission, particularly in the case of mild effects of medication error.
“Poisoning” is a loaded word. Mitchell et al.'s analysis highlights that the benefits medicines have achieved for humankind care are tempered by the potential for iatrogenic harm, particularly among people living with dementia. These data serve as an additional call to arms, to both consumers and healthcare workers, for a vigilant focus on safety of older people living with dementia, and a particular focus on safer use of medicines. In addition to the commonly cited high personal risk situations such as driving, accidental fire, falls and becoming lost, safety in relation to medicines, and other poisons needs to be consistently addressed for older people, particularly those with cognitive impairments.
Conflict of Interest
None.