Effects of Cholinesterase Inhibitors on Postoperative Outcomes of Older Adults With Dementia Undergoing Hip Fracture Surgery

Kunin-Lunenfeld Applied Research Unit, Baycrest Center, Toronto, Ontario, Canada.
The American journal of geriatric psychiatry: official journal of the American Association for Geriatric Psychiatry (Impact Factor: 4.24). 09/2011; 19(9):803-13. DOI: 10.1097/JGP.0b013e3181ff67a1
Source: PubMed


Cholinesterase inhibitors (ChEIs) may interact with muscle relaxants given during general anesthesia (GA), increasing the risk of postoperative complications. We evaluated the effects of ChEIs on the postoperative outcomes of older adults who underwent hip fracture surgery.
Population-based cohort study using linked administrative databases.
All individuals with dementia age 66 years or older, who underwent hip fracture surgery between April 1, 2003, and December 31, 2007, in Ontario, Canada. EXPOSURES: Use of any ChEI (donepezil, rivastigmine, or galantamine) before surgery.
The primary composite outcome included any of the following: 30-day postoperative mortality; intensive care unit admissions; or in-hospital resuscitation. Secondary outcomes included postoperative respiratory failure and pneumonia.
We stratified the study sample on the basis of residence (community or long-term care [LTC]) and type of anesthetic (general or regional) to create four residence/anesthesia groups. We used propensity scores to match users and nonusers of ChEIs within the residence/anesthesia strata. We then calculated the relative risks (RR) and 95% confidence intervals (CI) for outcomes associated with ChEIs in the matched groups.
A total of 624 pairs of individuals from the community and 725 pairs from LTC were created among individuals who received GA. High rates of postoperative mortality and complications were observed in both ChEI users and nonusers. The RR of the primary outcome associated with ChEI use for individuals receiving GA was 0.88 (95% CI: 0.68-1.16; χ2 = 0.93; df = 1; p = 0.34) and 0.82 (95% CI: 0.63-1.04; χ2 = 2.59; df = 1; p = 0.11) in the community and LTC groups, respectively. In addition, ChEIs were not associated with any significant increased risk of postoperative respiratory complications.
ChEI use was not associated with an increased risk of postoperative complications among older adults with dementia who underwent hip fracture surgery. However, the poor postoperative outcomes overall reinforced the need to prevent fractures and improve outcomes in this population.

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    ABSTRACT: To evaluate the association between dementia and postoperative outcomes of older adults with hip fractures. Population-based, retrospective cohort study. Province of Ontario, Canada. All individuals with hip fractures who underwent hip fracture surgery in Ontario, Canada between April 1, 2003 and March 31, 2010 were identified. Physician-diagnosed dementia, prior to hip fracture, was identified using a diagnostic algorithm in the administrative databases. The preoperative characteristics of older adults with and without dementia were compared separately for individuals admitted to hospital from community or long term care (LTC). Multivariable regression was used to compare postoperative health service utilization, time with LTC admission, and mortality for individuals with and without dementia. A total of 45,602 older adults had hip fractures and individuals with dementia accounted for 23.9% and 83.5% of all hip fractures from the community and LTC settings, respectively. Compared with those without dementia, individuals with dementia were less likely to be admitted to rehabilitation facilities. Among community-dwelling older adults, dementia was associated with an increased risk of LTC admission [hazard ratio (HR) = 2.49, 95% confidence interval (CI): 2.38-2.61, P < .0001]. Dementia was also associated with a higher mortality for older adults from community (HR = 1.47, 95% CI: 1.41-1.52, P < .0001) and LTC (HR = 1.10; 95% CI: 1.02-1.18, P = .005) settings. Dementia is common among older adults with hip fractures and associated with poor prognosis following hip fracture surgery. Specialized services targeting the growing number of older adults with dementia may help to prevent hip fractures and optimize postoperative care for this vulnerable population.
    No preview · Article · Feb 2014 · Journal of the American Medical Directors Association
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    ABSTRACT: Objective To evaluate the incidence, characteristics and correlates of antidepressant drug therapy initiation among community-dwelling older adults following hip fracture. Design Retrospective cohort study using linked, population-based administrative data Setting Province of Ontario, Canada Participants Older adults, age 65 years or older, with a hip fracture and hip fracture surgery between April 1, 2003 and February 28, 2011. The study sample was restricted to individuals who returned home following surgery and who had not been dispensed an antidepressant in the year prior to their fracture (n=25,436). Measurements We determined the incidence of new antidepressant use defined by the dispensing of antidepressant drug therapy within 90 days of discharge home. We identified independent correlates of antidepressant initiation using multivariate regression. Results Overall, antidepressants were newly initiated in 8.8% of older adults with hip fracture in the 90 days following hospital discharge. There was a statistically significant, 1.3 fold increase in incidence of antidepressant prescribing from 2003 to 2010. Trazodone, frequently prescribed at a low dose, accounted for 39.0% of newly dispensed antidepressants, followed by selective serotonin reuptake inhibitors (36.9%). Rehabilitation admission, psychiatric evaluation, a diagnosis of dementia, and baseline benzodiazepine use were the strongest independent correlates of antidepressant initiation. Conclusion The period after a hip fracture is associated with a high rate of initiation of antidepressant therapy. The data raise the possibility that antidepressants are frequently prescribed ‘off-label’ in these patients. Further research is needed to investigate the safety and efficacy of antidepressant use in this vulnerable population.
    No preview · Article · Mar 2014 · American Journal of Geriatric Psychiatry
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    ABSTRACT: Objectives To examine the association between anesthetic technique and postoperative complications in older adults with dementia undergoing hip fracture surgery.DesignPopulation-based, retrospective cohort study.SettingOntario, Canada.ParticipantsAll older adults with dementia who underwent surgery for hip fracture repair in Ontario, Canada, between April 1, 2003 and March 31, 2011.MeasurementsThe baseline characteristics of individuals who received general anesthesia (GA) and regional anesthesia (RA) were compared. Individuals who received GA were matched to similar individuals who received RA using propensity scores to control for confounding, and their outcomes compared, including 30-day mortality, intensive care unit (ICU) admissions, specific postoperative medical complications, and hospital length of stay (LOS).ResultsIn the 6,135 matched pairs, there was no statistically significant difference in postoperative 30-day mortality (GA, 11.3%; RA, 10.8%, P = .44). There were no statistically significant differences in the rates of specific postoperative medical complications or LOS in the two anesthetic groups, but GA was associated with higher rates of ICU admissions (6.1% vs 4.2%, P < .001).Conclusion For older adults with dementia undergoing hip fracture surgery, GA and RA are associated with similar rates of most perioperative adverse events. Further studies are required to determine the optimal methods of providing anesthesia and perioperative care for older adults with dementia undergoing surgical procedures.
    No preview · Article · Nov 2014 · Journal of the American Geriatrics Society
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