Polypharmacy at admission prolongs length of hospitalization in gastrointestinal surgery patients

Association between changes in potentially inappropriate medication use and adverse outcomes during hospitalization in older adults: A retrospective study

PURPOSE

To evaluate the association between the change in the number of PIMs in older adults during hospitalization and adverse outcomes.

METHODS

This retrospective cohort study was conducted in the internal medicine wards of a tertiary teaching hospital between May and December 2017. 3,460 patients (77.5±8.4 years, 60.4% male) were enrolled, and 206 patients died during hospitalization. PIMs were defined using the Beers Criteria as suggested by the American Geriatrics Society. Adverse outcomes studied were functional decline (a loss in 1 or more activities of daily living from admission to discharge), prolonged length of stay (LOS) (≥14 days), and mortality.

RESULTS

2258 patients (65.3%) had increasing PIMs during hospitalization. They tended to be younger (77.0±8.3 versus 78.5±8.5 years, p<0.001) and had lower numbers of PIMs at admission (0.4±0.8 versus 0.8±1.1, p<0.001). Increasing PIM use was strongly associated with greater functional decline (aOR 1.36, 95%CI 1.01-1.67, p=0.005), prolonged LOS (aOR 3.47, 95%CI 2.71-4.44, p<0.001) and higher mortality rate (aOR 2.68, 95%CI 1.75-4.12, p<0.001), even after adjusting for all covariates. We observed a strong association between adverse outcomes and increasing PIMs in older adults during hospitalization (p for trend <0.001).

CONCLUSIONS

Older adults with increasing PIMs during hospitalization were at greater risk for functional decline, prolonged LOS, and mortality, especially in those with three or more PIMs. Further studies are needed to better understand the complex interactions and to evaluate the effectiveness of intervention programs to lower PIM number and improve discharge outcomes for patients who had increasing PIM use during hospitalization.

Effect of Comorbid Diseases on Hospitalization and In-Hospital Mortality of Elderly Patients Who Reapplied to the Emergency Department Within 72 Hours

OBJECTIVE

This study aimed to determine the effects of comorbidities on hospitalization and in-hospital mortality in patients aged 65 years and older who returned to the emergency department within 24, 48, and 72 hours of an initial visit.

METHODS

This study was conducted at the Department of Emergency Medicine, Firat University Faculty of Medicine, Elâzığ, Turkey. It has a retrospective design and received local ethics committee approval from the university. Patients aged 65 years and older who presented to the emergency department within a one-year period (2022) were examined to identify those who returned to the emergency department within 24, 48, and 72 hours of an initial visit.

RESULTS

A total of 763 (3.2%) patients >65 years of age returned to the emergency department within the first three days of their initial visit. Of these returning patients, 349 returned within 24 hours (Group 1), 227 within 48 hours (Group 2), and 187 within 72 hours (Group 3). Being female, polypharmacy, the presence of at least one comorbidity, cancer, and chronic renal failure were found to be independent predictors of hospitalization, whereas polypharmacy was found to be an independent predictor of in-hospital mortality.

CONCLUSION

Patients returning to the emergency department shortly after an initial visit should be assessed more diligently due to the risk of mortality.

Polypharmacy in Older Adults Undergoing Major Surgery: Prevalence, Association With Postoperative Cognitive Dysfunction and Potential Associated Anesthetic Agents

BACKGROUND

Polypharmacy, which is defined as the use of 5 or more medications, can exert significant adverse impact on older adult patients. The objective of this study was to determine the prevalence of polypharmacy, and to investigate its association with postoperative cognitive dysfunction (POCD) in older adult patients who underwent elective major surgery at Siriraj Hospital-Thailand's largest national tertiary referral center.

METHODS

This prospective study included older adult patients aged ≥65 years who were scheduled for elective major surgery during December, 2017 to December, 2019 study period. Patient demographic, sociodemographic, anthropometric, clinical, comorbidity, anesthetic, surgical, and medication data were collected and compared between the polypharmacy and non-polypharmacy groups. Postoperative cognitive dysfunction (POCD) was diagnosed in patients with at least a 2-point decrease in their Montreal Cognitive Assessment score after surgery. Multivariate logistic regression analysis was used to identify independent predictors of POCD.

RESULTS

A total of 250 patients (141 males, 109 females) with an average age of 72.88 ± 6.93 years were included. The prevalence of polypharmacy was 74%. Preoperative data showed the polypharmacy group to be more likely to be receiving potentially inappropriate medications, to be scheduled for cardiovascular thoracic surgery, and to have more comorbidities. There was a non-significant trend in the association of polypharmacy and POCD (crude odds ratio (OR): 2.11, 95% confidence interval [CI]: 0.90-4.94; p = 0.08). Benzodiazepine, desflurane, or isoflurane administration during surgery were all significantly associated with POCD in univariate analysis. Multivariate analysis revealed intraoperative benzodiazepine (adjusted OR [aOR]: 2.24, 95% CI: 1.10-4.68; p = 0.026) and isoflurane (aOR: 2.80, 95% CI: 1.35-5.81; p = 0.006) as two independent variables associated with the development of POCD. Desflurane was found to be a protective factor for POCD with a crude OR of 0.17 (95% CI: 0.03-0.74, p = 0.019); however, independent association was not found in multivariate analysis.

CONCLUSION

There was a high prevalence of polypharmacy in this study; however, although close (p = 0.08), significant association was not found between polypharmacy and POCD. Benzodiazepine and isoflurane were both identified as independent predictors of the development of POCD among older adult patients undergoing elective major surgery, especially among those classified as polypharmacy.

Polypharmacy in elderly people

Polypharmacy characterizes ongoing prescription of multiple medications in a patient. Following the demographic change and growing number of elderly patients, polypharmacy is of major concern due to the associated risks and even mortality. Many causes made this geriatric syndrome more common in the past decade. First, the management of comorbidities is often lacking in disease-specific guidelines. Second, multimorbidity is rising due to the ageing population. Third, deprescribing methods are sparse, and results are conflicting. This mini review integrates the effects of polypharmacy on mortality and morbidity, the causes and confounders of polypharmacy, and presents a practical stepwise manual of deprescribing. The work is based on a literature search for randomized control trials and reviews in English and German from 2015 onwards in the PubMed database, with integration of relevant citations as a result of this search.

Preoperative Deprescribing for Medical Optimization of Older Adults Undergoing Surgery: A Systematic Review

OBJECTIVE

To summarize the evidence for preoperative deprescribing and its effect on postoperative outcomes in older adults undergoing surgery.

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

All available studies.

METHODS

We searched EMBASE, Cumulative Index of Nursing and Allied Health (CINAHL), and PubMed from inception to January 12, 2021. Settings included outpatient settings during the waiting period for surgery (ie, preoperative clinic) through to the preoperative period in the hospital. Participants who were older adults, aged ≥65 years, undergoing planned or emergency surgery with deprescribing or medication-related interventions were included for review.

RESULTS

We identified 3 different methods of deprescribing intervention delivery during the preoperative period: geriatrician-led (n = 2), interdisciplinary team-led (n = 8), and pharmacist-led (n = 6). Outcomes were related to health care utilization, patient outcomes, and medication changes; however, results were difficult to compare because of heterogeneous outcomes within the topics. Overall, results were either positive or neutral.

CONCLUSIONS AND IMPLICATIONS

The evidence for deprescribing during the preoperative period for older adults undergoing surgery is weak because of the heterogeneity of intervention delivery and outcomes, inclusion of nonoperative cases in some studies, and low power. This review highlights the need for future research, which may consider the following: (1) interdisciplinary approach, (2) coordination of deprescribing efforts with primary care provider from the waiting period for surgery up to after hospital discharge, and (3) validated deprescribing criteria such as STOPP/START that is easy to implement. It is important to note that results yielded positive and neutral results, not negative ones, which should reassure clinicians to implement deprescribing for older adults during the surgical period. Additionally, policy initiatives such as integrated electronic medical records or increased reimbursement of deprescribing efforts for primary care providers and/or hospitals should be pursued to prevent adverse postoperative events for this population.

Multimorbidity, polypharmacy, and mortality in older patients with pacemakers

Background

The prevalence of multimorbidity and polypharmacy and its association with all‐cause mortality in older patients with pacemakers are largely unknown. We aimed to clarify the prevalence of multimorbidity and polypharmacy, and its association with all‐cause mortality in patients ≥75 years of age with pacemakers.

Methods

We retrospectively investigated 256 patients aged ≥75 years (mean age 84.0 ± 5.3 years; 45.7% male) with newly implanted pacemakers. The study endpoint was all‐cause mortality (“with events”). Multimorbidity was defined as a Charlson Comorbidity Index ≥3. Polypharmacy was defined as the use of ≥5 medications.

Results

During the follow‐up period (median, 3.1 years), 60 all‐cause deaths were reported. The Charlson Comorbidity Index (2.9 ± 1.9 vs. 1.7 ± 1.7, p < .001) and prevalence of multimorbidity (56.7% vs. 26.0%, p < .001) were significantly higher in deceased patients than in survivors. The number of drugs (6.9 ± 3.0 vs. 5.9 ± 3.3, p = .03) and the prevalence of polypharmacy (78.3% vs. 63.8%, p = .04) were significantly higher in patients with events than in those without events. The event‐free survival rate was significantly higher among patients without multimorbidity than in those with multimorbidity (log‐rank, p < .001), and was also significantly higher among patients without polypharmacy than in those with polypharmacy (log‐rank, p < .001). Multimorbidity (hazard ratio [HR]: 3.21; 95% confidence interval [CI]: 1.85–5.58; p < .001) and polypharmacy (HR: 1.97; 95% CI: 1.03–3.77; p = .04) were independent predictors of all‐cause mortality.

Conclusions

Multimorbidity and its associated polypharmacy, which are common in the older population, are prevalent in patients with pacemakers and are independent predictors of poor prognosis.

Polypharmacy at admission prolongs length of hospitalization in gastrointestinal surgery patients

Aim

Polypharmacy in elderly people is a social issue and has been reported to cause not only drug adverse events, but also falls, dysfunction and cognitive decline. Those events may trigger prolonged length of hospitalization. Therefore, the aim of this study was to investigate whether polypharmacy has a prolonging effect on hospitalization.

Methods

The study subjects were 584 patients in a university hospital in Japan who had been admitted for hepatectomy, pancreaticoduodenectomy, gastrectomy or colectomy, and to whom clinical pathways had been applied. In this study, polypharmacy was defined as taking five or more regular oral medications, and prolonged hospitalization was defined as hospitalization longer than that determined by the clinical pathway. Multiple logistic regression analysis was performed to investigate whether polypharmacy affects the length of hospitalization.

Results

The subjects were 348 males and 236 females, mean ± SD age of 65.8 ± 12.9 years. Among all subjects, 228 (39.0%) were receiving polypharmacy at admission, and the number of patients with prolonged hospitalization was 262 (44.9%). Multiple logistic regression analysis revealed that the following variables were significantly associated with prolonged hospitalization; polypharmacy (odds ratio = 1.532; 95% confidence interval = 1.010–2.327), age 50–59; 2.971 (1.216–7.7758), age 60–69; 2.405 (1.059–5.909), organ pancreas; 0.298 (0.122–0.708), operation time ≥386 min; 2.050 (1.233–3.432), intraoperative bleeding volume ≥401 mL; 2.440 (1.489–4.038), postoperative delirium; 2.395 (1.240–4.734), postoperative infection; 10.715 (4.270–33.059).

Conclusion

The current study revealed that polypharmacy at admission was an independent factor for prolonged hospitalization. In future, measures against polypharmacy are required, collaborating with outpatient clinics, family doctors and dispensing pharmacies. Geriatr Gerontol Int 2020; 20: 1085–1090..