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Patient Safety Tip
of the Week
March
29, 2022
Disturbing
Stats on Perioperative Benzodiazepine Use in Elderly Patients
One
of the most well-recognized risk factors for delirium in elderly patients is
use of benzodiazepines. So, some recent statistics about perioperative
benzodiazepine use in elderly surgical patients are particularly troublesome.
Cozowicz et al. analyzed a database of almost 3 million
patients undergoing total knee or hip arthroplasty from 2006 to 2019 (Cozowicz 2022). Benzodiazepine use on the day of
surgery occurred in 80.5% of TKAs (72.6% short-acting and 7.9% long-acting) and
76.1% of THAs (68.4% short-acting and 7.7% long-acting). Midazolam was
by far the most frequently used benzodiazepine (89.5%), with lorazepam,
diazepam, alprazolam, and clonazepam each less than 3%. Benzodiazepine use
increased from 2006, peaking in 2011, then decreasing to just below 2006 levels
by 2019.
While
short-acting benzodiazepines were predominant, long-acting formulations were administered
in approximately 8% of cases. Benzodiazepine use was also associated with significantly
increased opioid consumption, especially in patients receiving long-acting
benzodiazepines. Benzodiazepine use was more frequent in younger patients
(median age 69!).
The
authors note that, despite growing evidence and several guidelines supporting cautious
use of benzodiazepines, the persistent high utilization rate across the 14-year
study period is surprising, especially given the increasing number of elderly patients
receiving THA and TKA. Use of long-acting benzodiazepines is known to be
associated with higher rates of postoperative delirium. They also note a
disturbing association of increased opioid use in patients receiving benzodiazepines.
The
authors call for future research to provide evidence-based guidelines on
appropriate use and indications for benzodiazepines in the perioperative
period.
A
second study looked at the association between perioperative medication use and
postoperative delirium and cognition in adults ≥70 years without dementia
undergoing elective noncardiac surgery (Duprey 2022). While hospitalized, patients were assessed
daily for delirium using the CAM (Confusion Assessment Method) and a validated
chart review method. Cognition was evaluated preoperatively and 1 month after
surgery using a neurocognitive battery. Among 560 patients enrolled, 134 (24%)
developed delirium during hospitalization. While prehospital benzodiazepine use
was not associated with post-op delirium, postoperative hospital benzodiazepine
use was associated with greater delirium (adjusted hazard ratio 3.23). But
association between inhospital, postoperative
medication use and cognition at 1 month, independent
of delirium, was not detected.
(Gracie 2021) of articles on patients who were undergoing
elective, nonemergent inpatient surgery confirmed a significant association
between preoperative frailty and postoperative delirium in elective surgical
patients age 65 years or older. It would be of interest to know whether the
presence of frailty further increases the risk of postoperative delirium in patients
receiving perioperative benzodiazepines.
An
interesting study analyzed risk factors for postoperative delirium in
critically ill patients the surgical ICU (Chaiwat 2019). Of 250 patients enrolled, delirium was
found in 61 (24.4%). Independent risk factors for delirium were age, diabetes
mellitus, severity of disease (SOFA score), perioperative use of
benzodiazepine, and mechanical ventilation. They then developed a predictive
score, weighting each of those 6 variables. That predictive score had a
sensitivity of 72.13% and a specificity of 80.95% at their suggested cut point.
Note that hospital mortality rate was significantly greater among the delirious
than the non-delirious patients (25% vs. 6%).
Sharon Inouye, one of the worlds leading
delirium researchers and key architect of HELP (Hospital Elder Life Program),
described a case of postoperative delirium in a New England Journal of Medicine
Perspective the patient was her own father (Inouye
2020).
She discussed the multiple contributing factors and fact that multiple
caregiver teams each prescribed many drugs to address his ailments, seemingly
without consideration of drug interactions, renal dose-adjustment protocols, or
his heightened sensitivity to psychoactive drugs. At one point, he was on more
than 20 medications, including a benzodiazepine for sleep and several other
drugs with psychoactive effects. Asking herself whether her fathers delirium could
have been prevented, she responds I believe so. Indeed, all the precipitating
factors were potentially reversible or remediable. Yet I realized that no person
working alone not even a delirium expert can prevent delirium. It takes an
enlightened, coordinated health care system with motivated interdisciplinary health
care professionals working together to improve care for older adults. Delirium
prevention truly requires a coordinated system with all healthcare workers
working together.
Managing delirium is difficult, so preventing
it is of utmost importance. Exposure to benzodiazepines is one of the
contributing factors that all healthcare workers must recognize in elderly
patients undergoing surgery.
Some of our prior columns on delirium
assessment and management:
- October
21, 2008 Preventing
Delirium
- October
14, 2008 Managing
Delirium
- February
10, 2009 Sedation
in the ICU: The Dexmedetomidine Study
- March
31, 2009 Screening
Patients for Risk of Delirium
- June
23, 2009 More
on Delirium in the ICU
- January
26, 2010 Preventing
Postoperative Delirium
- August
31, 2010 Postoperative
Delirium
- September
2011 Modified
HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery
- December
2010 The
ABCDE Bundle
- February
28, 2012 AACN Practice Alert on Delirium in
Critical Care
- April 3, 2012 New Risk for Postoperative Delirium:
Obstructive Sleep Apnea
- August
7, 2012 Cognition,
Post-Op Delirium, and Post-Op Outcomes
- February
2013 The
ABCDE Bundle in Action
- September
2013 Disappointing
Results in Delirium
- October
29, 2013 PAD:
The Pain, Agitation, and Delirium Care Bundle
- February
2014 New
Studies on Delirium
- March
25, 2014 Melatonin
and Delirium
- May
2014 New
Delirium Severity Score
- August
2014 A
New Rapid Screen for Delirium in the Elderly
- August
2014 Delirium
in Pediatrics
- November
2014 The
3D-CAM for Delirium
- December
2014 American
Geriatrics Society Guideline on Postoperative Delirium in Older Adults
- June
16, 2015 Updates
on Delirium
- October
2015 Predicting
Delirium
- April
2016 Dexmedetomidine and Delirium
- April
2016 Can Antibiotics Lead to Delirium?
- July
2016 New Simple Test for Delirium
- September
20, 2016 Downloadable ABCDEF Bundle Toolkits for
Delirium
- January
24, 2017 Dexmedetomidine to Prevent Postoperative
Delirium
- March
21, 2017 Success at Preventing Delirium
- July
2017 HELP Program Reduces Delirium Rate and
LOS
- January
2018 What Happens After Delirium?
- February
20, 2018 Delirium and Falls
- October
2018 Rapid Screening for Delirium
- November
13, 2018 Antipsychotics Fail in ICU Delirium
·
February
12, 2019 2 ER Drug Studies: Reassurances and
Reservations
·
September
17, 2019 American
College of Surgeons Geriatric Surgery Verification Program
·
March
2021 The Fiscal Costs of Delirium
- March
16, 2021 Sleep Program Successfully Reduces Delirium
- January
4, 2022 Spin or Not: A Useful Secondary Finding in a Study
- February
1, 2022 Perioperative Delirium is Not Just Postoperative
References:
Cozowicz C, Zhong H, Illescas
A, et al. The Perioperative Use of Benzodiazepines for Major Orthopedic Surgery
in the United States. Anesthesia & Analgesia 2022; 134(3); 486-495
Duprey
MS, Devlin JW, Griffith JL, et al. Association Between Perioperative Medication
Use and Postoperative Delirium and Cognition in Older Adults Undergoing
Elective Noncardiac Surgery. Anesthesia & Analgesia 2022; Published ahead
of print February 24, 2022
Gracie
TJ, Caufield-Noll C, Wang N-Y, et al. The Association of Preoperative Frailty
and Postoperative Delirium: A Meta-analysis. Anesthesia & Analgesia 2021;
133(2); 314-323
Chaiwat O, Chanidnuan M, Pancharoen W, et al. Postoperative Delirium in Critically
Ill Surgical Patients. Incidence, Risk Factors, and Predictive Scores. BMC Anesthesiol 2019; 19(39)
https://bmcanesthesiol.biomedcentral.com/articles/10.1186/s12871-019-0694-x
Inouye SK. Joining Forces against Delirium
From Organ-System Care to Whole-Human Care. N Engl J
Med 2020; 382(6): 499-501
https://www.nejm.org/doi/full/10.1056/NEJMp1910499
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