Frailty and polypharmacy increase with age and present concerns when older adults with thoracic malignancies are considered for surgical intervention. An allied risk is the prescription of medications considered inappropriate for older individuals.

However, a retrospective study at Brigham and Women’s Hospital found that polypharmacy, potentially inappropriate medications, and frailty were not associated with complications after surgery for thoracic malignancies, although frailty was associated with increased length of hospital stay.

Lisa Cooper, MD, of the Brigham’s Division of Aging, Laura N. Frain, MD, MPH, a geriatrician at the Center for Older Adult Health Services, and colleagues detail the findings in the Journal of Geriatric Oncology.

Methods

The analysis included 59 patients who were evaluated in the multidisciplinary geriatric–thoracic clinic at the Brigham between January 2016 and January 2019 and later underwent major thoracic surgery.

The researchers assessed relationships between surgical outcomes (postoperative complications and length of stay) and:

• Polypharmacy (defined as the use of five or more medications)

• Potentially inappropriate medications (PIM) for older adults, defined based on the American Geriatrics Society 2015 Beers Criteria (the latest edition was published in 2019)

• Frailty, defined as a score ≥5 on the Clinical Frailty Scale assigned after comprehensive geriatric assessment

Characteristics of the Cohort

The cohort was 54% female and had a median age of 75 (range, 62–88). Most patients were independent in basic activities of daily living (98%) and instrumental activities of daily living (81%).

The prevalence of polypharmacy was 86% (median number of medications, 8; range, 1–24). 90% of patients used at least one PIM (median number, 2; range, 0–5). The most common PIMs were aspirin, omeprazole, lorazepam, and oxycodone.

36% of patients were frail. Polypharmacy and PIM >1 were not significantly associated with frailty.

Postoperative Complications

The complication rate was 37%. Grade II complications represented 27%; only 5% of patients had a grade IV complication and none died. On multivariable logistic analyses, postoperative complications were not associated with frailty, the number of medications, or the number of PIMs, even after adjustment for type of procedure.

Length of Stay

The median length of stay (LOS) was four days (range, 1–35). Frailty was associated with prolonged average LOS (β=2.75; P=0.011) and the association persisted after adjustment for procedure type.

Esophagectomy (vs. wedge resection) was also associated with prolonged LOS (β=9.81; P<0.001). Polypharmacy and PIMs were not.

The Value of Geriatric Co-Management

The rate of postoperative delirium was only 5%, and most patients were discharged home with services. These findings and the low rate of life-threatening complications are at least partly attributable to the geriatric co-management program:

• Social strengths and vulnerabilities (such as living situation, social supports, and caregiver burden) were assessed preoperatively and the geriatric team planned accordingly for discharge

• Information derived from the comprehensive geriatric assessment and any social vulnerabilities were presented to the surgical team during multidisciplinary clinic visits, and the treatment plan was adjusted if necessary

• Postoperatively, a member of the geriatric team was present on the thoracic surgery floor for further co-management of these patients