Association of pre-operative medication use with post-operative delirium in surgical oncology patients receiving comprehensive geriatric assessment

Abstract

BackgroundOlder patients undergoing surgery tend to have a higher frequency of delirium. Delirium is strongly associated with poor surgical outcomes. This study evaluated the association between pre-operative medication use and post-operative delirium (POD) in surgical oncology patients receiving comprehensive geriatric assessment (CGA).MethodsA total of 475 patients who were scheduled for cancer surgery and received CGA from January 2014 to June 2015 were included. Pre-operative medication review through CGA was conducted on polypharmacy (≥5 medications), delirium-inducing medications (DIMs), fall-inducing medications (FIMs), and potentially inappropriate medications (PIMs). POD was confirmed by psychiatric consultation, and DSM-V criteria were used for diagnosing delirium. The model fit of the prediction model was assessed by computing the Hosmer-Lemeshow goodness-of-fit test. Effect size was measured using the Nagelkerke R2. Discrimination of the model was assessed by an analysis of the area under receiver operating curve (AUROC).ResultsTwo models were constructed for multivariate analysis based on univariate analysis; model I included dementia and DIM in addition to age and sex, and model II included PIM instead of DIM of model I. Every one year increase of age increased the risk of POD by about 1.1-fold. DIM was a significant factor for POD after adjusting for confounders (AOR 12.78, 95 % CI 2.83-57.74). PIM was also a significant factor for POD (AOR 5.53, 95 % CI 2.03-15.05). The Hosmer-Lemeshow test results revealed good fits for both models (χ2 = 3.842, p = 0.871 for model I and χ2 = 8.130, p = 0.421 for model II). The Nagelkerke R2 effect size and AUROC for model I was 0.215 and 0.833, respectively. Model II had the Nagelkerke R2effect size of 0.174 and AUROC of 0.819.ConclusionsThese results suggest that pharmacists’ comprehensive review for pre-operative medication use is critical for the post-operative outcomes like delirium in older patients.Electronic supplementary materialThe online version of this article (doi:10.1186/s12877-016-0311-5) contains supplementary material, which is available to authorized users.

Delirium Prediction using Machine Learning Models on Predictive Electronic Health Records Data

“…On the other hand, discriminative models learn a direct map from the input data to the response labels such as logistic regression and generalized additive model (29). Logistic regression is widely used in medical literature, and has been used previously for prediction models for delirium (30, 31); with the predicted risk monotonically increasing or decreasing. Generalized additive models are additive regression models that can relax the monotonicity assumption of logistic models and offer the advantage of estimating non-linear risk functions for continuous variables.…”

Preoperative medication use and its association with postoperative length of hospital stay in surgical oncology patients receiving comprehensive geriatric assessment

“…Preoperative discontinuation‐requiring medications were defined as medications that should be discontinued before surgery due to surgical risks, such as antithrombotic agents for postoperative hemorrhage, metformin for lactic acidosis, exogenous hormones for venous thromboembolism and herbal medications for the uncertainty about their actual contents (Table ) …”

“…Deliriants including high‐dose narcotics, benzodiazepines and anticholinergic medications were also included in DIM (Table ) . Antihypertensive agents, diuretics, glucose‐lowering agents, antihistamines, laxatives, antipsychotics, neuroleptics, antidepressants, hypnotics and sedatives, and opioids were classified as fall‐inducing medications (Table ) . PIM were evaluated based on the 2015 Beers criteria .…”

“…Inclusion criteria in the present study were patients aged ≥65 years and scheduled for cancer surgery after presentation for preoperative CGA at the geriatric center in Seoul National University Bundang Hospital, Seongnam, Korea, from January 2014 to June 2015, as described in a previous study. 6 Patients who refused surgery or did not undergo cancer surgery were excluded. The study was approved by the Seoul National University Bundang Hospital Institutional Review Board (IRB # B-1507/308-112).…”

“…Preoperative discontinuation-requiring medications were defined as medications that should be discontinued before surgery due to surgical risks, such as antithrombotic agents for postoperative hemorrhage, metformin for lactic acidosis, exogenous hormones for venous thromboembolism and herbal medications for the uncertainty about their actual contents (Table 1). 6 DIM were regarded as medications whose adverse events included delirium, confusion or hallucination, and were reported as >1% by the drug information database, Micromedex. Deliriants including high-dose narcotics, benzodiazepines and anticholinergic medications were also included in DIM (Table 1).…”