The association of polypharmacy with functional decline in elderly patients undergoing cardiac surgery

Abstract

Aims Identifying preoperative risk factors in older patients becomes more important to reduce adverse functional outcome. This study investigated the association between preoperative medication use and functional decline in elderly cardiac surgery patients and compared polypharmacy as a preoperative screening tool to a clinical frailty assessment. Methods This sub‐study of the Anaesthesia Geriatric Evaluation study included 518 patients aged ≥70 years undergoing elective cardiac surgery. The primary outcome was functional decline, defined as a worse health‐related quality of life or disability 1 year after surgery. The association between polypharmacy (i.e. ≥5 prescriptions and <10 prescriptions) or excessive polypharmacy (i.e. ≥10 prescriptions) and functional decline was investigated using multivariable Poisson regression. Discrimination, calibration and reclassification indices were used to compare preoperative screening tools for patient selection. Results Functional decline was reported in 284 patients (55%) and preoperative polypharmacy and excessive polypharmacy showed higher risks (adjusted relative risk 1.57, 95% confidence interval [CI] 1.23–1.98 and 1.93, 95% CI 1.48–2.50, respectively). Besides cardiovascular medication, proton‐pump inhibitors and central nervous system medication were significantly associated with functional decline. Discrimination between models with polypharmacy or frailty was similar (area under the curve 0.67, 95% CI 0.61–0.72). The net reclassification index improved when including polypharmacy to the basic model (17%, 95% CI 0.06–0.27). Conclusion Polypharmacy is associated with functional decline in elderly cardiac surgery patients. A preoperative medication review is easily performed and could be used as screening tool to identify patients at risk for adverse outcome after cardiac surgery.

Preoperative polypharmacy assessment for risk stratification and management

“…[12][13][14] Notably, CNS drugs and proton pump inhibitors, in addition to cardiovascular drugs, were also significantly associated with 12-month functional decline in the study by Arends et al 9 This suggests that targeted deprescribing interventions might be particularly beneficial, although it is important to emphasise that, in this study, no assessment of individual medication appropriateness was conducted. 9 Even assuming that a targeted deprescribing intervention is scientifically and clinically justified, when should that be implemented? This issue is particularly important in the pre-operative setting.…”

“…Notably, adding polypharmacy and excessive polypharmacy to the basic model also led to a correct reclassification to a different functional decline risk group in 17% of study participants. 9 Pending confirmation in other cohorts, the results of the study by Arends et al provide some novel insights into the practical applications of assessing polypharmacy in the pre-operative setting. For example, the similar, albeit limited, impact of polypharmacy and frailty in terms of improving the capacity to predict postsurgery functional decline means that the former might theoretically replace the latter in circumstances where a comprehensive geriatric assessment, or other types of frailty assessment, cannot be performed due to limited staff resources or expertise.…”

“…A similar AUC value was observed after adding measures of frailty instead of polypharmacy (0.67 vs. 0.67). Notably, adding polypharmacy and excessive polypharmacy to the basic model also led to a correct reclassification to a different functional decline risk group in 17% of study participants 9 …”

“…6,7 The latter, notably, can often manifest as functional and/or cognitive decline, with consequent loss of independence, and be erroneously confused with the process of advancing age per se. 8 The capacity of preoperative polypharmacy and frailty to predict postsurgical functional decline has been investigated in this issue of the Journal by Arends et al 9 The authors performed a comprehensive assessment of polypharmacy (defined as ≥5 and <10 concomitant medications), excessive polypharmacy (defined as ≥10 concomitant medications), and 11 frailty domains in 518 patients ≥70 years awaiting elective cardiac surgery. The combined prevalence of polypharmacy and excessive polypharmacy was relatively high, 67%.…”

“…In summary, the study by Arends et al provides some novel insights into the practical utility of polypharmacy as an alternative tool to assess pre-operative frailty and predict postsurgical functional decline. 9 At the same time, pending confirmatory studies, it generates several additional questions regarding the nature and the appropriate timing of deprescribing interventions in this and other patient groups. This is particularly important as recent studies have shown that deprescribing specific drugs in older hospitalized patients, for example, antihypertensives and statins, might increase the risk of adverse outcomes following discharge.…”