Batty, Gwenno M.

Grant, Robert R.

Jackson, Stephen H. D.

Lowe, Derek

Manyemba, Juliet

Pearson, Michael G.

Potter, Jonathan M.

English

Kingston University Research Repository

Research letters• Patients are generally content for most of theirconfidential medical information to be shared with mostgroups.• Patients believe it is important to be asked about, andinvolved in, any decisions regarding sharing of theirconfidential information with people not involved withtheir health care.JAMES TIERNAN1∗, JOHN STARR21 c/o Dr John Starr, Royal Victoria Hospital, 13 CraigleithRoad, Edinburgh EH4 2DN, UK2 c/o Royal Victoria Hospital, 13 Craigleith Road, EdinburghEH4 2DN, UKEmail: jamestiernanwork@hotmail.co.uk∗To whom correspondence should be addressedReferences1. General Medical Council (2001); Good Medical Practice (3rdedn). http://www.gmc-uk.org/guidance/library/duties of adoctor.asp (last accessed 7 September 2006).2. General Medical Council (2004); Confidentiality: Pro-tecting and Providing Information. http://www.gmc-uk.org/guidance/library/confidentiality.asp (last accessed 19September 2006).3. General Medical Council (2001); Good Medical Practice(3rd edn). http://www.gmc-uk.org/guidance/good medicalpractice/index.asp (last accessed 7 September 2006).4. Scottish Executive (2000); Adults with Incapacity (Scotland) Act2000. http://www.scotland.gov.uk/Topics/Justice/Civil (lastaccessed 7 September 2006).5. Nelson G, Kinjo K, Meier DE, Ahmad K, Morrison RS. Whencritical illness becomes chronic: informational needs of patientsand families. J Crit Care 2005; 20: 79–89.6. Hagerty RG, Butow PN, Ellis PM et al. Communicating withrealism and hope: incurable cancer patients’ views on thedisclosure of prognosis. J Clin Oncol 2005; 23: 1278–88.7. Hodkinson HM. Evaluation of a mental test score for assessmentof mental impairment in the elderly. Age Ageing 1972; 1: 233–8.8. Folstein M, Folstein S, McHugh P. ‘Mini-Mental State’: Apractical method for grading the cognitive state of patients forthe clinician. J Psychiatr Res 1975; 12: 189–98.doi:10.1093/ageing/afm020Published electronically 27 April 2007Prescription of paracetamol-containingmedications as indicator of quality ofprescribingSIR—Paracetamol is widely prescribed for mild to moderatepain and pyrexia. It is available as a single ingredient and alsoin combination with opiate analgesics such as codeine anddihydrocodeine. The recommended dose of paracetamol foradults is 0.5 to 1 g every 4–6 h to a maximum of 4 g in agiven 24-h period [1].Hepatotoxicity is rare if doses of paracetamol <12 g(or 150 mg/kg body weight) are ingested [2] althoughit is described [3, 4]. Patients with poor nutrition areparticularly at risk of hepatotoxicity even at doses withinthe recommended range [5]. This may be relevant for olderpeople in hospital as the prevalence of malnutrition is knownto be high in this population [6]. However, we are notaware of clinical trial evidence to suggest that older peopleshould have a lower recommended dose. In fact, the currentrecommended dose is not based on randomised controlledtrial data. Using a single intravenous dose of 500 mg ofparacetamol, Wynne et al. showed paracetamol clearance todecrease with age and frailty [7]. Miners et al. showed thatafter administering a single oral dose of 1 g of paracetamolthe total clearance and clearance by glucuronidation did notchange with age although there was a reduction in clearanceby sulphation and renal clearance [8]. Interestingly there wasno age effect on the cytochrome P450 mediated clearance ofthe reactive toxic metabolite. This has also been seen in ratstudies [9].While deliberate overdose of paracetamol is well known,inadvertent, iatrogenic over-dosage is less well recognised.The National Sentinel Audit of Evidence Based Prescribingfor Older People supported improvements in prescribingby measuring the quality of prescribing practice [10].We report here on the prescription of paracetamol andparacetamol-containing preparations in 102 hospitals thatparticipated in the audit and give an estimate of the risk ofexceeding the recommended dose of paracetamol. The datawere collected prior to the withdrawal of Co-Proxamol,dextropropoxyphene in combination with paracetamol,withdrawn in January 2005, because of poorly establishedefficacy and unacceptable risk of toxicity in overdose [11].MethodsHospitals in England and Wales were invited to volunteerto participate in the study in 1999 and 102 hospitals agreed.Prescribing data on paracetamol-containing medicationswere collected from drug charts of 100 consecutive medicalin-patients aged 65 years or older on a selected day for eachhospital. Data collected included the dose and frequency ofall paracetamol containing medications prescribed. The totalparacetamol content in milligrams prescribed to patientswas evaluated over a 24 h period. We did not collectdata on medications actually administered and nurses didnot prescribe. Patients were considered to be at risk ofoverdosage if there was the potential to be administered over4 g of paracetamol in 24 h.ResultsData were collected for 9,979 patients. Of these, 9,927patients had one or more drugs prescribed. Among thesepatients 6,141 (62%) were prescribed 6,560 medications582 at kingstonuni on November 22, 2010ageing.oxfordjournals.orgDownloaded from Research letterscontaining paracetamol. Apart from paracetamol tablets,four combination preparations were prescribed (Table 1).Data to enable estimation of total dosage was complete foronly 6,060 patients prescribed 6,465 medications containingparacetamol (Table 2). There was a potential risk of aparacetamol overdosage for 732/6,060 (12%) of patientsprescribed medication containing paracetamol. The risk ofthe potential for overdosage increased with the number ofparacetamol-containing medications prescribed per patient.The percentage of patients at risk of potential overdosage waslow (7%) when only one paracetamol-containing medicationwas prescribed. However, the risk increased dramatically to90% when two paracetamol-containing medications wereprescribed and to 100% with three or more paracetamol-containing medications (Table 2). Data were collected a yearlater in the second loop of the audit cycle and no significantchanges were found.DiscussionThis study demonstrates that medical in-patients aged65 years or older are at potential risk, through suboptimalprescribing, of being administered paracetamol exceeding therecommended therapeutic dose. The main problems were:(i) failure to specify the dose frequency; and (ii) prescribingmore than one paracetamol-containing medication.Although this study was conducted prior to the withdrawalof Co-Proxamol we do not expect the situation to havechanged much since. As paracetamol is available in a numberof compound analgesic preparations, a common error isto co-prescribe paracetamol with a compound analgesicTable 1. Paracetamol-containingmedications prescribedName of medication Number of prescriptions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Paracetamol 5,274Co-Proxamol 376Co-Dydramol 326Co-Codamol 8/500 502Co-Codamol 30/500 82Total 6,560Table 2. The relationship between number ofparacetamol-containing preparations prescribed and thepotential for excessive dosingNo. of paracetamol- No. of patients No. of patientscontaining prescribed where excessivemedications paracetamol-containing dosing could haveprescribed medication(s) occurred (%)per patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 5,668 376 (6.6)2 368 332 (90.2)3 or more 24 24 (100)Total 6,060 732 (12.1)containing paracetamol and exceed the recommended limit.Recently, SUREMED, an anonymous self-reporting schemefor medication errors [12, 13] alerted prescribers in King’sCollege Hospital of such duplicate dose errors (internalcommunication). The alert advised that when prescribinganalgesics which patients bring into hospital, doctors needto check the paracetamol content and review the currentmedication chart to ensure that no other paracetamol-basedanalgesics are prescribed.The main limitation of our study was the unavailabilityof data on clinical endpoints and medications administered,which the audit was not designed to measure. While datawere collected for 100 consecutive patients over the age of 65on medical wards on a selected day for each hospital, we donot have data on the number of all inpatients at the time ofaudit. Over 98% of the patients prescribed paracetamolor paracetamol-containing medication had dosage dataavailable. We did not feel that we could make a meaningfulcomparison between patients with and without dosage databecause the latter group had only 81 patients compared with6,040 with dosage data available.ConclusionParacetamol is a popular first-line choice for managementof pain and pyrexia in patients of all ages. When used atrecommended doses it seldom causes adverse events [14, 15].To reduce the risk of exceeding the recommended dose ofparacetamol prescribers should avoid prescribing the drugas more than one preparation. There is no rationale formore than two preparations to be prescribed concurrently. Inaddition, prescribers should not rely on those who administermedicines to quantify the total dosage of potentiallyharmful drugs. The prescription of multiple preparations ofparacetamol can be used as a marker of quality of prescribing.As mentioned earlier in this paper, there is no evidence tosuggest a lower recommended dose of paracetamol forolder people. The prevalence of prescriptions allowing theadministration of greater than 4 g of paracetamol in a 24 hperiod can be used to reflect the risk of iatrogenic over-dosagein adult patients in general.AcknowledgementsWe thank the hospitals that participated in the study.This work was undertaken by the Royal College ofPhysicians’ Clinical Effectiveness and Evaluation Unit andthe Clinical Age Research Unit of the Department of ClinicalGerontology, King’s College Hospital, who received fundingfrom the National Institute of Clinical Excellence. The viewsexpressed in this publication are those of the authors.Key points• Paracetamol is commonly prescribed as a single ingredientor as a compound analgesic.583 at kingstonuni on November 22, 2010ageing.oxfordjournals.orgDownloaded from Research letters• The recommended maximum dose of paracetamol foradults is 4 g in a given 24-h period.• This study showed that the risk of exceeding this dose isincreased dramatically when more than one paracetamol-containing medication is prescribed.• The prevalence of prescriptions allowing the administra-tion of greater than 4 g of paracetamol in a 24 h periodcan be used to reflect the quality of prescribing in hospitalin-patients.Conflict of interestNoneJULIET MANYEMBA1∗, GWENNO M. BATTY2, ROBERT R. GRANT3,DEREK LOWE3, JONATHAN M. POTTER2, MICHAEL G. PEARSON3,STEPHEN H. D. JACKSON11Clinical Age Research Unit, King’s College Hospital,Bessemer Road, London SE5 9PJ, UKE-mail: Juliet.manyemba@kch.nhs.uk2Department of Healthcare of Older People, Kent andCanterbury Hospital, Canterbury, Kent CT1 3NG, UK3Clinical Effectiveness and Evaluation Unit, Royal College ofPhysicians, 11 St Andrew’s Place, Regents Park,London NW1 4LE, UK∗To whom correspondence should be addressedReferences1. British National Formulary March 2006; 51: 220.2. Routledge P, Vale JA, Bateman DN et al. Paracetamol(acetaminophen) poisoning. BMJ 1998; 317: 1609–10.3. Ericksson LS, Broome U, Kalin M, Lindholm M. Hepatotoxi-city due to repeated intake of low doses of paracetamol. J InternMed 1992; 231: 567–70.4. Schiodt FV, Rochling FA, Casey DL, Lee WM. Acetaminophentoxicity in an urban county hospital. N Engl J Med 1997; 337:1112–8.5. Kurtovic J, Riordan SM. Paracetamol-induced hepatotoxicityat recommended dosage (Case report). J Intern Med 2003; 253:240–3.6. Brantervik AM, Jacobson IE, Grimby A, Wallen TC,Bosaeus IG. Older hospitalised patients at risk of malnutrition:correlation with quality of life, aid from the social welfaresystem and length of stay? Age Ageing 2005; 34: 444–9.7. Wynne HA, Cope LH, Herd B, Rawlins MD, James OFW,Woodhouse KW. The association of age and frailty withparacetamol conjugation in man. Age Ageing 1990; 19:419–24.8. Miners JO, Penhall R, Robson RA, Birkett DJ. Comparison ofparacetamol metabolism in young adults and elderly males. EurJ Clin Pharmacol 1988; 35: 157–60.9. Rikans LE, Moore DR. Acetaminophen hepatotoxicity in agingrats. Drug Chem Toxicol 1988; 11: 237–47.10. Grant RL, Aggarwal R, Lowe D et al. National sentinelclinical audit of evidence-based prescribing for older people:methodology and development. J Eval Clin Pract 2002; 8:189–98.11. Anonymous. Co-proxamol to be withdrawn from the market.MHRA 31st January 2005; http://www.mhra.gov.uk.12. Cavell G. Anonymous reporting of medication errors. J MedDef Union 1995; 11: 86–7.13. A report by the Chief Pharmaceutical Officer. 34480/Buildinga Safer NHS: Improving Medication Safety. UKDepartment of Health Publications 22 January 2004; 146–7,www.doh.gov.uk/buildsafenhs/medicationsafety.14. Prescott LF. Paracetamol: past, present, and future. Am J Ther2000; 7: 143–7.15. Prescott LF. Therapeutic misadventure with paracetamol: factor fiction? Am J Ther 2000; 7: 99–114.doi:10.1093/ageing/afm090Published electronically 22 August 2007Do we really need palliative care for severedementia patients?SIR—The decision about the most appropriate care modelfor patients affected by severe dementia and acute somaticdiseases is a major topic in the discussion regarding hospitalprocesses. With this in mind, we read with interest theeditorial by Parker et al. on ‘Acute hospital care for frailolder people’ and the paper by Zvi Aminoff and Adunskyrecently published in Age and Ageing [1, 2]. We share mostof the statements by the authors regarding the care ofelderly people in the acute hospital setting. Moreover, weappreciate the attention given to this topic in a periodwhen geriatric wards are under pressure with the generaltrend to reduce acute hospital beds. In particular, the Italiannational agenda is dominated mostly by an emphasis ondeveloping intermediate care and community services forolder people [3]. Some acute geriatric wards are closing andothers are being converted to departments of ‘low care’ [4].The remaining geriatric hospital wards have to face thedifficult task of caring for a higher number of old patientswith an increase in the average level of illness severity andcomplexity. In order to answer these difficulties we needto define new models of inpatient units. Special acute careunits for elderly patient (ACE) like sub-intensive care unitsfor the elderly, stroke units, hip units and delirium unitshave been developed. Most of them have been shown to beeffective for specific clinical conditions. However, for manypatients, i.e. those with severe dementia, the effectiveness ofhospital admission has not been completely evaluated, andnew models of care are in the process of being developed.Among these models, palliative care seems inspired by themost diffused cultural backgrounds.In this framework, we would like to present our data, inorder to contribute to the ongoing discussion.From 1 January to 31 December 2003, there were 1,418patients who were consecutively admitted to our ward. Onehundred and eight patients were under 65 years of age andwere excluded from the analysis, and 16 patients were lost at584 at kingstonuni on November 22, 2010ageing.oxfordjournals.orgDownloaded from 

Prescription of paracetamol-containing medications as indicator of quality of prescribing

Prescription of paracetamol-containing medications as indicator of quality of prescribing

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