Advertisement

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

Published:November 30, 2021DOI:https://doi.org/10.1016/j.jamda.2021.11.005

      Abstract

      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.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Barnett K.
        • Mercer S.W.
        • Norbury M.
        • Watt G.
        • Wyke S.
        • Guthrie B.
        Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study.
        Lancet. 2012; 380: 37-43
        • Kantor E.D.
        • Rehm C.D.
        • Haas J.S.
        • Chan A.T.
        • Giovannucci E.L.
        Trends in prescription drug use among adults in the United States from 1999-2012.
        JAMA. 2015; 314: 1818-1831
        • Kim J.
        • Parish A.L.
        Polypharmacy and medication management in older adults.
        Nurs Clin North Am. 2017; 52: 457-468
        • Masnoon N.
        • Shakib S.
        • Kalisch-Ellett L.
        • Caughey G.E.
        What is polypharmacy? A systematic review of definitions.
        BMC Geriatr. 2017; 17: 1-10
        • Steinman M.A.
        • Seth Landefeld C.
        • Rosenthal G.E.
        • Berthenthal D.
        • Sen S.
        • Kaboli P.J.
        Polypharmacy and prescribing quality in older people.
        J Am Geriatr Soc. 2006; 54: 1516-1523
        • Guillot J.
        • Maumus-Robert S.
        • Marceron A.
        • Noize P.
        • Pariente A.
        • Bezin J.
        The burden of potentially inappropriate medications in chronic polypharmacy.
        J Clin Med. 2020; 9: 3728
      1. Office of Disease Prevention and Health Promotion. Adverse Drug Events. US Department of Health and Human Services. https://health.gov/our-work/health-care-quality/adverse-drug-events; 2020.

      2. Center for Education and Research on Therapeutics. Preventable Adverse Drug Reactions: A Focus on Drug Interactions. US Food & Drug Administration. https://www.fda.gov/drugs/drug-interactions-labeling/preventable-adverse-drug-reactions-focus-drug-interactions; 2018.

        • Placido A.I.
        • Herdeiro M.T.
        • MOrgado M.
        • Figueriras A.
        • Roque F.
        Drug-related problems in home-dwelling older adults: a systematic review.
        Clin Ther. 2020; 42: 559-572
        • Carli F.
        • Baldini G.
        From preoperative assessment to preoperative optimization of frail older patients.
        Eur J Surg Oncol. 2021; 47: 519-523
        • Lawrence V.A.
        • Hazuda H.P.
        • Cornell J.E.
        • et al.
        Functional independence after major abdominal surgery in the elderly.
        J Am Coll Surg. 2004; 199: 762-772
        • Saljuqi A.T.
        • Hanna K.
        • Asmar S.
        • et al.
        Prospective evaluation of delirium in geriatric patients undergoing emergency general surgery.
        J Am Coll Surg. 2020; 230: 758-765
        • Fenton R.
        • Brook-Barclay L.
        • Delaney C.L.
        • Spark J.I.
        • Miller M.D.
        Do medications commonly prescribed to patients with peripheral arterial disease have an effect on nutritional status? A review of the literature.
        Ann Vasc Surg. 2016; 32: 145-175
        • Syed Q.
        • Hendler K.T.
        • Koncilja K.
        The impact of aging and medical status on dysgeusia.
        Am J Med. 2016; 129: e1-e6
        • Jennings E.L.M.
        • Murphy K.D.
        • Gallagher P.
        • O’Mahony D.
        In-hospital adverse drug reactions in older adults; prevalence, presentation and associated drugs - a systematic review and meta-analysis.
        Age Ageing. 2020; 49: 948-958
        • Passarelli M.C.G.
        • Jacob-Filho W.
        • Figueras A.
        Adverse drug reactions in an elderly hospitalised population: inappropriate prescription is a leading cause.
        Drugs Aging. 2005; 22: 767-777
        • Sakiris M.A.
        • Sawan M.
        • Hilmer S.N.
        • Awadalla R.
        • Gnjidic D.
        Prevalence of adverse drug events and adverse drug reactions in hospital among older patients with dementia: a systematic review.
        Br J Clin Pharmacol. 2020; 87: 375-385
        • Härstedt M.
        • Rogmark C.
        • Sutton R.
        • Melander O.
        • Fedorowski A.
        Polypharmacy and adverse outcomes after hip fracture surgery.
        J Orthop Surg Res. 2016; 11: 1-7
        • Lester L.
        Anesthetic considerations for common procedures in geriatric patients: hip fracture, emergency general surgery, and transcatheter aortic valve replacement.
        Anesthesiol Clin. 2015; 33: 491-503
        • Hernandez M.H.
        • Mestres C.
        • Modamio P.
        • et al.
        Adverse drug events in patients with dementia and neuropsychiatric/behavioral, and psychological symptoms, a one-year prospective study.
        Int J Environ Res Public Health. 2019; 16: 934
        • 2019 American Geriatrics Society Beers Criteria Update Expert Panel
        American Geriatics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults.
        J Am Geriatr Soc. 2019; 67: 674-694
        • Lindley C.M.
        • Tully M.P.
        • Paramsothy V.
        • Tallis R.C.
        Inappropriate medication is a major cause of adverse drug reactions in elderly patients.
        Age Ageing. 1992; 21: 294-300
        • Xing X.X.
        • Zhu C.
        • Liang H.Y.
        • et al.
        Associations between potentially inapprorpiate medications and adverse heatlh outcomes in the elderly: a systematic review and meta-analysis.
        Ann Pharmacother. 2019; 53: 1005-1019
        • Reeve E.
        • Gnjidic D.
        • Long J.
        • Hilmer S.
        A systematic review of the emerging definition of “deprescribing” with network analysis: implications for future research and clinical practice.
        Br J Clin Pharmacol. 2015; 80: 1254-1268
        • Bloomfield H.E.
        • Greer N.
        • Linsky A.M.
        • et al.
        Deprescribing for community-dwelling older adults: a systematic review and meta-analysis.
        J Gen Intern Med. 2020; 35: 3323-3332
        • Kua C.H.
        • Mak V.S.L.
        • Huey Lee S.W.
        Health outcomes of deprescribing interventions among older residents in nursing homes: a systematic review and meta-analysis.
        J Am Med Dir Assoc. 2019; 20: 362-372.e11
        • Page A.T.
        • Clifford R.M.
        • Potter K.
        • Schwartz D.
        • Etherton-Beer C.D.
        The feasibility and effect of deprescribing in older adults on mortality and health: a systematic review and meta-analysis.
        Br J Clin Pharmacol. 2016; 82: 583-623
        • Rankin A.
        • Cadogan C.A.
        • Patterson S.M.
        • et al.
        Interventions to improve the appropriate use of polypharmacy for older people.
        Cochrane Database Syst Rev. 2018; 9: CD008165
        • White P.F.
        Multimodal therapy facilitates a fast-track recovery after surgery - are potential drug-drug interactions of clinical significance in the perioperative period?.
        J Clin Anesth. 2017; 39: 98-99
        • Jeong Y.M.
        • Lee E.
        • Kim K.
        • et al.
        Association of pre-operative medication use with post-operative delirium in surgical oncology patients receiving comprehensive geriatric assessment.
        BMC Geriatr. 2016; 16: 134
        • Katz M.
        • Silverstein N.
        • Coll P.
        • et al.
        Surgical care of the geriatric patient.
        Curr Probl Surg. 2019; 56: 260-329
        • Auerbach A.D.
        • Vittinghoff E.
        • Maselli J.
        • Pekow P.S.
        • Young J.Q.
        • Lindenauer P.K.
        Perioperative use of selective serotonin reuptake inhibitors and risks for adverse outcomes of surgery.
        JAMA Inten Med. 2013; 173: 1075-1081
        • Haelst I.M.M. van
        • Egberts T.C.G.
        • Doodeman H.J.
        • et al.
        Use of serotonergic antidepressants and bleeding risk in orthopedic patients.
        Anesthesiology. 2010; 112: 631-636
        • Sajan F.
        • Conte J.V.
        • Tamargo R.J.
        • Riley L.H.
        • Rock P.
        • Faraday N.
        Association of selective serotonin reuptake inhibitors with transfusion in surgical patients.
        Anesth Analg. 2016; 123: 21-28
        • Singh I.
        • Achuthan S.
        • Chakrabarti A.
        • Rajagopalan S.
        • Srinivasan A.
        • Hota D.
        Influence of pre-operative use of serotonergic antidepressants (SADs) on the risk of bleeding in patients undergoing different surgical interventions: a meta-analysis.
        Pharmacoepidemiol Drug Saf. 2015; 24: 237-245
        • Abe N.
        • Kakamu T.
        • Kumagai T.
        • et al.
        Polypharmacy at admission prolongs length of hospitalization in gastrointestinal surgery patients.
        Geriatr Gerontol Int. 2020; 20: 1085-1090
        • Marcantonio E.R.
        • Goldman L.
        • Mangione C.M.
        • et al.
        A clinical prediction rule for delirium after elective noncardiac surgery.
        JAMA. 1994; 271: 134-139
        • Cho Y.J.
        • Gong H.S.
        • Song C.H.
        • Lee Y.H.
        • Goo H.B.
        Evaluation of physical performance level as a fall risk factor in women with a distal radial fracture.
        J Bone Joint Surg Am. 2014; 96: 361-365
        • Nagai T.
        • Nagaoka M.
        • Tanimoto K.
        • Tomizuka Y.
        • Uei H.
        • Nakanishi K.
        Relationship between potentially inappropriate medications and functional prognosis in elderly patients with distal radius fracture: a retrospective cohort study.
        J Orthop Surg Res. 2020; 15: 321
        • Choi K.S.
        • Jeong Y.M.
        • Lee E.
        • et al.
        Association of pre-operative medication use with post-surgery mortality and morbidity in oncology patients receiving comprehensive geriatric assessment.
        Aging Clin Exp Res. 2018; 30: 1177-1185
        • Fried T.R.
        • O’Leary J.
        • Towle V.
        • Goldstein M.K.
        • Trentalange M.
        • Martin D.K.
        Health outcomes associated with polypharmacy in community-dwelling older adults: systematic review.
        J Am Geriatr Soc. 2014; 62: 2261-2272
        • McIsaac D.I.
        • Wong C.A.
        • Bryson G.L.
        • Van Walraven C.
        Association of polypharmacy with survival, complications, and healthcare resource use after elective noncardiac surgery: a population-based cohort study.
        Anesthesiology. 2018; 128: 1140-1150
        • Sugidono M.
        • Lo M.
        • Young R.
        • et al.
        Impact of polypharmacy prior to allogeneic hematopoietic stem cell transplantation in older adults.
        Transplant Cell Ther. 2021; 27: 344.e1-344.e5
        • Mullen M.G.
        • Michaels A.D.
        • Mehaffey J.H.
        • et al.
        Risk associated with complications and mortality after urgent surgery vs elective and emergency surgery: implications for defining “quality” and reporting outcomes for urgent surgery.
        JAMA Surg. 2017; 152: 768-774
        • Eamer G.
        • Taheri A.
        • Chen S.S.
        • Daviduck Q.
        • Chambers T.
        • Shi X.K.R.
        Comprehensive geriatric assessment for older people admitted to a surgical service.
        Cochrane Database Syst Rev. 2018; 1: CD012485
        • Thillainadesan J.
        • Yumol M.F.
        • Hilmer S.
        • Aitken S.J.
        • Naganathan V.
        Interventions to improve clinical outcomes in older adults admitted to a surgical service: a systematic review and meta-analysis.
        J Am Med Dir Assoc. 2020; 21: 1833-1843.e20
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        BMJ. 2009; 339: 332-336
        • Dang D.
        • Dearholt S.
        Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines.
        3rd ed. 2017 (Sigma Theta Tau International)
        • Higgins J.P.T.
        • Thomas J.
        Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0. The Cochrane Collaboration.
        www.handbook.cochrane.org
        Date: 2011
        Date accessed: May 3, 2021
      3. Sterne J, Hernan M, McAleenan A, Reeves B, Higgins J. Cochrane Handbook for Systematic Reviews of Interventions. www.training.cochrane.org/handbook; 2021. Accessed 3 May 2021.

      4. Wells G, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-analyses. The Ottawa Hospital Reserach Institute. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed May 3, 2021.

        • Heltne M.
        • Saltvedt I.
        • Lydersen S.
        • Prestmo A.
        • Sletvold O.
        • Spigset O.
        Patterns of drug prescriptions in an orthogeriatric ward as compared to orthopaedic ward: results from the Trondheim Hip Fracture Trial—a randomised clinical trial.
        Eur J Clin Pharmacol. 2017; 73: 937-947
        • Boersma M.N.
        • Huibers C.J.A.
        • Drenth-van Maanen A.C.
        • Emmelot-Vonk M.H.
        • Wilting I.
        • Knol W.
        The effect of providing prescribing recommendations on appropriate prescribing: A cluster-randomized controlled trial in older adults in a preoperative setting.
        Br J Clin Pharmacol. 2019; 85: 1974-1983
        • Cronin J.
        • Livhits M.
        • Mercado C.
        • et al.
        Quality improvement pilot program for vulnerable elderly surgical patients.
        Am Surg. 2011; 77: 1305-1308
        • Hohn N.
        • Langer S.
        • Kalder J.
        • Jacobs M.J.
        • Marx G.
        • Eisert A.
        Optimizing the pharmacotherapy of vascular surgery patients by medication reconciliation.
        J Cardiovasc Surg (Torino). 2014; 55: 175-181
        • Al-Jazairi A.S.
        • Al-Suhaibani L.K.
        • Al-Mehizia R.A.
        • et al.
        Impact of a medication reconciliation program on cardiac surgery patients.
        Asian Cardiovasc Thorac Ann. 2017; 25: 579-585
        • Cortez R.
        Geriatric Trauma Protocol.
        J Trauma Nurs. 2018; 25: 218-227
        • Mason M.C.
        • Crees A.L.
        • Dean M.R.
        • Bashir N.
        Establishing a proactive geriatrician led comprehensive geriatric assessment in older emergency surgery patients: outcomes of a pilot study.
        Int J Clin Pract. 2018; 72: 1-5
        • Shafiekhani M.
        • Moosavi N.
        • Firouzabadi D.
        • Namazi S.
        Impact of clinical pharmacist’s interventions on potential drug–drug interactions in the cardiac care units of two university hospitals in Shiraz, South of Iran.
        J Res Pharm Pract. 2019; 8: 143
        • Zullig L.L.
        • Kimmick G.
        • Smith V.
        • et al.
        Using a geriatric oncology assessment to link with services (GOAL).
        J Geriatr Oncol. 2019; 10: 164-168
        • Vilches-Moraga A.
        • Fox J.
        • Paracha A.
        • et al.
        Baseline characteristics and clinical outcomes of older patients admitted as an emergency to general surgical wards. Salford-POPS – GS.
        Eur Geriatr Med. 2017; 8: 499-504
        • Lin R.J.
        • Shahrokni A.
        • Dahi P.B.
        • et al.
        Pretransplant comprehensive geriatric assessment in hematopoietic cell transplantation: a single center experience.
        Bone Marrow Transplant. 2018; 53: 1184-1187
        • McDonald S.R.
        • Heflin M.T.
        • Whitson H.E.
        • et al.
        Association of integrated care coordination with postsurgical outcomes in high-risk older adults the Perioperative Optimization of Senior Health (POSH) initiative.
        JAMA Surg. 2018; 153: 454-462
        • Bansal N.
        • Tai W.T.
        • Chen L.C.
        Implementation of an innovative surgical pharmacy service to improve patient outcomes—twelve-month outcomes of the Enhanced Surgical Medicines Optimization Service.
        J Clin Pharm Ther. 2019; 44: 904-911
        • Gleich J.
        • Pfeufer D.
        • Zeckey C.
        • et al.
        Orthogeriatric treatment reduces potential inappropriate medication in older trauma patients: a retrospective, dual-center study comparing conventional trauma care and co-managed treatment.
        Eur J Med Res. 2019; 24: 4
        • Kimura T.
        • Ogura F.
        • Kukita Y.
        • et al.
        Efficacy of pharmacists’ assessment and intervention based on Screening Tool for Older Persons’ Appropriate Prescriptions for Japanese compared with Screening Tool of Older Persons' potentially inappropriate Prescriptions criteria version 2 in older patients with cardiovascular disease.
        Geriatr Gerontol Int. 2019; 19: 1101-1107
        • Mehta N.
        • Martinez Guasch F.
        • Kamen C.
        • et al.
        Proton pump inhibitors in the elderly hospitalized patient: evaluating appropriate use and deprescribing.
        J Pharm Technol. 2020; 36: 54-60
        • Thillainadesan J.
        • Gnjidic D.
        • Green S.
        • Hilmer S.N.
        Impact of deprescribing interventions in older hospitalised patients on prescribing and clinical outcomes: a systematic review of randomised trials.
        Drugs Aging. 2018; 35: 303-319
        • Ibrahim K.
        • Cox N.J.
        • Stevenson J.M.
        • Lim S.
        • Fraser S.D.S.
        • Roberts H.C.
        A systematic review of the evidence for deprescribing interventions among older people living with frailty.
        BMC Geriatr. 2021; 21: 1-16