Polypharmacy in older surgical patients: practical steps for managing perioperative medications.

Abstract

The likelihood of developing a medical condition requiring pharmacologic therapy increases with age. Older patients frequently take multiple medications, including prescription, over-the-counter (OTC) or complementary medicines, often termed polypharmacy. The average age of surgical patients is older than that of the general population, 1 so encountering polypharmacy perioperatively is common. In a South Korean review of 7.36 million patients in the National Health Insurance claims database, 36.9% of patients over the age of 65 used ≥ 5 prescription medications, while 7.1% used 10 or more medications. 2 In the United States, examination of the National Ambulatory Medical Care Survey revealed a point prevalence of polypharmacy ( ≥ 5 medications) of 44% in community-dwelling patients 65 years or older who did not have dementia, and 72% in those who did have dementia. 3 In a Danish population, the broader issues of potentially inappropriate medication (PIM) use was examined through a population-based register. 4 PIM can include inappropriate drug choice, polypharmacy, or potential drug-drug interactions, but generally refers to medications that should be avoided in older people due to the potential risks outweighing the bene fi ts. Although the use of PIM decreased from 2000 to 2015 (from 54.7% to 43.5% in people with dementia and from 39.5% to 28.8% in people without dementia), there remained a high prevalence of potentially inappropriate prescribing practices, including in patients with dementia. 4 While the term polypharmacy indicates the administration of multiple medications in a patient, there is no consensus de fi nition. A systematic review of polypharmacy de fi nitions categorized them as “ (1) numerical only (using the number of medications to de fi ne polypharmacy), (2) numerical with an associated duration of therapy or health care setting (such as during hospital stay), or (3) descriptive (using a brief description to de fi ne polypharmacy).