The Association of Cognitive Status and Post-Operative Opioid Prescribing in Older Adults

OBJECTIVE: To examine the differences in opioid prescribing by cognitive status following common elective surgical procedures among Medicare beneficiaries. BACKGROUND: Older individuals commonly experience changes in cognition with age. Although opioid prescribing is common after surgery, differences in opioid prescribing after surgery by cognitive status are poorly understood. METHODS: We conducted a retrospective analysis of patients ≥65 years participating in the Health and Retirement Study (HRS) linked with Medicare claims data who underwent surgeries between January 2007 and November 2016 and had cognitive assessments before the index operation. Cognitive status was defined as normal cognition, mild cognitive impairment (MCI), or dementia. Outcomes assessed were initial perioperative opioid fill rates, refill rates, and high-risk prescriptions fill rates. The total amount of opioids filled during the 30-day postdischarge period was also assessed. Adjusted rates were estimated for patient factors using the Cochran-Armitage test for trend. RESULTS: Among the 1874 patients included in the analysis, 68% had normal cognition, 21.3% had MCI, and 10.7% had dementia. Patients with normal cognition (58.1%) and MCI (54.5%) had higher initial preoperative fill rates than patients with dementia (33.5%) (P < 0.001). Overall, patients with dementia had similar opioid refill rates (21%) to patients with normal cognition (24.1%) and MCI (26.5%) (P = 0.322). Although prior opioid exposure did not differ by cognitive status (P = 0.171), among patients with high chronic preoperative use, those with dementia had lower adjusted prescription sizes filled within 30 days following discharge (281 OME) than patients with normal cognition (2147 OME) and MCI (774 OME) (P < 0.001; P = 0.009 respectively). Among opioid-naive patients, patients with dementia also filled smaller prescription sizes (97 OME) compared to patients with normal cognition (205 OME) and patients with MCI (173 OME) (P < 0.001 and P = 0.019, respectively). CONCLUSIONS: Patients with dementia are less likely to receive postoperative prescriptions, less likely to refill prescriptions, and receive prescriptions of smaller sizes compared to patients with normal cognition or MCI. A cognitive assessment is an additional tool surgeons can use to determine a patient’s individualized postoperative pain control plan.