Percentage of patients > 70 years old who received a benzodiazepine perioperatively.

Benzodiazepines, especially midazolam, are widely used as anxiolytics during surgery. However, in the geriatric population, the side effect profile of benzodiazepines may outweigh the benefits. Acknowledging that the literature is still evolving and in some cases there may be benefits to geriatric patients receiving benzodiazepines (for example, preoperative anxiety, if left untreated, may be associated with decreased patient satisfaction scores, increased postoperative pain, opioid requirements, postoperative anxiety, and even mortality.¹), the American Geriatric Society suggests the avoidance of benzodiazepines in older adults.² 

Reasons for guidance include: 

1. Benzodiazepines may be administered in combination with opioids, and synergistic effects may increase the potency of both classes of medications.³ 
2. Alterations in pharmacokinetics and pharmacodynamics of benzodiazepines in geriatric patients can lead to higher risk of adverse effects.⁴ 
3. Long-acting benzodiazepines may cause prolonged sedation, impaired delirium, and cognitive impairment.⁵ This may lead to increased falls and fractures in the older adult population.⁶ 

Preop Start to PACU End

Patients > 70 years old requiring anesthesia.

• Age < 70 years
• ASA 5 & 6 cases including Organ Procurement (CPT: 01990)
• Floor/ICU emergent Intubation only cases
• Patients transferred to ICU as defined by the Postoperative Destination phenotype value code 0

Avoiding administration of benzodiazepines from immediate preoperative period through PACU stay.

*This measure will include valid MPOG cases defined by Is Valid Case Phenotype.

Not applicable.

1. Preoperative benzodiazepine administration: Anesthesia provider(s) signed in at Anesthesia Start
2. Intraoperative benzodiazepine administration: Anesthesia provider(s) signed in at time of administration(s).
3. Postoperative benzodiazepine administration: Anesthesia provider(s) signed in at Anesthesia End.

*Multiple attribution rules will apply if benzodiazepine is administered in multiple phases of care.

1. Fong TG, Inouye SK. The inter-relationship between delirium and dementia: the importance of delirium prevention. Nat Rev Neurol. 2022 Oct;18(10):579-596.  10.1038/s41582-022-00698-7. Epub 2022 Aug 26. PMID: 36028563; PMCID: PMC9415264.
2. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. (2023, May 4). Journal of the American Geriatrics Society, 71(7), 2052–2081. https://doi.org/10.1111/jgs.18372
3. Elizabeth Kukielka, PharmD, MA, RPh . The Safety of Benzodiazepines and Opioids in the Geriatric Population: An Analysis of Patient Safety Events Reported by Hospitals and Ambulatory Surgical Facilities. Patient Safety. 2021;3(4):42-49. doi:10.33940/data/2021.12.5
4. Jenna D. Picton, Adriane Brackett Marino, Kimberly Lovin Nealy. Benzodiazepine use and cognitive decline in the elderly, American Journal of Health-System Pharmacy, Volume 75, Issue 1, 1 January 2018, Pages e6–e12, https://doi.org/10.2146/ajhp160381 
5. Natalie C. Moreland, Lena Scotto, Arnoley S. Abcejo, Emily Methangkool. Perioperative Brain Health: A Patient Safety Priority All Anesthesia Professionals Must Address. (n.d.). Anesthesia Patient Safety Foundation. ·        https://www.apsf.org/article/perioperative-brain-health-a-patient-safety-priority-all-anesthesia-professionals-must-address/ 
6. Todd Gress, Mark Miller, Charles Meadows, Shirley M Neitch. (2020). Benzodiazepine overuse in elders: Defining the problem and potential solutions. Cureus, 12 (10). https://doi.org/10.7759.cureus.11042