Potentially Inappropriate Medication Administration Is Associated With Adverse Postoperative Outcomes in Older Surgical Patients: A Retrospective Cohort Study

Abstract

BACKGROUND: The American Geriatrics Society (AGS) Beers Criteria is an explicit list of potentially inappropriate medications (PIMs) best avoided in adults ≥65 years of age. Cognitively impaired and frail surgical patients often experience poor outcomes after surgery, but the impacts of PIMs on these patients are unclear. Our objective was to assess whether perioperative PIM administration was associated with poor outcomes in geriatric surgical patients. We then evaluated the association between PIM administration and postoperative outcomes in subgroups of patients who were frail or cognitively impaired. METHODS: We performed a retrospective cohort study of patients ≥65 years of age who underwent elective inpatient surgery at a large academic medical center from February 2018 to January 2020. Edmonton Frail Scale and Mini-Cog screening tools were administered to all patients at their preoperative clinic visit. A Mini-Cog score of 0 to 2 was considered cognitive impairment, and frailty was defined by an Edmonton Frail Scale score of ≥8. Patients were divided into 2 groups depending on whether they received at least 1 PIM (PIM+), based on the 2019 AGS Beers Criteria, in the perioperative period or none (PIM−). We assessed the association of preoperative frailty, cognitive impairment, and perioperative PIM administration with the length of hospital stay and discharge disposition using multiple regression analyses adjusted for age, sex, ASA physical status, and intensive care unit (ICU) admission. RESULTS: Of the 1627 included patients (mean age, 73.7 years), 69.3% (n = 1128) received at least 1 PIM. A total of 12.7% of patients were frail, and 11.1% of patients were cognitively impaired; 64% of the frail patients and 58% of the cognitively impaired patients received at least 1 PIM. Perioperative PIM administration was associated with longer hospital stay after surgery (PIM−, 3.56 ± 5.2 vs PIM+, 4.93 ± 5.66 days; P < .001; 95% confidence interval [CI], 0.360–0.546). Frail patients who received PIMs had an average length of stay (LOS) that was nearly 2 days longer than frail patients who did not receive PIMs (PIM−, 4.48 ± 5.04 vs PIM+, 6.33 ± 5.89 days; P = .02). Multiple regression analysis revealed no significant association between PIM administration and proportion of patients discharged to a care facility (PIM+, 26.3% vs PIM−, 28.7%; P = .87; 95% CI, −0.046 to 0.054). CONCLUSIONS: Perioperative PIM administration was common in older surgical patients, including cognitively impaired and frail patients. PIM administration was associated with an increased hospital LOS, particularly in frail patients. There was no association found between PIM administration and discharge disposition.

Pro-Con Debate: Judicious Benzodiazepine Administration for Preoperative Anxiolysis in Older Patients

“…For example, a recent study of perioperative potentially inappropriate medication (PIM) administration demonstrated that frail patients who received PIMs had a length of stay nearly 2 days longer than those who did not. 15 Although we did not find studies directly comparing preoperative anxiety in older versus younger populations, there are conditions where older surgical patients are known to have a different postoperative course than their younger counterparts including postoperative pain and postoperative nausea and vomiting. 57,58 In a study of patients with an average age of 78 years undergoing cataract surgery with topical anesthesia, a double-blind controlled clinical trial found that intravenous midazolam did not significantly reduce pain or anxiety compared to topical anesthesia alone.…”

“…For example, a recent study of perioperative potentially inappropriate medication (PIM) administration demonstrated that frail patients who received PIMs had a length of stay nearly 2 days longer than those who did not. 15 Although we did not find studies directly comparing preoperative anxiety in older versus younger populations, there are conditions where older surgical patients are known to have a different postoperative course than their younger counterparts including postoperative pain and postoperative nausea and vomiting. 57,58…”

“…In another large academic hospital, >38% of patients aged 65 and older undergoing inpatient, noncardiac surgery received midazolam perioperatively. 15 This is massive use of a drug with very serious potential risks. We agree that benzodiazepines such as midazolam are attractive for their rapid onset, short duration, and amnestic properties.…”

Challenging Paradigms and Trusting Evidence: New Approaches to Perioperative Care

“…This approach is all the more relevant as the population ages; surgical populations are aging faster than the general population and phrases like “potentially inappropriate medications” and “deprescribing” have already entered the perioperative lexicon. 1-3 As we write this from the University of Colorado, the Rocky Mountains are visible on the horizon and the words of famed rock-climber Yvon Choinard come to mind: “The more you know, the less you need.” 4…”

“…This approach is all the more relevant as the population ages; surgical populations are aging faster than the general population and phrases like "potentially inappropriate medications" and "deprescribing" have already entered the perioperative lexicon. [1][2][3] As we write this from the University of Colorado, the Rocky Mountains are visible on the horizon and the words of famed rock-climber Yvon Choinard come to mind: "The more you know, the less you need." 4 In the first Original Research article, Krause et al 5 report the results of a pilot trial in which 100 patients were randomized to receive induction of general anesthesia titrated with processed electroencephalography monitoring (SedLine ® monitors; Masimo, Irvine, CA) to a Patient State Index (PSI) of less than 50 versus standard weight-based dosing.…”