1 Introduction

Long medication lists are a typical feature of fragility fracture patients (FFPs) for many reasons. The presence of multiple comorbidities, advances in disease-specific drug treatment, increased diagnostic testing and changing thresholds for treatment have contributed to significant increases in the number of medications prescribed for older adults. The majority of older adults take more than five prescribed medications [1] and 40% of nursing home residents use nine or more medications each day [2]. The potential benefits of these medications are often offset by risks related to interactions and toxicities in frail older patients. Adverse drug reactions due to common medications (ie, anticoagulants, antithrombotics, antidiabetic medications, and digoxin) account for a significant number of emergency hospitalizations [3], and benzodiazepenes, antihistamines, and opioids are often implicated in delirium [4].

Common postoperative complications related to polypharmacy include:

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  Hypotension due to the combination of blood loss, opiates and home antihypertensive agents

  
  
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  Acute renal failure related to diuretics and angiotensin-converting enzyme inhibitors

  
  
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  Sedation and delirium due to interactions between postoperative pain medications and home medications (eg, antidepressants, muscle relaxants, and psychiatric medications)

  
  
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  Urinary retention and constipation due to opioids and anticholinergic agents

Addressing polypharmacy is fundamental to optimal short- and long-term outcomes for orthogeriatric fracture patients. Standardized medication reconciliation by appropriate orthogeriatric team members at each transition of care is the primary tool to reduce unnecessary and harmful medications during hospitalization and at the time of discharge.

2 Unique prescribing issues for older adults

There are a number of issues that make current disease specific prescribing guidelines problematic for older adults:

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  Lack of valid clinical trials:

  
  

  The vast majority of clinical trials of pharmacological interventions are not validated in older or highly comorbid populations, making risks and benefits uncertain, even for many standard medications.

  
  
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  Lower dose thresholds for toxicity:

  
  

  Age- and disease-related changes in drug absorption, distribution, metabolism and excretion can result in lower thresholds for drug toxicity in older adults.

  
  
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  Limited lifespan:

  
  

  Older adults may not have sufficient remaining lifespan to realize the benefit of many standard chronic disease-directed drug therapies, making potential benefits unlikely.

Common drug side effects like delirium, constipation, anorexia and hypotension often complicate the perioperative and postsurgical course of orthogeriatric patients and have a big impact on recovery and outcomes. These factors should result in a general reluctance to routinely prescribe many medications found in standard disease-specific guidelines, and support the geriatric maxim to “start low, go slow” whenever choosing medications and doses in this population.

3 Definitions and challenges

Polypharmacy can be defined in many ways:

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  Five or more medications [5]. This is the most common definition but other studies use cut-offs as low as two and as high as eleven.

  
  
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  The use of one or more medications, herbal remedies, or supplements with potential interactions.

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  Inappropriate use of any specific medication in an older adult. Each medication should have a clear indication and be prescribed at the minimum effective dose. Short life expectancy, side effects, and goals of care can all impact the appropriateness of specific medications for individual patients.

The risk of drug-related adverse events is higher as the number of medications increases, with nearly 20% of patients on eight or more medications likely to experience an adverse drug event [6].

Obtaining an accurate admission medication list for all orthogeriatric patients is essential, but not the only step in managing medications in the hospital setting. Regardless of the criteria, polypharmacy occurs as a result of a lack of appropriate and thoughtful review of the patients’ medication regimen [7–9]. Many home medications may need to be stopped or the dose reduced during the perioperative period.

It can be challenging to correctly identify polypharmacy, as most patients take medications consistent with disease-specific clinical guidelines. Despite having appropriate indications, individual patients can have side effects or toxicities that make the risks of a particular medication or medication dose excessive. The cumulative effect of medications can produce symptoms that sometimes are mistakenly attributed to other etiologies or new medical problems. Acutely compromised orthogeriatric patients can become vulnerable to previously well-tolerated medications. For any significant sign or symptoms, the clinician should always evaluate the patient′s current medication regimen as a potential contributor.

4 Strategies to safely reduce medications

Despite the need to stop or reduce the dose of some long-term medications in the perioperative setting, specific approaches to achieve this are not well studied or specified [10]. Moreover, the few available studies are limited by being observational and short term.

We offer the following 3-step approach to evaluating and modifying the medication regimen for FFP ( Table 1.13-1 ).

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   Stop medications that are likely to delay surgical repair or are expected to produce clinically significant side effects in the perioperative period. Each prescribed medication should be reviewed to ensure that it is clinically necessary at the time of surgery, and it is being prescribed at the most appropriate dose. Moreover, clinicians should verify that there are no other treatment alternatives with significantly less side effects.

   
   
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   Stop medications that are likely to interfere with postoperative recovery and rehabilitation, especially those that produce excessive sedation, hypotension, or delirium.

   
   
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   Stop medications that have no obvious clinical indication, might produce significant side effects, or lead to complications.

With each of these steps, the clinician needs to consider the risk for medication withdrawal, especially for those medications for which there are known withdrawal syndromes, eg, benzodiazepines, opiates, some antidepressants, clonidine, and beta-blockers. Rapid discontinuation of some of these medications—most likely drugs with cardiovascular and neurological indications—can cause adverse events [11].

Medication management needs to be coordinated by team members with experience in perioperative and geriatric medicine. Some common issues are summarized in Table 1.13-2 .

The STOPP/START criteria are the best studied single point of care intervention aimed at modifying drug regimens [12]. These criteria use a structured and detailed approach to evaluating patient and disease factors that should prompt appropriate prescribing. The benefits of applying these criteria have been demonstrated up to 6 months after hospitalization.

In addition, the STOPP/START criteria make appropriate suggestions for dosage selection, particular for older adults with reduced renal function [12]. Patients with high degrees of inappropriate prescribing as measured by STOPP/START criteria appear to be at higher risk for mortality after hip fracture [11]. These criteria are generally too cumbersome to use in a busy clinical setting but do support the rationale for more limited prescribing.