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Re: Inappropriate Medication Use in Older Adults Undergoing Surgery: A National Study
1212
GERIATRICS
classes of drugs prescribed for urological conditions fall into the Beers Criteria listings of medications that should be avoided. These agents include some antibiotics, analgesics, sedative hypnotics, antispasmodics and hormonal agents. Many medications with urological indications also have potent anticholinergic properties that could be associated with increased risk of delirium, falls, fractures and other negative outcomes. These recommendations will be used for clinical care, education and research. They are designed to be patient centered, with the primary goal to improve prescribing patterns for these potentially vulnerable patients. The writing panel emphasizes that the recommendations should be used within the overall context of care, and in some cases medications on the list may be clinically indicated and useful. However, care needs to be tailored specifically to the patient and his or her individual needs. Past guideline listings have been adopted by various policy making entities in an effort to improve care and monitor quality. It will be interesting to see how this new update will be incorporated with rapidly changing technology for electronic prescribing and health records. The new partnership with the American Geriatrics Society will allow for ongoing updating of this information to maintain an accurate and timely evidence-based guideline. Tomas L. Griebling, M.D., M.P.H.
Re: Inappropriate Medication Use in Older Adults Undergoing Surgery: A National Study E. Finlayson, J. Maselli, M. A. Steinman, M. B. Rothberg, P. K. Lindenauer and A. D. Auerbach Department of Surgery, University of California, San Francisco, California J Am Geriatr Soc 2011; 59: 2139 –2144.
Objectives: To determine the prevalence and factors associated with use of potentially inappropriate medications (PIMs) in older adults undergoing surgery. Design: Retrospective cohort study. Setting: Three hundred seventy-nine acute care hospitals participating in the nationally representative Perspective database (2006 –2008). Participants: Individuals aged 65 and older undergoing major inpatient gastrointestinal, gynecological, urological, and orthopedic surgery (N⫽272,351). Measurements: Medications were classified as PIMs using previously published criteria defining 33 medications deemed potentially inappropriate in people aged 65 and older. Information about participant and provider characteristics and administration of PIMs was obtained from hospital discharge file data. Logistic regression techniques were used to examine factors associated with use of PIMs in the perioperative period. Results: One-quarter of participants received at least one PIM during their surgical admission. Meperidine was the most frequently prescribed PIM (37,855, 14% of participants). In adjusted analysis, PIM use was less likely as age advanced (adjusted odds ratio (AOR)⫽0.98 per year of age, 95% confidence interval (CI)⫽0.97– 0.98) and in men (AOR⫽0.83, 95% CI⫽0.81– 0.85). PIMs were more likely to be prescribed to participants cared for by orthopedic surgeons than for those cared for by general surgeons (AOR⫽1.22, 95% CI⫽1.08 –1.40). Participants undergoing surgery in the West (AOR⫽1.79, 95% CI⫽1.02–3.16) and South (AOR⫽2.24, 95% CI⫽1.38 –3.64) were more likely to receive a PIM than those in the Northeast. Conclusion: Receipt of PIMs in older adults undergoing surgery is common and varies widely between providers and geographic regions and according to participant characteristics. Interventions aimed at reducing the use of PIMs in the perioperative period should be considered in quality improvement efforts. Editorial Comment: More than half of all surgeries in the United States, including urological procedures, are performed in patients 65 years or older. Most patients undergoing surgery will be prescribed some medications in association with their care. It has long been recognized that some drugs are associated with increased risks of adverse events in older adults due to changes in metabolism, or interactions either between drugs or with an underlying comorbid condition. The authors examined prescribing patterns in a large cohort of older adults undergoing major surgery. Overall, 25% of the more than 272,000
GERIATRICS
1213
elderly patients in this study received a PIM. In fact, 14% were prescribed meperidine, a drug consistently cited as one to avoid due to difficulties with drug clearance, development of toxic metabolites and other untoward potential side effects. It was interesting that compared to other specialists, urologists had the lowest overall PIM usage (OR 0.91, 95% CI 0.82–1.00). However, 19% of patients undergoing urological surgery received a PIM in this study, which indicates there is still much room for improvement in prescribing patterns. Urologists need to be familiar with evidence-based recommendations, which can help guide and improve prescribing choices in this growing patient population. Tomas L. Griebling, M.D., M.P.H.
Re: Accumulated Frailty Characteristics Predict Postoperative Discharge Institutionalization in the Geriatric Patient T. N. Robinson, J. I. Wallace, D. S. Wu, A. Wiktor, L. F. Pointer, S. M. Pfister, T. J. Sharp, M. J. Buckley and M. Moss Department of Surgery, University of Colorado at Denver School of Medicine, Aurora, Colorado J Am Coll Surg 2011; 213: 37– 44.
Background: Frailty is a state of increased vulnerability to health-related stressors and can be measured by summing the number of frailty characteristics present in an individual. Discharge institutionalization (rather than discharge to home) represents disease burden and functional dependence after hospitalization. Our aim was to determine the relationship between frailty and need for postoperative discharge institutionalization. Study Design: Subjects ⱖ 65 years undergoing major elective operations requiring postoperative ICU admission were enrolled. Discharge institutionalization was defined as need for institutionalized care at hospital discharge. Fourteen preoperative frailty characteristics were measured in 6 domains: comorbidity burden, function, nutrition, cognition, geriatric syndromes, and extrinsic frailty. Results: A total of 223 subjects (mean age 73 ⫾ 6 years) were studied. Discharge institutionalization occurred in 30% (n ⫽ 66). Frailty characteristics related to need for postoperative discharge institutionalization included: older age, Charlson index ⱖ 3, hematocrit ⬍35%, any functional dependence, up-and-go ⱖ 15 seconds, albumin ⬍3.4 mg/dL, MiniCog score ⱕ 3, and having fallen within 6 months (p ⬍ 0.0001 for all comparisons). Multivariate logistic regression retained prolonged timed up-and-go (p ⬍ 0.0001) and any functional dependence (p ⬍ 0.0001) as the variables most closely related to need for discharge institutionalization. An increased number of frailty characteristics present in any one subject resulted in increased rate of discharge institutionalization. Conclusions: Nearly 1 in 3 geriatric patients required discharge to an institutional care facility after major surgery. The frailty characteristics of prolonged up-and-go and any functional dependence were most closely related to the need for discharge institutionalization. Accumulation of a higher number of frailty characteristics in any one geriatric patient increased their risk of discharge institutionalization. Editorial Comment: Frailty is a syndrome often seen in older patients which may increase the risk of negative clinical outcomes. The authors examined frailty variables in a prospective cohort of 223 elderly patients undergoing surgery at a single Veterans Administration medical center. Overall, 30% required at least temporary discharge to an institutional facility, most commonly for rehabilitation services or due to other factors associated with changes in levels of activities of daily living. The researchers used a number of validated measures to assess function across multiple domains and frailty characteristics. The timed up-and-go test (a validated measure of mobility) and presence of any functional dependence (impaired activities of daily living) were the strongest independent predictors of need for institutional placement after major surgery. Nearly $40 billion is spent annually on this type of post-discharge care, which represents approximately 10% of the total Medicare budget. This study demonstrates that frailty variables can be easily measured in the preoperative setting and may be highly predictive of placement outcomes. These clinical data may contribute important information to the surgical decision making pro-
GERIATRICS
classes of drugs prescribed for urological conditions fall into the Beers Criteria listings of medications that should be avoided. These agents include some antibiotics, analgesics, sedative hypnotics, antispasmodics and hormonal agents. Many medications with urological indications also have potent anticholinergic properties that could be associated with increased risk of delirium, falls, fractures and other negative outcomes. These recommendations will be used for clinical care, education and research. They are designed to be patient centered, with the primary goal to improve prescribing patterns for these potentially vulnerable patients. The writing panel emphasizes that the recommendations should be used within the overall context of care, and in some cases medications on the list may be clinically indicated and useful. However, care needs to be tailored specifically to the patient and his or her individual needs. Past guideline listings have been adopted by various policy making entities in an effort to improve care and monitor quality. It will be interesting to see how this new update will be incorporated with rapidly changing technology for electronic prescribing and health records. The new partnership with the American Geriatrics Society will allow for ongoing updating of this information to maintain an accurate and timely evidence-based guideline. Tomas L. Griebling, M.D., M.P.H.
Re: Inappropriate Medication Use in Older Adults Undergoing Surgery: A National Study E. Finlayson, J. Maselli, M. A. Steinman, M. B. Rothberg, P. K. Lindenauer and A. D. Auerbach Department of Surgery, University of California, San Francisco, California J Am Geriatr Soc 2011; 59: 2139 –2144.
Objectives: To determine the prevalence and factors associated with use of potentially inappropriate medications (PIMs) in older adults undergoing surgery. Design: Retrospective cohort study. Setting: Three hundred seventy-nine acute care hospitals participating in the nationally representative Perspective database (2006 –2008). Participants: Individuals aged 65 and older undergoing major inpatient gastrointestinal, gynecological, urological, and orthopedic surgery (N⫽272,351). Measurements: Medications were classified as PIMs using previously published criteria defining 33 medications deemed potentially inappropriate in people aged 65 and older. Information about participant and provider characteristics and administration of PIMs was obtained from hospital discharge file data. Logistic regression techniques were used to examine factors associated with use of PIMs in the perioperative period. Results: One-quarter of participants received at least one PIM during their surgical admission. Meperidine was the most frequently prescribed PIM (37,855, 14% of participants). In adjusted analysis, PIM use was less likely as age advanced (adjusted odds ratio (AOR)⫽0.98 per year of age, 95% confidence interval (CI)⫽0.97– 0.98) and in men (AOR⫽0.83, 95% CI⫽0.81– 0.85). PIMs were more likely to be prescribed to participants cared for by orthopedic surgeons than for those cared for by general surgeons (AOR⫽1.22, 95% CI⫽1.08 –1.40). Participants undergoing surgery in the West (AOR⫽1.79, 95% CI⫽1.02–3.16) and South (AOR⫽2.24, 95% CI⫽1.38 –3.64) were more likely to receive a PIM than those in the Northeast. Conclusion: Receipt of PIMs in older adults undergoing surgery is common and varies widely between providers and geographic regions and according to participant characteristics. Interventions aimed at reducing the use of PIMs in the perioperative period should be considered in quality improvement efforts. Editorial Comment: More than half of all surgeries in the United States, including urological procedures, are performed in patients 65 years or older. Most patients undergoing surgery will be prescribed some medications in association with their care. It has long been recognized that some drugs are associated with increased risks of adverse events in older adults due to changes in metabolism, or interactions either between drugs or with an underlying comorbid condition. The authors examined prescribing patterns in a large cohort of older adults undergoing major surgery. Overall, 25% of the more than 272,000
GERIATRICS
1213
elderly patients in this study received a PIM. In fact, 14% were prescribed meperidine, a drug consistently cited as one to avoid due to difficulties with drug clearance, development of toxic metabolites and other untoward potential side effects. It was interesting that compared to other specialists, urologists had the lowest overall PIM usage (OR 0.91, 95% CI 0.82–1.00). However, 19% of patients undergoing urological surgery received a PIM in this study, which indicates there is still much room for improvement in prescribing patterns. Urologists need to be familiar with evidence-based recommendations, which can help guide and improve prescribing choices in this growing patient population. Tomas L. Griebling, M.D., M.P.H.
Re: Accumulated Frailty Characteristics Predict Postoperative Discharge Institutionalization in the Geriatric Patient T. N. Robinson, J. I. Wallace, D. S. Wu, A. Wiktor, L. F. Pointer, S. M. Pfister, T. J. Sharp, M. J. Buckley and M. Moss Department of Surgery, University of Colorado at Denver School of Medicine, Aurora, Colorado J Am Coll Surg 2011; 213: 37– 44.
Background: Frailty is a state of increased vulnerability to health-related stressors and can be measured by summing the number of frailty characteristics present in an individual. Discharge institutionalization (rather than discharge to home) represents disease burden and functional dependence after hospitalization. Our aim was to determine the relationship between frailty and need for postoperative discharge institutionalization. Study Design: Subjects ⱖ 65 years undergoing major elective operations requiring postoperative ICU admission were enrolled. Discharge institutionalization was defined as need for institutionalized care at hospital discharge. Fourteen preoperative frailty characteristics were measured in 6 domains: comorbidity burden, function, nutrition, cognition, geriatric syndromes, and extrinsic frailty. Results: A total of 223 subjects (mean age 73 ⫾ 6 years) were studied. Discharge institutionalization occurred in 30% (n ⫽ 66). Frailty characteristics related to need for postoperative discharge institutionalization included: older age, Charlson index ⱖ 3, hematocrit ⬍35%, any functional dependence, up-and-go ⱖ 15 seconds, albumin ⬍3.4 mg/dL, MiniCog score ⱕ 3, and having fallen within 6 months (p ⬍ 0.0001 for all comparisons). Multivariate logistic regression retained prolonged timed up-and-go (p ⬍ 0.0001) and any functional dependence (p ⬍ 0.0001) as the variables most closely related to need for discharge institutionalization. An increased number of frailty characteristics present in any one subject resulted in increased rate of discharge institutionalization. Conclusions: Nearly 1 in 3 geriatric patients required discharge to an institutional care facility after major surgery. The frailty characteristics of prolonged up-and-go and any functional dependence were most closely related to the need for discharge institutionalization. Accumulation of a higher number of frailty characteristics in any one geriatric patient increased their risk of discharge institutionalization. Editorial Comment: Frailty is a syndrome often seen in older patients which may increase the risk of negative clinical outcomes. The authors examined frailty variables in a prospective cohort of 223 elderly patients undergoing surgery at a single Veterans Administration medical center. Overall, 30% required at least temporary discharge to an institutional facility, most commonly for rehabilitation services or due to other factors associated with changes in levels of activities of daily living. The researchers used a number of validated measures to assess function across multiple domains and frailty characteristics. The timed up-and-go test (a validated measure of mobility) and presence of any functional dependence (impaired activities of daily living) were the strongest independent predictors of need for institutional placement after major surgery. Nearly $40 billion is spent annually on this type of post-discharge care, which represents approximately 10% of the total Medicare budget. This study demonstrates that frailty variables can be easily measured in the preoperative setting and may be highly predictive of placement outcomes. These clinical data may contribute important information to the surgical decision making pro-