Caution: Perioperative Surgery Medications

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Caution: Perioperative Surgery Medications - #12

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Perioperative medication that may increase delirium risk.

Assessment

“FACE” High-Risk Medication List

(Froedtert Acute Care for the Elderly)

The Froedtert ACE List is a reference list of medications to avoid in elderly patients based on a compilation of the Beer’s Criteria1, The Medical Letter2Chutka et al3

Potential adverse effect

Notes & Alternatives(s)*

Class: Benzodiazepines, anxiolytics: alprazolam (Xanax), Diazepam (Valium), Chlordiazepoxide (Librium), Meprobamate (Equanil)

Prolonged sedation, cognitive impairment, dependence, increased fall risk, addiction risk

Lorazepam, oxazepam (lowest dose, shortest duration of therapy possible) – Lorazepam doses > 3mg = excessive sedation*

Class: Antidepressants Amnitriptyline (Elavil), Chlordiazepoxide/amitriptyline (Limbitrol), Doxepin (Senequan) e.g. sertraline, paroxetine

Anti-cholinergic effects, orthostatic, hypotension, sedation, cardiac arrhythmias

SSRIs (other than fluoxetine).

Class: Non-steroidal anti-inflammatory (NSAIDs): Ibuprofen (Motrin) Indomethacin (Indocin),  Piroxicam (Feldene), Oxaprozin (Daypro)
  1. Serious GI toxicity. If used, titrate to lowest effective dose and monitor for GI Toxicity
  2. Possible renal toxicity
  1. Acetaminophen (4 gm/day), tramadol, non-acetylated salicylates (Trilisate), morphine3
  2. [Ketorolac: if used titrate to lowest effective dose and monitor for GI toxicity (15 mg QID x 5 days maximum)]

Class: Analgesics

  1. Propoxyphene, including combos (Darvon, Davocet)
  2. Pentazocine (Talwin)
  3. Meperidine Demerol)

 

  1. Propoxyphene: Convulsions, CNS toxicity, limited effectiveness
  2. Pentazocine: Psychotropic effects, hallucinations, seizure risk
  3. Meperidine: Confusion, convulsions, tremors, myoclonus

 

Acetaminophen (.4gm/day), tramadol, non-acetylated salicylates (e.g., Trilisate), morphine3

Class: Antihistamines

  1. Diphenhydramine (Benadryl)
  2. Clorpheniramine (Chlor-Trimeton)
  3. Hydroxyzine (Vistaril, Atarax)

Anti-cholinergic, highly sedating, delirium, cognitive decrease.

Loratadine (Claritin)

Cetririzine (Zyrtec)

Class: Muscle Relaxants:

  1. Carisoprodol (Soma)
  2. Cyclobenzaprine (Flexeril)
  3. Methocarbamol (Robaxin)

 

Anti-cholinergic symptoms, limited effect

Class: Barbiturates

(e.g., Phenobarbital [Luminal],

Secobarbital (Seconal), pentobarbital [Nembual]

Sedation, decreased attention (risk of falls), respiratory depression, addition risk, hallucinations

Benzodiazepines (lorazepam, oxazepam)

May be appropriate as an anticonvulsant

Class: Antiemetics

Trimethobenzamide (Tigan)

Extrapyramidal effects, lower potency, sedating

 

Prochlorperazane (Compazine)

5HT3-Antagonists: ondansetron (Zofran)

Context

Geriatric patient in a post surgery hospital setting.

Action

Patient needs medications for pain, medical management, etc. but the medications required can cause delirium. Patient has a history of dementia.

Incidence / Prevalence

Adults ≥ 65 yr old are prescribed the highest proportion of medications in relation to their percentage of the U.S. population. Currently, approximately 13% of the U.S. population is ≥ 65 yr old; this age group purchases 33% of all prescription drugs (Holmes).

Underlying Sciences

The cause of delirium is typically multifactorial. The development of delirium involves the complex interrelationship between a vulnerable patient and exposure to precipitating factors or insults. Extensive evidence supports the role of cholinergic deficiency. Dopaminergic excess also appears to contribute to delirium. Perturbations of other neurotransmitters, such as norepinephrine, serotonin, gamma aminobutyric acid, glutamate, and melatonin may also have a role in the pathophysiology of delirium, but the evidence is less well developed.

Science Principles

Impaired homeostasis
Post-mitotic tissue and age related degeneration

Objectives

1.List 4 classes of medication that may precipitate delirium in elderly susceptible patients.

2.Identify the mechanism of action of those 4 medication classes which my precipitate delirium.

3.Identify one neurotransmitter whose perturbation may lead to delirium.

Keywords/Tags

References

  1. Fick D M, Cooper J W, Wade W E, Waller J L, Maclean J R, Beers M H. Updating the Beers criteria for potentially inappropriate medication use in older adults. Arch Intern Med. 2003;163:2716-2724.
  2. Drugs in the elderly. The Medical Letter 2006; 48:6-7.
  3. Chutka D S, Takahashi P Y, Hoel R W. Inappropriate medications for elderly patients. Mayo Clinic Proc. 2004; 79:122-139.
  4. Holmes HM, Hayley DC, Alexander GC, et al. Reconsidering medication appropriateness for patients late in life. Arch Intern Med. 2006;16699):605-609.
This GFF ___ my competence in geriatrics.

Authors

Kathryn Denson MD, John Petronovich

Author Affiliation

Medical College of Wisconsin, Milwaukee, Wisconsin.

Copyright

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