For Student

An 84-year-old woman with dementia is admitted from a residential home because she has had
some falls. The patient is described as being frail. She is restless and agitated and has a
respiratory infection. Her skin is fragile, with several small lacerations and bruises caused by her
recent falls. The electronic prescribing process prompts the admitting medical team to assess for
venous thromboembolism (VTE) Iatrogenic illness in frail older patients 177 risk. She is
considered at risk because of her age, dehydration and infection. Should she be prescribed VTE
prophylaxis with subcutaneous enoxaparin?

Tasks:
1. What iatrogenic illness may result from the given intervention?
Task 1 (3.0)Head injury and intracranial bleeding are a substantial risk because of the
patient’s frailty, confusion and risk of further falls. Low-dose enoxaparin will
substantially increase this risk. The distress caused by subcutaneous injections may
exacerbate the patient’s delirium. There may be cutaneous bruising at injection sites and
elsewhere due to the patient’s restlessness and agitation and resulting minor trauma.

2. What risk factors for iatrogenic illness are present in this case?
Task 2 (2.0)Fall-related head injury carries a higher than normal risk of intracranial
bleeding, particularly subdural haemorrhage, because of age- and dementia-associated
cerebral atrophy.

3. Suggest some alternative management strategies.

Task 3 (2.0)The patient could be assessed for anti-thromboembolic stockings if
peripheral circulation is satisfactory. Rehydration, treatment of respiratory infection and
supervised mobilization will reduce the risk of VTE.

4. How can these complications be minimized?

Task 4 (3.0)The risk of VTE has to be balanced against the substantial risk (in this case)
of harm from increased bleeding. A supportive nursing environment and medical
management aiming to reverse treatable conditions and resolve delirium are important. If
the patient is judged not to have capacity to participate in treatment-related decisions,
then the medical team should act in her best interests. Timely involvement of family
members or any legally appointed representative (lasting power of attorney) is imperative