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# 012 Caution: Perioperative Surgery Medications

Fast Facts and Concepts #012 PDF

Authors: Kathryn Denson MD, John Petronovich, Bambi Wessel

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.

ACGME Competencies: Medical Knowledge, Patient Care

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 Science: 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. 

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 Letter2, Chutka et al3 and Froedtert geriatric specialists' expert opinions Medication / Class

Potential adverse effect

Notes & Alternative(s)*

Class: Benzodiazepines, anxiolytics:

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

Lorazepam, oxazepam (lowest dose, shortest duration of therapy possible)

alprazolam (Xanax),Diazepam (Valium), Flurazepam (Dalmane), Chlordiazepoxide (Librium), Meprobamate (Equanil)

*Lorazepam doses > 3mg = excessive sedation*

Class: Antidepressants: Amitriptyline (Elavil), Chlordiazepoxide/amitriptyline (Limbitrol), Doxepin (Sinequan)

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

SSRIs (other than fluoxetine).

e.g sertraline, paroxetine

Class: Non-steroidal anti-inflammatory (NSAIDs): Ibuprofen (Motrin) Indomethacin (Indocin), Naproxen (Aleve, Anaprox, Naprosyn), Piroxicam (Feldene), Oxaprozin (Daypro)

Serious GI toxicity. If used, titrate to lowest effective dose and monitor for GI toxicity

Acetaminophen (<4gm/day), tramadol, non-acetylated salicylates (Trilisate), morphine3

Possible renal toxicity

[Ketorolac: If used, titrate to lowest effective dose and monitor for GI toxicity (15mg QID x 5 days maximum)]

Class: Analgesics (misc):

1. Propoxyphene: Convulsions, CNS toxicity, limited effectiveness

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

1. Propoxyphene, including combos (Darvon, Darvocet)

2. Pentazocine: Psychotropic effects, hallucinations, seizure risk

2. Pentazocine (Talwin)

3. Meperidine: Confusion, convulsions, tremors, myoclonus

3. Meperidine (Demerol)

 

Class: Antihistamines Diphenhydramine (Benadryl) Chlorpheniramine (Chlor-Trimeton) Hydroxyzine (Vistaril, Atarax)

Anti-cholinergic, highly sedating, delirium, cognitive decrease

Loratadine (Claritin)

Cetirizine (Zyrtec)

Class: Muscle Relaxants:

Anti-cholinergic symptoms, limited effect

Carisoprodol (Soma) Cyclobenzaprine (Flexeril) Methocarbamol (Robaxin) Metaxalone (Skelaxin)

Class : Barbiturates

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

Benzodiazepines (lorazepam, oxazepam)

(eg Phenobarbital [Luminal], secobarbital [Seconal], pentobarbital [Nembutal]

May be appropriate as an anticonvulsant3

Class: Antiemetics Trimethobenzamide (Tigan) Promethazine (Phenergan)

Extrapyramidal effects, lower potency, sedating

Prochlorperazine (Compazine)

5HT3-antagonists: ondansetron (Zofran)

 

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.

Author Affiliation: Medical College of Wisconsin, Milwaukee, Wisconsin.

Geriatric Fast Facts are edited by the faculty of the Geriatric Education Teams (GETS) program funded by the Reynolds Foundation, Kathryn Denson, MD, Steven Denson, MD, & Edmund Duthie, MD from the Division of Geriatrics, Medical College of Wisconsin, and are published by the Geriatric Fast Facts Website at the Medical College of Wisconsin. For more information write Kathryn Denson, MD. More information, as well as the complete set of Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm

Copyright/Referencing Information: Users are free to download and distribute Geriatric Fast Facts for educational purposes only.  Citation: Kathryn Denson MD, John Petronovich, Bambi Wessel - Fast Fact #12: Caution: Perioperative Surgery Medications. February 2012, 14, Geriatric Fast Facts, available at www.mcw.edu/Geriatric-Fast-Facts.htm

Disclaimer: Geriatric Fast Facts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Geriatric Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

 

 

 

 

 

 

        

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