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Rawle MJ, Lau WCY, Gonzalez-Izquierdo A, Patalay P, Richards M, Davis D. Associations Between Midlife Anticholinergic Medication Use and Subsequent Cognitive Decline: A British Birth Cohort Study. Drugs Aging 2024:10.1007/s40266-024-01116-x. [PMID: 38740716 DOI: 10.1007/s40266-024-01116-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Anticholinergic medication use is associated with cognitive decline and incident dementia. Our study, a prospective birth cohort analysis, aimed to determine if repeated exposure to anticholinergic medications was associated with greater decline, and whether decline was reversed with medication reduction. METHODS From the Medical Research Council (MRC) National Survey of Health and Development, a British birth cohort with all participants born in a single week of March 1946, we quantified anticholinergic exposure between ages 53 and 69 years using the Anticholinergic Cognitive Burden Scale (ACBS). We used multinomial regression to estimate associations with global cognition, quantified by the Addenbrooke's Cognitive Examination, 3rd Edition (ACE-III). Longitudinal associations between ACBS and cognitive test results (Verbal memory quantified by the Word Learning Test [WLT], and processing speed quantified by the Timed Letter Search Task [TLST]) at three time points (age 53, 60-64 and 69) were assessed using mixed and fixed effects linear regression models. Analyses were adjusted for sex, childhood cognition, education, chronic disease count and severity, and mental health symptoms. RESULTS Anticholinergic exposure was associated cross-sectionally with lower ACE-III scores at age 69, with the greatest effects in those with high exposure at ages 60-64 (mean difference - 2.34, 95% confidence interval [CI] - 3.51 to - 1.17). Longitudinally, both mild-moderate and high ACBS scores were linked to lower WLT scores, again with high exposure showing larger effects (mean difference with contemporaneous exposure - 0.90, 95% CI - 1.63 to - 0.17; mean difference with lagged exposure - 1.53, 95% CI - 2.43 to - 0.64). Associations remained in fixed effects models (mean difference with contemporaneous exposure -1.78, 95% CI -2.85 to - 0.71; mean difference with lagged exposure - 2.23, 95% CI - 3.33 to - 1.13). Associations with TLST were noted only in isolated contemporaneous exposure (mean difference - 13.14, 95% CI - 19.04 to - 7.23; p < 0.01). CONCLUSIONS Anticholinergic exposure throughout mid and later life was associated with lower cognitive function. Reduced processing speed was associated only with contemporaneous anticholinergic medication use, and not historical use. Associations with lower verbal recall were evident with both historical and contemporaneous use of anticholinergic medication, and associations with historical use persisted in individuals even when their anticholinergic medication use decreased over the course of the study.
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Affiliation(s)
- Mark J Rawle
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK.
- Academic Centre for Healthy Ageing (ACHA) @ Whipps Cross University Hospital, Barts Health NHS Trust, Whipps Cross Road, London, E11 1NR, UK.
| | - Wallis C Y Lau
- Research Department of Practice and Policy, School of Pharmacy, UCL, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, The University of Hong Kong, Pok Fu Lam, Hong Kong
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Pak Shek Kok, Hong Kong
| | - Arturo Gonzalez-Izquierdo
- Institute of Health Informatics and Health Data Research UK, UCL, London, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
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Kochar B, Rusher A, Araka E, Glasser R, Lai J, Ritchie C, Ananthakrishnan AN. Prevalence and Appropriateness of Polypharmacy in Older Adults with Inflammatory Bowel Diseases. Dig Dis Sci 2024; 69:766-774. [PMID: 38273076 DOI: 10.1007/s10620-023-08250-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 12/14/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Despite the growing prevalence of older adults with inflammatory bowel diseases (IBD), polypharmacy, an important geriatric construct, is poorly understood. We described polypharmacy and its implications in older adults with IBD. METHODS In a cross sectional study of adults ≥ 60 years with IBD, we obtained medication lists from the medical record and patients. We assessed medications by the Beer's criteria, anti-cholinergic burden and drug-drug interactions. We constructed multi-variate logistic regression models to assess association between polypharmacy with low quality-of-life, controlling for age, sex, IBD-type, number of comorbidities and depression. RESULTS In 100 adults ≥ 60 years with IBD, with a median age of 68 years, 56% met criteria for remission by a validated disease activity index. Polypharmacy, defined as ≥ 5 concomitant medications, was noted in 86% of the cohort and 45% had severe polypharmacy, defined as ≥ 10 concomitant medications. In this cohort, 48% were on ≥ 1 medication that met Beer's criteria for potentially inappropriate in older adults and 24% had a cumulative anti-cholinergic drug burden score of ≥ 3, the threshold for serious adverse events attributed to anti-cholinergic burden. Serious drug-drug interactions were found in 26% with 7% involving an IBD medication. Controlling for potential confounders, polypharmacy, defined both numerically (OR 22.79, p < 0.01) and by medication appropriateness (OR 1.95, p < 0.01), was significantly associated with low quality of life. CONCLUSION Polypharmacy is prevalent in older adults with IBD and independently associated with low quality of life. Describing polypharmacy can guide de-prescription strategies tailored to GI clinic for older adults with IBD.
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Affiliation(s)
- Bharati Kochar
- Division of Gastroenterology, Massachusetts General Hospital, Crohn's & Colitis Center, 165 Cambridge Street, 9th Floor, Boston, MA, 02114, USA
- The Mongan Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Alison Rusher
- Division of Gastroenterology, Massachusetts General Hospital, Crohn's & Colitis Center, 165 Cambridge Street, 9th Floor, Boston, MA, 02114, USA
| | - Elizabeth Araka
- Division of Gastroenterology, Massachusetts General Hospital, Crohn's & Colitis Center, 165 Cambridge Street, 9th Floor, Boston, MA, 02114, USA
| | - Rachel Glasser
- Division of Gastroenterology, Massachusetts General Hospital, Crohn's & Colitis Center, 165 Cambridge Street, 9th Floor, Boston, MA, 02114, USA
| | - Jennifer Lai
- Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, CA, USA
| | - Christine Ritchie
- The Mongan Institute, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ashwin N Ananthakrishnan
- Division of Gastroenterology, Massachusetts General Hospital, Crohn's & Colitis Center, 165 Cambridge Street, 9th Floor, Boston, MA, 02114, USA.
- The Mongan Institute, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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Svensson M, Elmståhl S, Sanmartin Berglund J, Rosso A. Association of systemic anticholinergic medication use and accelerated decrease in lung function in older adults. Sci Rep 2024; 14:4362. [PMID: 38388652 PMCID: PMC10883995 DOI: 10.1038/s41598-024-54879-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 02/17/2024] [Indexed: 02/24/2024] Open
Abstract
Older adults are frequently exposed to medicines with systemic anticholinergic properties, which are linked to increased risk of negative health outcomes. The association between systemic anticholinergics and lung function has not been reported. The aim of this study was to investigate if exposure to systemic anticholinergics influences lung function in older adults. Participants of the southernmost centres of the Swedish National study on Aging and Care (SNAC) were followed from 2001 to 2021. In total, 2936 subjects (2253 from Good Aging in Skåne and 683 from SNAC-B) were included. An extensive medical examination including spirometry assessments was performed during the study visits. The systemic anticholinergic burden was described using the anticholinergic cognitive burden scale. The effect of new use of systemic anticholinergics on the annual change in forced expiratory volume (FEV1s) was estimated using mixed models. During follow-up, 802 (27.3%) participants were exposed to at least one systemic anticholinergic medicine. On average, the FEV1s of participants without systemic anticholinergic exposure decreased 37.2 ml/year (95% CI [33.8; 40.6]) while participants with low and high exposure lose 47.2 ml/year (95% CI [42.4; 52.0]) and 43.7 ml/year (95% CI [25.4; 62.0]). A novel association between new use of medicines with systemic anticholinergic properties and accelerated decrease in lung function in older adults was found. The accelerated decrease is comparable to that observed in smokers. Studies are needed to further explore this potential side effect of systemic anticholinergics.
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Affiliation(s)
- Markus Svensson
- Division of Geriatric Medicine, Department of Clinical Sciences, Lund University, Jan Waldenströms Gata 35, 205 02, Malmö, Sweden.
| | - Sölve Elmståhl
- Division of Geriatric Medicine, Department of Clinical Sciences, Lund University, Jan Waldenströms Gata 35, 205 02, Malmö, Sweden
| | | | - Aldana Rosso
- Division of Geriatric Medicine, Department of Clinical Sciences, Lund University, Jan Waldenströms Gata 35, 205 02, Malmö, Sweden
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Peralta V, de Jalón EG, Moreno-Izco L, Peralta D, Janda L, Sánchez-Torres AM, Cuesta MJ. The effect of anticholinergic burden of psychiatric medications on major outcome domains of psychotic disorders: A 21-year prospective cohort study. Schizophr Res 2024; 264:386-393. [PMID: 38237360 DOI: 10.1016/j.schres.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 09/20/2023] [Accepted: 01/07/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Most medications used to treat psychotic disorders possess anticholinergic properties. This may result in a considerable anticholinergic burden (ACB), which may have deleterious effects on long-term outcomes. The extent to which cumulative ACB over years of treatment with psychotropic medications impacts different outcome domains remains unknown. METHODS This was a naturalistic study of 243 subjects with first-episode psychosis aimed at examining the cumulative effect of ACB of psychotropic medications administered over the illness course (ACB-years exposure) on several outcome domains assessed after a mean 21-year follow-up. Associations between ACB and the outcomes were modelled accounting for relevant confounding factors by using hierarchical linear regression analysis. RESULTS Over the study period, 81.9 % of the participants were dispensed at least one drug with strong anticholinergic effects for at least 1 year; at the follow-up visit, 60.5 % of the participants continued to take medications with strong ACB. ACB-years exposure was uniquely related to severity of negative symptoms (β = 0.144, p = 0.004), poor psychosocial functioning (β = 0.186, p < 0.001) and poor cognitive performance (β = -0.273, p < 0.001). This association pattern was independent of a schizophrenia diagnosis. Most of the associations between ACB at the follow-up visit and the outcomes were accounted for ACB-years exposure. CONCLUSION Lifetime ACB of psychotropic medications has deleterious effects on the outcome of psychotic disorders. Clinicians should avoid prescribing medications with strong ACB, since there are numerous alternatives within each psychotropic drug group for prescribing medications with low ACB.
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Affiliation(s)
- Victor Peralta
- Mental Health Department, Servicio Navarro de Salud, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain.
| | - Elena García de Jalón
- Mental Health Department, Servicio Navarro de Salud, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - Lucía Moreno-Izco
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain; Department of Psychiatry, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - David Peralta
- Mental Health Department, Servicio Navarro de Salud, Pamplona, Spain
| | - Lucía Janda
- Mental Health Department, Servicio Navarro de Salud, Pamplona, Spain
| | - Ana M Sánchez-Torres
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain; Department of Psychiatry, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Manuel J Cuesta
- Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain; Department of Psychiatry, Complejo Hospitalario de Navarra, Pamplona, Spain
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Yoshimatsu Y, Kragholm K, Clemmensen SZ, Melgaard D, Torp-Pedersen C, Smithard DG, Riis J. The predictive value of anticholinergic drug exposure and the outcome of pneumonia: a Danish database study. Age Ageing 2024; 53:afae012. [PMID: 38337045 DOI: 10.1093/ageing/afae012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Indexed: 02/12/2024] Open
Abstract
INTRODUCTION Older adults are susceptible to anticholinergic effects. Dysphagia and pneumonia are associated with anticholinergic usage, though a definitive causative relationship has not been established. There is no effective way to predict the prognosis of older adults with pneumonia; therefore, this study investigates the predictive value of anticholinergic burden. METHODS Patients aged 65 years and above admitted for community-acquired pneumonia from 2011 to 2018 in Denmark were included through Danish registries. We calculated anticholinergic drug exposure using the CRIDECO Anticholinergic Load Scale (CALS). The primary outcome was in-hospital mortality, and other outcomes included intensive care unit admission, ventilator usage, length of stay, 30-day/90-day/1-year mortality, institutionalisation, home care utilisation and readmission. RESULTS 186,735 patients were included in the in-hospital outcome analyses, 165,181 in the readmission analysis, 150,791 in the institutionalisation analysis, and 95,197 and 73,461 patients in the home care analysis at follow-up. Higher CALS score was associated with higher in-hospital mortality, with a mean risk increasing from 9.9% (CALS 0) to 16.4% (CALS >10), though the risk plateaued above a CALS score of 8. A higher CALS score was also associated with greater mortality after discharge, more home health care, more institutionalizations and higher readmission rates. CONCLUSIONS High anticholinergic burden levels were associated with poor patient outcomes including short-/long-term mortality, dependence and readmission. It may be useful to calculate the CALS score on admission of older patients with pneumonia to predict their prognosis. This also highlights the importance of avoiding the use of drugs with a high anticholinergic burden in older patients.
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Affiliation(s)
- Yuki Yoshimatsu
- Geriatric Medicine, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, London, UK
- Centre for Exercise Activity and Rehabilitation, School of Human Sciences, University of Greenwich, London, UK
| | - Kristian Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Dorte Melgaard
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - David G Smithard
- Geriatric Medicine, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, London, UK
- Centre for Exercise Activity and Rehabilitation, School of Human Sciences, University of Greenwich, London, UK
| | - Johannes Riis
- Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark
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6
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Smith H, Fligelstone H. Reducing patient and planetary harms from high anticholinergic burden medication. BMJ 2024; 384:e075708. [PMID: 38224974 DOI: 10.1136/bmj-2023-075708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Affiliation(s)
- Honey Smith
- Richmond Medical Centre, Sheffield, UK
- South Yorkshire Integrated Care Board
- Greener Practice Community Interest Company, Sheffield
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7
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Evans T, Binns H, Mandal AK, De'Ath HD, Missouris CG. The impact of anticholinergic burden on clinical outcomes in older hospitalised surgical patients. Br J Hosp Med (Lond) 2024; 85:1-9. [PMID: 38300682 DOI: 10.12968/hmed.2023.0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
Polypharmacotherapy is an ever-increasing issue with an ageing patient population. Anticholinergic medications make up a large proportion of patient medication but cause significant side effects, contributing to well-documented issues within the older population and in hospital medicine. This review explores the documented impact of anticholinergic burden in older surgical patients on postoperative delirium, infection, length of stay and readmission, urinary retention, ileus and mortality. It also highlights the need for further high-quality research into anticholinergic burden management among older surgical patients to further impact practice and policy in the area.
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Affiliation(s)
- Thomas Evans
- Department of General Internal Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Hannah Binns
- Department of General Internal Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Amit Kj Mandal
- Department of General Internal Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Henry D De'Ath
- Department of General Surgery, Frimley Park Hospital, Frimley Health NHS Foundation Trust, Frimley, Surrey UK
| | - Constantinos G Missouris
- Department of Cardiology, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
- University of Nicosia Medical School, Cyprus, UK
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8
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Saz HG, Yalçın N, Demirkan K, Halil MG. Clinical pharmacist-led assessment and management of anticholinergic burden and fall risk in geriatric patients. BMC Geriatr 2023; 23:863. [PMID: 38102545 PMCID: PMC10724986 DOI: 10.1186/s12877-023-04599-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/14/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND The aim of this study was to examine the risk of fall with the surrogate outcome of the Aachen Falls Prevention Scale and to assess the clinical pharmacist interventions in order to minimize anticholinergic drug burden and associated risk of fall according to a fall risk assessment scale in the older adults. METHODS Patients who admitted to the geriatric outpatient clinic of a university hospital and taking at least one anticholinergic drug were evaluated both retrospectively and prospectively as groups of different patients by the clinical pharmacist. Patients' anticholinergic burden was assessed using the Anticholinergic Cognitive Burden Scale. For fall risk assessment, the Aachen Falls Prevention Scale was also administered to each patient whose anticholinergic burden was determined in the prospective phase of the study. RESULTS A total of 601 patients were included. Risk of falls increased 2.50 times in patients with high anticholinergic burden (OR (95% CI) = 2.503 (1.071-5.852); p = 0.034), and the existing history of falls increased the risk of high anticholinergic burden 2.02 times (OR (95%CI) = 2.026 (1.059-3.876); p = 0.033). In addition, each unit increase in the fall scale score in the prospective phase increased the risk of high anticholinergic burden by 22% (p = 0.028). Anticholinergic burden was significantly reduced as a result of interventions by the clinical pharmacist in the prospective phase (p = 0.010). CONCLUSION Our study revealed that incorporating a clinical pharmacist in the handling of geriatric patients aids in the detection, reduction, and prevention of anticholinergic adverse effects.
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Affiliation(s)
- Hilal Gökçay Saz
- Department of Clinical Pharmacy, Faculty of Pharmacy, Hacettepe University, Ankara, 06230, Turkey
| | - Nadir Yalçın
- Department of Clinical Pharmacy, Faculty of Pharmacy, Hacettepe University, Ankara, 06230, Turkey.
| | - Kutay Demirkan
- Department of Clinical Pharmacy, Faculty of Pharmacy, Hacettepe University, Ankara, 06230, Turkey
| | - Meltem Gülhan Halil
- Division of Geriatric Medicine, Department of Internal Medine, Faculty of Medicine, Hacettepe University, Ankara, 06230, Turkey
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Vidal N, Brunet-Gouet E, Frileux S, Aouizerate B, Aubin V, Belzeaux R, Courtet P, D'Amato T, Dubertret C, Etain B, Haffen E, Januel D, Leboyer M, Lefrere A, Llorca PM, Marlinge E, Olié E, Polosan M, Schwan R, Walter M, Passerieux C, Roux P. Comparative analysis of anticholinergic burden scales to explain iatrogenic cognitive impairment and self-reported side effects in the euthymic phase of bipolar disorders: Results from the FACE-BD cohort. Eur Neuropsychopharmacol 2023; 77:67-79. [PMID: 37741163 DOI: 10.1016/j.euroneuro.2023.08.502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 08/21/2023] [Accepted: 08/29/2023] [Indexed: 09/25/2023]
Abstract
Bipolar disorders (BD) are characterized by cognitive impairment during the euthymic phase, to which treatments can contribute. The anticholinergic properties of medications, i.e., the ability of a treatment to inhibit cholinergic receptors, are associated with cognitive impairment in elderly patients and people with schizophrenia but this association has not been well characterized in individuals with remitted BD. Moreover, the validity of only one anticholinergic burden scale designed to assess the anticholinergic load of medications has been tested in BD. In a literature review, we identified 31 existing scales. We first measured the associations between 27 out of the 31 scales and objective cognitive impairment in bivariable regressions. We then adjusted the bivariable models with covariates: the scales significantly associated with cognitive impairment in bivariable and multiple logistic regressions were defined as having good concurrent validity to assess cognitive impairment. In a sample of 2,031 individuals with euthymic BD evaluated with a neuropsychological battery, two scales had good concurrent validity to assess cognitive impairment, whereas chlorpromazine equivalents, lorazepam equivalents, the number of antipsychotics, or the number of treatments had not. Finally, similar analyses with subjective anticholinergic side-effects as outcome variables reported 14 scales with good concurrent validity to assess self-reported peripheral anticholinergic side-effects and 13 to assess self-reported central anticholinergic side-effects. Thus, we identified valid scales to monitor the anticholinergic burden in BD, which may be useful in estimating iatrogenic cognitive impairment in studies investigating cognition in BD.
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Affiliation(s)
- N Vidal
- Fondation FondaMental, Créteil, France; Centre Hospitalier de Versailles, Service Hospitalo-Universitaire de Psychiatrie d'Adultes et d'Addictologie, Le Chesnay; Université Paris-Saclay, Université de Versailles Saint-Quentin-En-Yvelines; DisAP-DevPsy-CESP, INSERM UMR 1018, Villejuif, France.
| | - E Brunet-Gouet
- Fondation FondaMental, Créteil, France; Centre Hospitalier de Versailles, Service Hospitalo-Universitaire de Psychiatrie d'Adultes et d'Addictologie, Le Chesnay; Université Paris-Saclay, Université de Versailles Saint-Quentin-En-Yvelines; DisAP-DevPsy-CESP, INSERM UMR 1018, Villejuif, France
| | - S Frileux
- Fondation FondaMental, Créteil, France; Centre Hospitalier de Versailles, Service Hospitalo-Universitaire de Psychiatrie d'Adultes et d'Addictologie, Le Chesnay; Université Paris-Saclay, Université de Versailles Saint-Quentin-En-Yvelines; DisAP-DevPsy-CESP, INSERM UMR 1018, Villejuif, France
| | - B Aouizerate
- Fondation FondaMental, Créteil, France; Centre Hospitalier Charles Perrens, Laboratoire NutriNeuro (UMR INRA 1286), Université de Bordeaux, Bordeaux, France
| | - V Aubin
- Fondation FondaMental, Créteil, France; Pôle de Psychiatrie, Centre Hospitalier Princesse Grace, Monaco
| | - R Belzeaux
- Fondation FondaMental, Créteil, France; Pôle universitaire de psychiatrie, CHU de Montpellier, Montpellier, France; INT-UMR7289, CNRS Aix-Marseille Université, Marseille, France
| | - P Courtet
- Fondation FondaMental, Créteil, France; CHU Montpellier, Hôpital Lapeyronie, Psychiatric Emergency and Post Emergency Department, Pole Urgence; IGF, Université de Montpellier, CNRS, INSERM, Montpellier, France
| | - T D'Amato
- Fondation FondaMental, Créteil, France; University Lyon 1, Villeurbanne; INSERM, U1028; CNRS, UMR5292, Lyon Neuroscience Research Center, Psychiatric Disorders: From Resistance to Response Team, Lyon, France
| | - C Dubertret
- Fondation FondaMental, Créteil, France; AP-HP, Groupe Hospitalo-Universitaire AP-HP Nord, DMU ESPRIT, Service de Psychiatrie et Addictologie, Hôpital Louis Mourier, Colombes, France, Université de Paris, Inserm UMR1266, Sorbonne Paris Cité, Faculté de Médecine, Paris, France
| | - B Etain
- Fondation FondaMental, Créteil, France; Assistance publique des Hôpitaux de Paris, Groupe Hospitalo-universitaire AP-HP Nord, DMU Neurosciences, Hôpital Fernand Widal, Département de Psychiatrie et de Médecine Addictologique, Université de Paris, INSERM UMR-S 1144, Optimisation Thérapeutique en Neuropsychopharmacologie OTeN, Paris, France
| | - E Haffen
- Fondation FondaMental, Créteil, France; Service de Psychiatrie de l'Adulte, CIC-1431 INSERM, CHU de Besançon, Laboratoire de Neurosciences, UFC, UBFC, Besançon, France
| | - D Januel
- Fondation FondaMental, Créteil, France; Unité de Recherche Clinique, EPS Ville-Evrard, 93332 Neuilly-sur-Marne, France
| | - M Leboyer
- Fondation FondaMental, Créteil, France; Univ Paris Est Créteil, INSERM U955, IMRB, Translational NeuroPsychiatry Laboratory,; AP-HP, Hôpitaux Universitaires Henri Mondor, Département Médico-Universitaire de Psychiatrie et d'Addictologie (DMU IMPACT), Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Créteil, France
| | - A Lefrere
- Fondation FondaMental, Créteil, France; Pôle de Psychiatrie, Assistance Publique Hôpitaux de Marseille, Marseille, France, INT-UMR7289, CNRS Aix-Marseille Université, Marseille, France
| | - P M Llorca
- Fondation FondaMental, Créteil, France; Centre Hospitalier et Universitaire, Département de Psychiatrie, Université d'Auvergne, EA 7280, Clermont-Ferrand, France
| | - E Marlinge
- Fondation FondaMental, Créteil, France; Assistance publique des Hôpitaux de Paris, Groupe Hospitalo-universitaire AP-HP Nord, DMU Neurosciences, Hôpital Fernand Widal, Département de Psychiatrie et de Médecine Addictologique, Université de Paris, INSERM UMR-S 1144, Optimisation Thérapeutique en Neuropsychopharmacologie OTeN, Paris, France
| | - E Olié
- Fondation FondaMental, Créteil, France; CHU Montpellier, Hôpital Lapeyronie, Psychiatric Emergency and Post Emergency Department, Pole Urgence; IGF, Université de Montpellier, CNRS, INSERM, Montpellier, France
| | - M Polosan
- Fondation FondaMental, Créteil, France; Univ. Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences, Grenoble, France
| | - R Schwan
- Fondation FondaMental, Créteil, France; Université de Lorraine, Centre Psychothérapique de Nancy, Inserm U1254, Nancy, France
| | - M Walter
- Fondation FondaMental, Créteil, France; Service Hospitalo-Universitaire de Psychiatrie Générale et de Réhabilitation Psycho Sociale 29G01 et 29G02, CHRU de Brest, Hôpital de Bohars, Brest, France
| | - C Passerieux
- Fondation FondaMental, Créteil, France; Centre Hospitalier de Versailles, Service Hospitalo-Universitaire de Psychiatrie d'Adultes et d'Addictologie, Le Chesnay; Université Paris-Saclay, Université de Versailles Saint-Quentin-En-Yvelines; DisAP-DevPsy-CESP, INSERM UMR 1018, Villejuif, France
| | - P Roux
- Fondation FondaMental, Créteil, France; Centre Hospitalier de Versailles, Service Hospitalo-Universitaire de Psychiatrie d'Adultes et d'Addictologie, Le Chesnay; Université Paris-Saclay, Université de Versailles Saint-Quentin-En-Yvelines; DisAP-DevPsy-CESP, INSERM UMR 1018, Villejuif, France
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10
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Novella A, Elli C, Ianes A, Pasina L. Anticholinergic Burden and Cognitive Impairment in Nursing Homes: A Comparison of Four Anticholinergic Scales. Drugs Aging 2023; 40:1017-1026. [PMID: 37620654 DOI: 10.1007/s40266-023-01058-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Medications with anticholinergic effects are commonly used in nursing homes, and their cumulative effect is of particular concern for the risk of adverse effects on cognition. OBJECTIVE The relation between cognitive function and anticholinergic burden measured with four scales, the Anticholinergic Cognitive Burden (ACB) Scale, the Anticholinergic Risk Scale, the German Anticholinergic Burden Scale, and the CRIDECO Anticholinergic Load Scale, is assessed according to the hypothesis that a higher anticholinergic burden is associated with reduced cognitive performance. METHODS This retrospective cross-sectional multicenter study was conducted in a sample of Italian long-term-care nursing homes (NH). Sociodemographic details, diagnosis, and drug treatments of each NH resident were collected using medical records four times during 2018 and 2019. Cognitive status was rated with the Mini-Mental State Examination (MMSE). The prevalence of anticholinergic use and its burden were calculated referring to the last time point for each patient. A longitudinal analysis was done on NH residents with at least two MMSE between 2018 and 2019 to assess the relation between the anticholinergic load and decline in MMSE. The relationship between drug-related anticholinergic burden and cognitive performance was analyzed using Poisson regression model theory. Multivariate analyses were adjusted according to the known risk factors of reduced cognitive performance available [age, sex, history of stroke or transient ischemic attack (TIA), and number of non-anticholinergic drugs] and for cholinesterase inhibitors. In view of the high number of subjects with an MMSE score = 0 among residents with dementia, for this group a zero-inflated Poisson regression model was used to give more consistent results. The association of anticholinergic burden with mortality was examined from each patient's last visit using a multivariate logistic model adjusted for age, sex, and Charlson Comorbidity Index (CCI). RESULTS Among 1412 residents recruited, a clear direct relationship was found between higher anticholinergic burden and cognitive impairment only for the Anticholinergic Cognitive Burden Scale. Residents taking an anticholinergic who scored 5 or more had 2.5 points more decline than those not taking them (p < 0.001). Among residents without dementia there was a trend toward direct relationship for the Anticholinergic Cognitive Burden Scale and the Anticholinergic Risk Scale. Residents with higher scores had about 2 points more decline than residents not taking anticholinergic drugs. No relation was found between anticholinergic burden and cognitive decline or mortality. CONCLUSIONS The cumulative effect of medications with modest antimuscarinic activity may influence the cognitive performance of NH residents. The anticholinergic burden measured with the ACB scale should help identify NH residents who may benefit from reducing the anticholinergic burden. A clear direct relationship between anticholinergic burden and cognitive impairment was found only for the ACB Scale.
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Affiliation(s)
- Alessio Novella
- Laboratory of Clinical Pharmacology and Appropriateness of Drug Prescription, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri, 2, 20156, Milan, Italy
| | - Chiara Elli
- Laboratory of Clinical Pharmacology and Appropriateness of Drug Prescription, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri, 2, 20156, Milan, Italy
| | | | - Luca Pasina
- Laboratory of Clinical Pharmacology and Appropriateness of Drug Prescription, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri, 2, 20156, Milan, Italy.
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11
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Schulthess-Lisibach AE, Gallucci G, Benelli V, Kälin R, Schulthess S, Cattaneo M, Beeler PE, Csajka C, Lutters M. Predicting delirium in older non-intensive care unit inpatients: development and validation of the DELIrium risK Tool (DELIKT). Int J Clin Pharm 2023; 45:1118-1127. [PMID: 37061661 PMCID: PMC10600272 DOI: 10.1007/s11096-023-01566-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/01/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND Effective delirium prevention could benefit from automatic risk stratification of older inpatients using routinely collected clinical data. AIM Primary aim was to develop and validate a delirium prediction model (DELIKT) suitable for implementation in hospitals. Secondary aim was to select an anticholinergic burden scale as a predictor. METHOD We used one cohort for model development and another for validation with electronically available data collected within the first 24 h of admission. Included were patients aged ≥ 65, hospitalised ≥ 48 h with no stay > 24 h in an intensive care unit. Predictors, such as administrative and laboratory variables or an anticholinergic burden scale, were selected using a combination of feature selection filter method and forward/backward selection. The final model was based on logistic regression and the DELIKT was derived from the β-coefficients. We report the following performance measures: area under the curve, sensitivity, specificity and odds ratio. RESULTS Both cohorts were similar and included over 10,000 patients each (mean age 77.6 ± 7.6 years) with 11% experiencing delirium. The model included nine variables: age, medical department, dementia, hemi-/paraplegia, catheterisation, potassium, creatinine, polypharmacy and the anticholinergic burden measured with the Clinician-rated Anticholinergic Scale (CrAS). The external validation yielded an AUC of 0.795. With a cut-off at 20 points in the DELIKT, we received a sensitivity of 79.7%, specificity of 62.3% and an odds ratio of 5.9 (95% CI 5.2, 6.7). CONCLUSION The DELIKT is a potentially automatic tool with predictors from standard care including the CrAS to identify patients at high risk for delirium.
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Affiliation(s)
- Angela E Schulthess-Lisibach
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, University Hospital and University of Lausanne, Rue du Bugnon 17, 1005, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, Écublens, Switzerland
| | - Giulia Gallucci
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
| | - Valérie Benelli
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
| | - Ramona Kälin
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
| | - Sven Schulthess
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
| | - Marco Cattaneo
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, Basel, Switzerland
| | - Patrick E Beeler
- Division of Occupational and Environmental Medicine, Epidemiology, Biostatistics and Prevention Institute, University of Zurich & University Hospital Zurich, Zurich, Switzerland
- Center for Primary and Community Care, University of Lucerne, Lucerne, Switzerland
| | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, University Hospital and University of Lausanne, Rue du Bugnon 17, 1005, Lausanne, Switzerland.
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland.
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, Écublens, Switzerland.
| | - Monika Lutters
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
- Swiss Federal Institute of Technology, Zurich, Switzerland
- Hospital Pharmacy, Cantonal Hospital of Aarau, Aarau, Switzerland
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12
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Selvaggi P, Fazio L, Toro VD, Mucci A, Rocca P, Martinotti G, Cascino G, Siracusano A, Zeppegno P, Pergola G, Bertolino A, Blasi G, Galderisi S. Effect of anticholinergic burden on brain activity during Working Memory and real-world functioning in patients with schizophrenia. Schizophr Res 2023; 260:76-84. [PMID: 37633126 DOI: 10.1016/j.schres.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 06/30/2023] [Accepted: 08/13/2023] [Indexed: 08/28/2023]
Abstract
Cognitive impairment has been associated with poor real-world functioning in patients with Schizophrenia. Previous studies have shown that pharmacological treatment with anticholinergic properties may contribute to cognitive impairment in Schizophrenia. We investigated the effect of the anticholinergic burden (ACB) on brain activity, cognition, and real-world functioning in Schizophrenia. We hypothesized that greater ACB would be associated with altered brain activity along with poorer cognitive performance and lower real-world functioning. A sample of 100 patients with a diagnosis of schizophrenia or schizoaffective disorder was recruited in the naturalistic multicenter study of the Italian Network for Research on Psychoses (NIRP) across 7 centres. For each participant, ACB was evaluated using the Anticholinergic Cognitive Burden scale. The association of ACB with brain function was assessed using BOLD fMRI during the N-Back Working Memory (WM) task in a nested cohort (N = 31). Real-world functioning was assessed using the Specific Level of Functioning (SLOF) scale. Patients with high ACB scores (≥3) showed lower brain activity in the WM frontoparietal network (TFCE corrected alpha <0.05) and poorer cognitive performance (p = 0.05) than patients with low ACB scores (<3). Both effects were unaffected by demographic characteristics, clinical severity, and antipsychotic dosage. Moreover, patients with high ACB showed poorer real-world functioning than patients with lower ACB (p = 0.03). Our results suggest that ACB in Schizophrenia is associated with impaired WM and abnormal underlying brain function along with reduced real-world functioning. Clinical practice should consider the potential adverse cognitive effects of ACB in the treatment decision-making process.
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Affiliation(s)
- Pierluigi Selvaggi
- Department of Translational Biomedicine and Neuroscience, University of Bari "Aldo Moro", Bari, Italy; Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Leonardo Fazio
- Department of Translational Biomedicine and Neuroscience, University of Bari "Aldo Moro", Bari, Italy; Department of Medicine and Surgery, LUM University, Casamassima, Bari, Italy
| | - Veronica Debora Toro
- Department of Translational Biomedicine and Neuroscience, University of Bari "Aldo Moro", Bari, Italy
| | - Armida Mucci
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paola Rocca
- Department of Neuroscience, Section of Psychiatry, University of Turin, Turin, Italy
| | - Giovanni Martinotti
- Department of Neuroscience and Imaging, G. D'Annunzio University, Chieti, Italy
| | - Giammarco Cascino
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Section of Neuroscience, University of Salerno, Salerno, Italy
| | - Alberto Siracusano
- Department of Systems Medicine, Psychiatry and Clinical Psychology Unit, Tor Vergata University of Rome, Rome, Italy
| | - Patrizia Zeppegno
- Department of Translational Medicine, Psychiatric Unit, University of Eastern Piedmont, Novara, Italy
| | - Giulio Pergola
- Department of Translational Biomedicine and Neuroscience, University of Bari "Aldo Moro", Bari, Italy
| | - Alessandro Bertolino
- Department of Translational Biomedicine and Neuroscience, University of Bari "Aldo Moro", Bari, Italy
| | - Giuseppe Blasi
- Department of Translational Biomedicine and Neuroscience, University of Bari "Aldo Moro", Bari, Italy.
| | - Silvana Galderisi
- Department of Psychiatry, University of Campania "Luigi Vanvitelli", Naples, Italy
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13
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Bishara D, Riaz S, Sauer J, Mueller C, Gee S, Taylor D, Wilcha RJ, Edwards M, Beehuspoteea N, Mallia AMB, Brook J, Balasundaram B, Harwood D, Funnell N, Strydom A, Stewart R. A tool for safer prescribing in vulnerable adults: the continuing development of the Medichec app and website. BJPsych Bull 2023:1-7. [PMID: 37671832 DOI: 10.1192/bjb.2023.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2023] Open
Abstract
AIMS AND METHOD Adverse effects are a common concern when prescribing and reviewing medication, particularly in vulnerable adults such as older people and those with intellectual disability. This paper describes the development of an app giving information on side-effects, called Medichec, and provides a description of the processes involved in its development and how drugs were rated for each side-effect. Medications with central anticholinergic action, dizziness, drowsiness, hyponatraemia, QTc prolongation, bleeding and constipation were identified using the British National Formulary (BNF) and frequency of occurrence of these effects was determined using the BNF, product information and electronic searches, including PubMed. RESULTS Medications were rated using a traffic light system according to how commonly the adverse effect was known to occur or the severity of the effect. CLINICAL IMPLICATIONS Medichec can facilitate access to side-effects information for multiple medications, aid clinical decision-making, optimise treatment and improve patient safety in vulnerable adults.
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Affiliation(s)
- Delia Bishara
- Mental Health of Older Adults and Dementia Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Sahar Riaz
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Justin Sauer
- Mental Health of Older Adults and Dementia Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Christoph Mueller
- Mental Health of Older Adults and Dementia Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Siobhan Gee
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - David Taylor
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Robyn-Jenia Wilcha
- Mental Health of Older Adults and Dementia Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Millie Edwards
- Mental Health of Older Adults and Dementia Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Nirja Beehuspoteea
- Mental Health of Older Adults and Dementia Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Anne Marie Bonnici Mallia
- Mental Health of Older Adults and Dementia Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Jennifer Brook
- Mental Health of Older Adults and Dementia Department, South London and Maudsley NHS Foundation Trust, London, UK
| | | | - Daniel Harwood
- Mental Health of Older Adults and Dementia Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Nicola Funnell
- Mental Health of Older Adults and Dementia Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Andre Strydom
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Robert Stewart
- Mental Health of Older Adults and Dementia Department, South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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Roncal-Belzunce V, Cedeño-Veloz BA, Elcano RSM, Gutiérrez-Valencia M, Izquieta VR, Guruceaga-Eguillor I, Marín-Epelde I, Echeverria-Beistegui I, Sánchez-Latorre M, Galbete A, Garaioa-Aramburu K, Martínez-Velilla N. Cognitive and functional trajectories in geriatric outpatients after a pharmacologic multidisciplinary intervention: A study protocol. Rev Esp Geriatr Gerontol 2023; 58:101386. [PMID: 37523939 DOI: 10.1016/j.regg.2023.101386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 05/14/2023] [Accepted: 07/07/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Polypharmacy is a common condition among older adults and is associated with adverse drug reactions and health outcomes, including falls, functional and cognitive impairment, and frailty. METHODS A prospective observational study will be conducted on older adults with polypharmacy. The aim is to assess the impact of a specialized outpatient clinic focused on pharmacotherapy optimization recently integrated into daily clinical practice in a Spanish public tertiary teaching hospital on patients' functional and cognitive abilities. Patients who attend a first consultation and meet inclusion criteria (≥75 years old, have a life expectancy≥3 months, and polypharmacy (≥5 prescribed medications) will be invited to participate in the study, until reach a calculated sample size of 104 participants. Patients will be excluded if they are enrolled in a clinical trial related to medication or in the event of a no-show or cancellation of the appointment at the first visit. Participants will receive usual care: a first consultation including multidisciplinary pharmacological optimization in the context of a CGA and subsequent face-to-face and/or telephone follow-up (∼3 and ∼6 months). The primary endpoint will be the functional (Barthel index) and cognitive change in capacities (IPCR - Índice de Incapacidad psíquica de la Cruz Roja). Secondary endpoints include medication changes, changes in patients' quality of life, rate of falling, and use of healthcare resources. DISCUSSION We expect that the close collaboration between professionals from different disciplines working together will be an effective strategy to improve the functional and cognitive abilities of older adults. TRIAL REGISTRATION ClinicalTrials.gov: NCT05408598 (March 1, 2022).
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Affiliation(s)
- Victoria Roncal-Belzunce
- Geriatric Unit, Navarrabiomed, Public University of Navarra (UPNA), Navarra Health Research Institute (IdisNa), Pamplona, Navarra, Spain.
| | - Bernardo Abel Cedeño-Veloz
- Geriatric Unit, Navarrabiomed, Public University of Navarra (UPNA), Navarra Health Research Institute (IdisNa), Pamplona, Navarra, Spain; Department of Geriatrics, Hospital Universitario de Navarra (HUN), Pamplona, Spain
| | | | - Marta Gutiérrez-Valencia
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain; Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | | | | | - Itxaso Marín-Epelde
- Geriatric Unit, Navarrabiomed, Public University of Navarra (UPNA), Navarra Health Research Institute (IdisNa), Pamplona, Navarra, Spain; Department of Geriatrics, Hospital Universitario de Navarra (HUN), Pamplona, Spain
| | - Iciar Echeverria-Beistegui
- Geriatric Unit, Navarrabiomed, Public University of Navarra (UPNA), Navarra Health Research Institute (IdisNa), Pamplona, Navarra, Spain
| | | | - Arkaitz Galbete
- Geriatric Unit, Navarrabiomed, Public University of Navarra (UPNA), Navarra Health Research Institute (IdisNa), Pamplona, Navarra, Spain
| | | | - Nicolás Martínez-Velilla
- Geriatric Unit, Navarrabiomed, Public University of Navarra (UPNA), Navarra Health Research Institute (IdisNa), Pamplona, Navarra, Spain; Department of Geriatrics, Hospital Universitario de Navarra (HUN), Pamplona, Spain
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15
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Al-Azayzih A, Jarab AS, Bani-Ahmad E, Smadi S, Kharaba Z, Al-Kubaisi KA. Anticholinergic burden risk and prevalence of medications carrying anticholinergic properties in elderly cancer patients in Jordan. Saudi Pharm J 2023; 31:101710. [PMID: 37559866 PMCID: PMC10406854 DOI: 10.1016/j.jsps.2023.101710] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/20/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Geriatric cancer patients are susceptible to adverse drug events due to the complexity of their chemotherapy regimens and collateral treatments for their comorbid conditions. Prescribing medications with anticholinergic burden characteristics can complicate their condition, leading to negative impacts on their health outcomes and quality of life, including an increase in adverse drug event frequency, physical and cognitive impairments. OBJECTIVE This study aims to examine the prevalence of anticholinergic prescribing and identify the cumulative anticholinergic load risk associated with drugs prescribed to elderly cancer patients. Also, to identify the predictors that might lead to raised anticholinergic burden in these patients. METHODOLOGY This retrospective cross-sectional study included elderly patients (age ≥ 65) diagnosed with cancer and admitted to the adult oncology unit at King Abdullah University Hospital (KAUH) in Jordan during the period between (January 1st, 2019, and January 1st, 2022). The medication charts of 420 patients were evaluated for study outcomes. RESULTS Of the total subjects, females represented 49.3%, and the average age was 72.95 (SD = 7.33). A total of 354 (84.3%) patients were prescribed at least one drug carrying anticholinergic burden properties. Median for anticholinergic medications was 3 (IQR = 4). Our study found that 194 (46.2%) patients were at a high risk of adverse events associated with anticholinergic load (cumulative score ≥ 3). Metoclopramide, furosemide, and tramadol were the most frequently prescribed drugs with anticholinergic properties. Alimentary tract drugs with anticholinergic action were the most commonly encountered items in our study population. CONCLUSION Our study revealed a significantly high prevalence of anticholinergic prescribing among elderly cancer patients. Nearly half of the patients were at high risk of developing serious effects related to anticholinergic activity from the drugs administered. Polypharmacy was strongly associated with increased anticholinergic burden score. Evidence-based recommendations utilizing prescribing strategies for safer alternatives and deprescribing of inappropriate medications could reduce such inappropriate prescribing.
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Affiliation(s)
- Ahmad Al-Azayzih
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology. P.O. Box 3030, Irbid 22110, Jordan
| | - Anan S. Jarab
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology. P.O. Box 3030, Irbid 22110, Jordan
- College of Pharmacy, AL Ain University, Abu Dhabi, United Arab Emirates
| | - Enas Bani-Ahmad
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology. P.O. Box 3030, Irbid 22110, Jordan
| | - Saja Smadi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology. P.O. Box 3030, Irbid 22110, Jordan
| | - Zelal Kharaba
- College of Pharmacy, AL Ain University, Abu Dhabi, United Arab Emirates
- Honorary Associate Lecturer, Faculty of Medical Sciences, Newcastle University, Newcastle upon tyne, UK
| | - Khalid A. Al-Kubaisi
- Department of Pharmacy Practice and Pharmacotherapeutics, College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
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16
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Michael HU, Enechukwu O, Brouillette MJ, Tamblyn R, Fellows LK, Mayo NE. The Prognostic Utility of Anticholinergic Burden Scales: An Integrative Review and Gap Analysis. Drugs Aging 2023; 40:763-783. [PMID: 37462902 DOI: 10.1007/s40266-023-01050-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Anticholinergic drugs are commonly prescribed, especially to older adults. Anticholinergic burden scales (ABS) have been used to evaluate the cumulative effects of multiple anticholinergics. However, studies have shown inconsistent results regarding the association between anticholinergic burden assessed with ABS and adverse clinical outcomes such as cognitive impairment, functional decline, and frailty. This review aims to identify gaps in research on the development, validation, and evaluation of ABS, and provide recommendations for future studies. METHOD A comprehensive search of five databases (MEDLINE, Embase, PsychInfo, CINAHL, CENTRAL) was conducted for relevant studies published from inception until 25 May 2023. Two reviewers screened for eligibility and assessed the quality of studies using different tools based on the study design and stage of the review framework. Research evidence was evaluated, and gaps were identified and grouped into evidence, knowledge, and methodological gaps, using evidence tables to summarize data. RESULTS Several evidence, knowledge, and methodological gaps in existing development, validation, and evaluation studies of ABS were identified. There is no universally accepted scale, and there is a need to define a clinically relevant threshold for measuring total anticholinergic burden. The current evidence has limitations, underrepresenting low- and middle-income countries, younger individuals, and populations with cognitive disabilities. The impact of anticholinergic burden on frailty is also understudied. Existing evaluation studies provide limited evidence on the benefit of reducing anticholinergic burden on clinical outcomes or the safety of anticholinergic deprescribing. There is also uncertainty regarding optimal reduction, clinically significant anticholinergic burden thresholds, and cost effectiveness. CONCLUSIONS Future research recommendations to bridge knowledge gaps include developing a risk assessment framework, refining ABS scales, establishing a standardized consensus scale, and creating a longitudinal measure of cumulative anticholinergic risk. Strategies to minimize bias, consider frailty, and promote multidisciplinary and multinational collaborations are also necessary to improve patient outcomes.
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Affiliation(s)
- Henry Ukachukwu Michael
- Division of Experimental Medicine, McGill University, Montreal, QC, Canada.
- Centre for Outcomes Research & Evaluation, Research Institute of McGill University Health Centre (RI-MUHC), 5252 de Maisonneuve, 2B:43, Montréal, QC, H4A 3S5, Canada.
| | | | - Marie-Josée Brouillette
- Department of Psychiatry, Faculty of Medicine, McGill University, Montreal, QC, Canada
- Chronic Viral Illness Service, McGill University Health Centre (MUHC), Montreal, QC, Canada
- Infectious Diseases and Immunity in Global Health Program, MUHC-RI, Montreal, QC, Canada
| | - Robyn Tamblyn
- Division of Experimental Medicine, McGill University, Montreal, QC, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Lesley K Fellows
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Nancy E Mayo
- Division of Experimental Medicine, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research & Evaluation, Research Institute of McGill University Health Centre (RI-MUHC), 5252 de Maisonneuve, 2B:43, Montréal, QC, H4A 3S5, Canada
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
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17
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Bishara D. Managing drugs with anticholinergic activity. Drug Ther Bull 2023; 61:135-139. [PMID: 37648260 DOI: 10.1136/dtb.2022.000066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Over the past two decades, considerable data have emerged on an association between drugs with anticholinergic activity and serious adverse effects in older people. Well-recognised anticholinergic adverse effects include dry mouth, blurred vision, constipation and urinary retention. Of particular concern is the potential impact on cognitive function with several studies showing that long-term use of medicines with anticholinergic activity is associated with worsening of cognitive function, increased incidence of dementia and increased mortality. This article gives an overview of the evidence, discusses some of the tools used to identify high-risk drugs and highlights issues to consider when prescribing drugs with anticholinergic activity with a view to reducing potential risks in older people and those at highest risk of cognitive impairment.
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Affiliation(s)
- Delia Bishara
- Mental Health of Older Adults and Dementia, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Rube T, Ecorcheville A, Londos E, Modig S, Johansson P. Development of the Swedish anticholinergic burden scale (Swe-ABS). BMC Geriatr 2023; 23:518. [PMID: 37626293 PMCID: PMC10464171 DOI: 10.1186/s12877-023-04225-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Drugs with anticholinergic properties are associated with cognitive adverse effects, especially in patients vulnerable to central muscarinic antagonism. A variety of drugs show weak, moderate or strong anticholinergic effects. Therefore, the cumulative anticholinergic burden should be considered in patients with cognitive impairment. This study aimed to develop a Swedish Anticholinergic Burden Scale (Swe-ABS) to be used in health care and research. METHODS A systematic literature review was conducted in PubMed and Ovid Embase to identify previously published tools quantifying anticholinergic drug burden (i.e., exposure). Drugs and grading scores (0-3, no to high anticholinergic activity) were extracted from identified lists. Enteral and parenteral drugs authorized in Sweden were included. Drugs with conflicting scores in the existing lists were assessed by an expert group. Two drugs that were not previously assessed were also added to the evaluation process. RESULTS The systematic literature search identified the following nine anticholinergic burden scales: Anticholinergic Activity Scale, Anticholinergic Burden Classification, updated Anticholinergic Cognitive Burden scale, Anticholinergic Drug Scale, Anticholinergic Load Scale, Anticholinergic Risk Scale, updated Clinician-rated Anticholinergic Scale, German Anticholinergic Burden Scale and Korean Anticholinergic Burden Scale. A list of drugs with significant anticholinergic effects provided by The Swedish National Board of Health and Welfare was included in the process. The suggested Swe-ABS consists of 104 drugs scored as having weak, moderate or strong anticholinergic effects. Two hundred and fifty-six drugs were listed as having no anticholinergic effects based on evaluation in previous scales. In total, 62 drugs were assessed by the expert group. CONCLUSIONS Swe-ABS is a simplified method to quantify the anticholinergic burden and is easy to use in clinical practice. Publication of this scale might make clinicians more aware of drugs with anticholinergic properties and patients' total anticholinergic burden. Further research is needed to validate the Swe-ABS and evaluate anticholinergic exposure versus clinically significant outcomes.
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Affiliation(s)
- Tanja Rube
- Memory Clinic, Ängelholm, SE-262 52, Sweden.
- Cognitive Disorders Research Unit, Department of Clinical Sciences, Lund University, Malmö, Sweden.
| | | | - Elisabet Londos
- Memory Clinic, Ängelholm, SE-262 52, Sweden
- Cognitive Disorders Research Unit, Department of Clinical Sciences, Lund University, Malmö, Sweden
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
| | - Sara Modig
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Primary Healthcare, Skåne County, Lund, Sweden
- Department of Medicines Management and Informatics in Skåne County, Malmö, Sweden
| | - Per Johansson
- Department of Clinical Sciences, Lund University, Helsingborg, Sweden
- Department of Internal Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Roytman S, Paalanen R, Griggs A, David S, Pongmala C, Koeppe RA, Scott PJH, Marusic U, Kanel P, Bohnen NI. Cholinergic system correlates of postural control changes in Parkinson's disease freezers. Brain 2023; 146:3243-3257. [PMID: 37086478 PMCID: PMC10393403 DOI: 10.1093/brain/awad134] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/16/2023] [Accepted: 04/06/2023] [Indexed: 04/24/2023] Open
Abstract
Postural instability and freezing of gait are the most debilitating dopamine-refractory motor impairments in advanced stages of Parkinson's disease because of increased risk of falls and poorer quality of life. Recent findings suggest an inability to efficaciously utilize vestibular information during static posturography among people with Parkinson's disease who exhibit freezing of gait, with associated changes in cholinergic system integrity as assessed by vesicular acetylcholine transporter PET. There is a lack of adequate understanding of how postural control varies as a function of available sensory information in patients with Parkinson's disease with freezing of gait. The goal of this cross-sectional study was to examine cerebral cholinergic system changes that associate with inter-sensory postural control processing features as assessed by dynamic computerized posturography and acetylcholinesterase PET. Seventy-five participants with Parkinson's disease, 16 of whom exhibited freezing of gait, underwent computerized posturography on the NeuroCom© Equitest sensory organization test platform, striatal dopamine, and acetylcholinesterase PET scanning. Findings demonstrated that patients with Parkinson's disease with freezing of gait have greater difficulty maintaining balance in the absence of reliable proprioceptive cues as compared to those without freezing of gait [β = 0.28 (0.021, 0.54), P = 0.034], an effect that was independent of disease severity [β = 0.16 (0.062, 0.26), P < 0.01] and age [β = 0.092 (-0.005, 0.19), P = 0.062]. Exploratory voxel-based analysis revealed an association between postural control and right hemispheric cholinergic network related to visual-vestibular integration and self-motion perception. High anti-cholinergic burden predicted postural control impairment in a manner dependent on right hemispheric cortical cholinergic integrity [β = 0.34 (0.065, 0.61), P < 0.01]. Our findings advance the perspective that cortical cholinergic system might play a role in supporting postural control after nigro-striatal dopaminergic losses in Parkinson's disease. Failure of cortex-dependent visual-vestibular integration may impair detection of postural instability in absence of reliable proprioceptive cues. Better understanding of how the cholinergic system plays a role in this process may augur novel treatments and therapeutic interventions to ameliorate debilitating symptoms in patients with advanced Parkinson's disease.
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Affiliation(s)
- Stiven Roytman
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Rebecca Paalanen
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Alexis Griggs
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Parkinson’s Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48109, USA
| | - Simon David
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Chatkaew Pongmala
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Morris K. Udall Center of Excellence for Parkinson’s Disease Research, University of Michigan, Ann Arbor, MI 48109, USA
| | - Robert A Koeppe
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Morris K. Udall Center of Excellence for Parkinson’s Disease Research, University of Michigan, Ann Arbor, MI 48109, USA
| | - Peter J H Scott
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Uros Marusic
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Institute for Kinesiology Research, Science and Research Centre Koper, 6000 Koper, Slovenia
- Department of Health Sciences, Alma Mater Europaea—ECM, 2000 Maribor, Slovenia
| | - Prabesh Kanel
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Parkinson’s Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48109, USA
- Morris K. Udall Center of Excellence for Parkinson’s Disease Research, University of Michigan, Ann Arbor, MI 48109, USA
| | - Nicolaas I Bohnen
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA
- Parkinson’s Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48109, USA
- Morris K. Udall Center of Excellence for Parkinson’s Disease Research, University of Michigan, Ann Arbor, MI 48109, USA
- Neurology Service and GRECC, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA
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20
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Layfield E, Hwa TP, Quimby AE, Brant JA, Bigelow D, Ruckenstein MJ, Eliades SJ. Impact of Anticholinergic Medications on Speech Perception Performance after Cochlear Implantation. Otol Neurotol 2023; 44:e364-e368. [PMID: 37205865 DOI: 10.1097/mao.0000000000003896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
OBJECTIVE To identify and characterize the impact of anticholinergic medications, which have known adverse effects on cognition in older adults, on speech perception after cochlear implantation. STUDY DESIGN Retrospective cohort. SETTING Tertiary referral center. SUBJECT POPULATION Adult patients who underwent cochlear implantation between January 2010 and September 2020 with speech perception scores at 3, 6, and 12 months. INTERVENTIONS Anticholinergic burden of patients' prescribed medications. MAIN OUTCOME MEASURES AzBio speech perception scores after implantation. RESULTS One hundred twenty-six patients had documented AzBio in quiet speech perception score at all three postactivation time points. Patients were divided into three groups by anticholinergic burden (ACB) score, including ACB = 0 (90 patients), 1 (23 patients), and ≥2 (13 patients). There was no statistically significant difference between ACB groups in audiologic performance at candidacy testing ( p = 0.77) or at 3 months after implantation ( p = 0.13). Beginning at 6 months, a lower mean AzBio was seen in patients with higher ACB scores (68% ACB = 0; 62% ACB = 1; 48.1% ACB ≥ 2; p = 0.03). At 12 months, there were further differences between the groups (71.0% ACB = 0, 69.5% ACB = 1, 48.0% ACB ≥2, p < 0.01). Controlling for the effects of age using multivariate linear regression showed persistent effects of ACB score on learning-related AzBio improvements. Comparatively, the negative impact of a single ACB score point was equivalent to nearly 10 years of aging ( p = 0.03). CONCLUSIONS Increased ACB is associated with worse speech perception scores after cochlear implantation, an effect that persists even when accounting for patient age, suggesting that these medications may have cognitive and learning effects that reduce cochlear implant performance.
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Affiliation(s)
- Eleanor Layfield
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Tiffany Peng Hwa
- Department of Otorhinolaryngology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Alexandra E Quimby
- Department of Otorhinolaryngology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jason A Brant
- Department of Otorhinolaryngology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Douglas Bigelow
- Department of Otorhinolaryngology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael J Ruckenstein
- Department of Otorhinolaryngology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Steven J Eliades
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina
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Poonawalla IB, Xu Y, Gaddy R, James A, Ruble M, Burns S, Dixon SW, Suehs BT. Anticholinergic exposure and its association with dementia/Alzheimer's disease and mortality in older adults. BMC Geriatr 2023; 23:401. [PMID: 37391728 PMCID: PMC10311860 DOI: 10.1186/s12877-023-04095-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/07/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Use of anticholinergic (ACH) medications is associated with increased risk of cognitive decline in the elderly. However, little is known about this association from a health plan perspective. METHODS This retrospective cohort study used the Humana Research Database to identify individuals with at least one ACH medication dispensed in 2015. Patients were followed until incidence of dementia/Alzheimer's disease, death, disenrollment or end of December 2019. Multivariate Cox regression models were used to assess the association between ACH exposure and study outcomes, adjusting for demographics and clinical characteristics. RESULTS A total of 12,209 individuals with no prior ACH use or dementia/Alzheimer's disease diagnosis were included. As ACH polypharmacy increased (i.e., from no ACH exposure, to one, two, three, and four or more ACH medications), there was a stair-step increase in the incidence rate of dementia/Alzheimer's disease (15, 30, 46, 56 and 77 per 1,000 person-years of follow-up) and in the incidence of mortality (19, 37, 80, 115 and 159 per 1,000 person-years of follow-up). After adjusting for confounders, ACH exposure to one, two, three and four or more ACH medications was associated with a 1.6 (95% CI 1.4-1.9), 2.1 (95% CI 1.7-2.8), 2.6 (95% CI 1.5-4.4), and 2.6 (95% CI 1.1-6.3) times, respectively, increased risk of a dementia/Alzheimer's disease diagnosis compared to periods of no ACH exposure. ACH exposure to one, two, three and four or more medications was associated with a 1.4 (95% CI 1.2-1.6), 2.6 (95% CI 2.1-3.3), 3.8 (95% CI 2.6-5.4), and 3.4 (95% CI 1.8-6.4) times, respectively, increased risk of mortality compared to periods of no ACH exposure. CONCLUSIONS Reducing ACH exposure may potentially minimize long-term adverse effects in older adults. Results suggest populations which may benefit from targeted interventions to reduce ACH polypharmacy.
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Affiliation(s)
- Insiya B Poonawalla
- Humana Healthcare Research, Humana Inc., 500 W Main St, Louisville, KY, 40202, USA.
| | - Yihua Xu
- Humana Healthcare Research, Humana Inc., 500 W Main St, Louisville, KY, 40202, USA
| | - Rainelle Gaddy
- Humana Pharmacy Solutions, Humana Inc., 500 W Main St, Louisville, KY, 40202, USA
| | - Alex James
- Humana Pharmacy Solutions, Humana Inc., 500 W Main St, Louisville, KY, 40202, USA
| | - Matt Ruble
- Humana Pharmacy Solutions, Humana Inc., 500 W Main St, Louisville, KY, 40202, USA
| | - Salina Burns
- Humana Pharmacy Solutions, Humana Inc., 500 W Main St, Louisville, KY, 40202, USA
| | - Suzanne W Dixon
- Humana Healthcare Research, Humana Inc., 500 W Main St, Louisville, KY, 40202, USA
| | - Brandon T Suehs
- Humana Healthcare Research, Humana Inc., 500 W Main St, Louisville, KY, 40202, USA
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Mahmoudi R, Novella JL, Laurent-Badr S, Boulahrouz S, Tran D, Morrone I, Jaïdi Y. Cholinergic Antagonists and Behavioral Disturbances in Neurodegenerative Diseases. Int J Mol Sci 2023; 24:ijms24086921. [PMID: 37108085 PMCID: PMC10138684 DOI: 10.3390/ijms24086921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/26/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
Cholinergic antagonists interfere with synaptic transmission in the central nervous system and are involved in pathological processes in patients with neurocognitive disorders (NCD), such as behavioral and psychological symptoms of dementia (BPSD). In this commentary, we will briefly review the current knowledge on the impact of cholinergic burden on BPSD in persons with NCD, including the main pathophysiological mechanisms. Given the lack of clear consensus regarding symptomatic management of BPSD, special attention must be paid to this preventable, iatrogenic condition in patients with NCD, and de-prescription of cholinergic antagonists should be considered in patients with BPSD.
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Affiliation(s)
- Rachid Mahmoudi
- Department of Geriatric and Internal Medicine, Reims University Hospitals, Maison Blanche Hospital, 51092 Reims, France
- UR 3797 Vieillissement, Fragilité (VieFra), Faculty of Medicine, University of Reims Champagne-Ardenne, 51687 Reims, France
| | - Jean Luc Novella
- Department of Geriatric and Internal Medicine, Reims University Hospitals, Maison Blanche Hospital, 51092 Reims, France
- UR 3797 Vieillissement, Fragilité (VieFra), Faculty of Medicine, University of Reims Champagne-Ardenne, 51687 Reims, France
| | - Sarah Laurent-Badr
- Department of Geriatric and Internal Medicine, Reims University Hospitals, Maison Blanche Hospital, 51092 Reims, France
| | - Sarah Boulahrouz
- Department of Geriatric and Internal Medicine, Reims University Hospitals, Maison Blanche Hospital, 51092 Reims, France
- UR 3797 Vieillissement, Fragilité (VieFra), Faculty of Medicine, University of Reims Champagne-Ardenne, 51687 Reims, France
| | - David Tran
- Department of Geriatric and Internal Medicine, Reims University Hospitals, Maison Blanche Hospital, 51092 Reims, France
| | - Isabella Morrone
- Department of Geriatric and Internal Medicine, Reims University Hospitals, Maison Blanche Hospital, 51092 Reims, France
- Cognition Health and Society Laboratory (C2S-EA 6291), Faculty of Medicine, University of Reims Champagne-Ardenne, 51687 Reims, France
| | - Yacine Jaïdi
- Department of Geriatric and Internal Medicine, Reims University Hospitals, Maison Blanche Hospital, 51092 Reims, France
- UR 3797 Vieillissement, Fragilité (VieFra), Faculty of Medicine, University of Reims Champagne-Ardenne, 51687 Reims, France
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Wong HL, Weaver C, Marsh L, Mon KO, Dapito JM, Amin FR, Chauhan R, Mandal AKJ, Missouris CG. Polypharmacy and cumulative anticholinergic burden in older adults hospitalized with fall. Aging Med (Milton) 2023. [DOI: 10.1002/agm2.12250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Affiliation(s)
- Ho Lun Wong
- Wexham Park Hospital, Frimley Health NHS Trust Slough UK
| | - Claire Weaver
- Wexham Park Hospital, Frimley Health NHS Trust Slough UK
| | - Lauren Marsh
- Wexham Park Hospital, Frimley Health NHS Trust Slough UK
| | - Khine Oo Mon
- Wexham Park Hospital, Frimley Health NHS Trust Slough UK
| | - John M. Dapito
- Wexham Park Hospital, Frimley Health NHS Trust Slough UK
| | - Fouad R. Amin
- Wexham Park Hospital, Frimley Health NHS Trust Slough UK
- Al Azhar University Cairo Egypt
| | - Rahul Chauhan
- Wexham Park Hospital, Frimley Health NHS Trust Slough UK
| | | | - Constantinos G. Missouris
- Wexham Park Hospital, Frimley Health NHS Trust Slough UK
- University of Nicosia Medical School Nicosia Cyprus
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24
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Birkmose ALL, Kristensen PK, Madsen M, Pedersen AB, Hjelholt TJ. Association of anticholinergic drug use with postoperative mortality among patients with hip fracture. A nationwide cohort study. Arch Gerontol Geriatr 2023; 113:105017. [PMID: 37116258 DOI: 10.1016/j.archger.2023.105017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 03/30/2023] [Accepted: 04/02/2023] [Indexed: 04/05/2023]
Abstract
PURPOSE Anticholinergic (AC) drugs are associated with various determinantal outcomes. Data regarding the effect of AC drugs on mortality among geriatric hip fracture patients are limited and inconsistent. METHODS Using Danish health registries, we identified 31,443 patients aged ≥65 years undergoing hip fracture surgery. AC burden was assessed 90 days before surgery by the Anticholinergic Cognitive Burden (ACB) score and number of AC drugs. Logistic and Cox regression producing odds ratios (OR) and hazard ratios (HR) for 30- and 365- day mortality, adjusting for age, sex, and comorbidities were computed. RESULTS AC drugs were redeemed by 42% of patients. The 30-day mortality increased from 7% for patients with ACB score of 0 to 16% for patients with ACB score of ≥5, corresponding to an adjusted OR 2.5 (CI: 2.0-3.1). The equivalent adjusted HR for 365-mortality was 1.9 (CI: 1.6-2.1). Using count of AC drugs as exposure we found a stepwise increase in ORs and HRs with increased number of AC drugs; Compared to non-users, adjusted ORs for 30-days mortality were 1.6 (CI: 1.4-1.7), 1.9 (CI: 1.7-2.1), and 2.3 (CI: 1.9-2.7) for users of 1, 2 and 3+ AC drugs. HRs for 365-day mortality were 1.4 (CI: 1.3-1.5), 1.6 (CI: 1.5-1.7) and 1.8 (CI: 1.7-2.0). CONCLUSION Use of AC drugs was associated with increased 30-day and 365-day mortality among older adults with hip fracture. Simply counting the number of AC drugs may be a clinically relevant and easy AC risk assessment tool. Continued effort to reduce AC drug-use is relevant.
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Farrell B, Raman-Wilms L, Sadowski CA, Mallery L, Turner J, Gagnon C, Cole M, Grill A, Isenor JE, Mangin D, McCarthy LM, Schuster B, Sirois C, Sun W, Upshur R. A Proposed Curricular Framework for an Interprofessional Approach to Deprescribing. MEDICAL SCIENCE EDUCATOR 2023; 33:551-567. [PMID: 37261023 PMCID: PMC10226933 DOI: 10.1007/s40670-022-01704-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/28/2022] [Indexed: 06/02/2023]
Abstract
Deprescribing involves reducing or stopping medications that are causing more harm than good or are no longer needed. It is an important approach to managing polypharmacy, yet healthcare professionals identify many barriers. We present a proposed pre-licensure competency framework that describes essential knowledge, teaching strategies, and assessment protocols to promote interprofessional deprescribing skills. The framework considers how to involve patients and care partners in deprescribing decisions. An action plan and example curriculum mapping exercise are included to help educators assess their curricula, and select and implement these concepts and strategies within their programs to ensure learners graduate with competencies to manage increasingly complex medication regimens as people age. Supplementary Information The online version contains supplementary material available at 10.1007/s40670-022-01704-9.
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Affiliation(s)
- Barbara Farrell
- Bruyère Research Institute, 43 Bruyère St, Ottawa, ON K1N 5C8 Canada
- Department of Family Medicine, University of Ottawa, Ottawa, ON Canada
- School of Pharmacy, University of Waterloo, Waterloo, ON Canada
| | - Lalitha Raman-Wilms
- College of Pharmacy, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB Canada
- Centre On Aging, Winnipeg, MB Canada
| | - Cheryl A. Sadowski
- Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta, Edmonton, AB Canada
| | - Laurie Mallery
- Faculty of Medicine, Dalhousie University, Halifax, NS Canada
| | - Justin Turner
- Faculty of Pharmacy, University of Montreal, Montreal, QC Canada
- Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, QC Canada
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia
| | - Camille Gagnon
- Canadian Deprescribing Network, Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, QC Canada
| | - Mollie Cole
- Canadian Gerontological Nursing Association, Calgary, AB Canada
| | - Allan Grill
- Dept. of Family & Community Medicine, University of Toronto, Toronto, ON Canada
- Markham Family Health Team, Markham, ON Canada
- Ontario Renal Network, Toronto, Canada
| | - Jennifer E. Isenor
- College of Pharmacy, Faculty of Health and Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, NS Canada
| | - Dee Mangin
- David Braley & Nancy Gordon Chair in Family Medicine, Department of Family Medicine, McMaster University, Hamilton, ON Canada
- Department of General Practice, University of Otago, Christchurch, New Zealand
| | - Lisa M. McCarthy
- Bruyère Research Institute, 43 Bruyère St, Ottawa, ON K1N 5C8 Canada
- School of Pharmacy, University of Waterloo, Waterloo, ON Canada
- Institute for Better Health and Pharmacy Department, Trillium Health Partners, Mississauga, ON Canada
- Leslie Dan Faculty of Pharmacy & Department of Family and Community Medicine, University of Toronto, Toronto, ON Canada
- Women’s College Research Institute, Toronto, ON Canada
| | - Brenda Schuster
- College of Medicine (Regina Campus), University of Saskatchewan, Regina, Saskachewan Canada
| | - Caroline Sirois
- Centre d’excellence Sur Le Vieillissement de Québec & VITAM - Research Centre On Sustainable Health, Québec, Canada
- Faculty of Pharmacy, Université Laval, Québec, Canada
| | - Winnie Sun
- Faculty of Health Sciences, Ontario Tech University, Oshawa, ON Canada
- Ontario Shores Centre for Mental Health Sciences, Whitby, ON Canada
| | - Ross Upshur
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
- Bridgepoint Collaboratory for Research and Innovation, Toronto, ON Canada
- Lunenfeld Tanenbaum Research Institute, Sinai Health, Toronto, ON Canada
- Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
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Dreischulte T, Sanftenberg L, Hennigs P, Zöllinger I, Schwaiger R, Floto C, Sebastiao M, Kühlein T, Hindenburg D, Gagyor I, Wildgruber D, Hausen A, Janke C, Hölscher M, Teupser D, Gensichen J. Detecting Medication Risks among People in Need of Care: Performance of Six Instruments. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2327. [PMID: 36767705 PMCID: PMC9915255 DOI: 10.3390/ijerph20032327] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/23/2023] [Accepted: 01/26/2023] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Numerous tools exist to detect potentially inappropriate medication (PIM) and potential prescribing omissions (PPO) in older people, but it remains unclear which tools may be most relevant in which setting. OBJECTIVES This cross sectional study compares six validated tools in terms of PIM and PPO detection. METHODS We examined the PIM/PPO prevalence for all tools combined and the sensitivity of each tool. The pairwise agreement between tools was determined using Cohen's Kappa. RESULTS We included 226 patients in need of care (median (IQR age 84 (80-89)). The overall PIM prevalence was 91.6 (95% CI, 87.2-94.9)% and the overall PPO prevalence was 63.7 (57.1-69.9%)%. The detected PIM prevalence ranged from 76.5%, for FORTA-C/D, to 6.6% for anticholinergic drugs (German-ACB). The PPO prevalences for START (63.7%) and FORTA-A (62.8%) were similar. The pairwise agreement between tools was poor to moderate. The sensitivity of PIM detection was highest for FORTA-C/D (55.1%), and increased to 79.2% when distinct items from STOPP were added. CONCLUSION Using a single screening tool may not have sufficient sensitivity to detect PIMs and PPOs. Further research is required to optimize the composition of PIM and PPO tools in different settings.
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Affiliation(s)
- Tobias Dreischulte
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Linda Sanftenberg
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Philipp Hennigs
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Isabel Zöllinger
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Rita Schwaiger
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, 80336 Munich, Germany
| | - Caroline Floto
- Institute of General Practice, Friedrich-Alexander-University of Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Maria Sebastiao
- Institute of General Practice, Friedrich-Alexander-University of Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Thomas Kühlein
- Institute of General Practice, Friedrich-Alexander-University of Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Dagmar Hindenburg
- Institute of General Practice, University Hospital of Julius-Maximilians-Universität Würzburg, 97070 Würzburg, Germany
| | - Ildikó Gagyor
- Institute of General Practice, University Hospital of Julius-Maximilians-Universität Würzburg, 97070 Würzburg, Germany
| | - Domenika Wildgruber
- Katholische Stiftungshochschule München/University of Applied Sciences, 81667 Munich, Germany
| | - Anita Hausen
- Katholische Stiftungshochschule München/University of Applied Sciences, 81667 Munich, Germany
| | - Christian Janke
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of LMU Munich, 80802 Munich, Germany
| | - Michael Hölscher
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of LMU Munich, 80802 Munich, Germany
| | - Daniel Teupser
- Institute of Laboratory Medicine, University Hospital of LMU Munich, 81377 Munich, Germany
| | - Jochen Gensichen
- Institute of General Practice and Family Medicine, University Hospital, LMU Munich, 80336 Munich, Germany
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Dinh TS, Meid AD, Rudolf H, Brueckle MS, González-González AI, Bencheva V, Gogolin M, Snell KIE, Elders PJM, Thuermann PA, Donner-Banzhoff N, Blom JW, van den Akker M, Gerlach FM, Harder S, Thiem U, Glasziou PP, Haefeli WE, Muth C. Anticholinergic burden measures, symptoms, and fall-associated risk in older adults with polypharmacy: Development and validation of a prognostic model. PLoS One 2023; 18:e0280907. [PMID: 36689445 PMCID: PMC9870119 DOI: 10.1371/journal.pone.0280907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 12/22/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Anticholinergic burden has been associated with adverse outcomes such as falls. To date, no gold standard measure has been identified to assess anticholinergic burden, and no conclusion has been drawn on which of the different measure algorithms best predicts falls in older patients from general practice. This study compared the ability of five measures of anticholinergic burden to predict falls. To account for patients' individual susceptibility to medications, the added predictive value of typical anticholinergic symptoms was further quantified in this context. METHODS AND FINDINGS To predict falls, models were developed and validated based on logistic regression models created using data from two German cluster-randomized controlled trials. The outcome was defined as "≥ 1 fall" vs. "no fall" within a 6-month follow-up period. Data from the RIME study (n = 1,197) were used in model development, and from PRIMUM (n = 502) for external validation. The models were developed step-wise in order to quantify the predictive ability of anticholinergic burden measures, and anticholinergic symptoms. In the development set, 1,015 patients had complete data and 188 (18.5%) experienced ≥ 1 fall within the 6-month follow-up period. The overall predictive value of the five anticholinergic measures was limited, with neither the employed anticholinergic variable (binary / count / burden), nor dose-dependent or dose-independent measures differing significantly in their ability to predict falls. The highest c-statistic was obtained using the German Anticholinergic Burden Score (0.73), whereby the optimism-corrected c-statistic was 0.71 after interval validation using bootstrapping and 0.63 in the external validation. Previous falls and dizziness / vertigo had the strongest prognostic value in all models. CONCLUSIONS The ability of anticholinergic burden measures to predict falls does not appear to differ significantly, and the added value they contribute to risk classification in fall-prediction models is limited. Previous falls and dizziness / vertigo contributed most to model performance.
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Affiliation(s)
- Truc Sophia Dinh
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Andreas D. Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Henrik Rudolf
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr-University Bochum, Bochum, Germany
| | - Maria-Sophie Brueckle
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - Veronika Bencheva
- HELIOS University Clinic Wuppertal, Philipp Klee-Institute for Clinical Pharmacology, University of Witten / Herdecke, Witten, Germany
| | - Matthias Gogolin
- HELIOS University Clinic Wuppertal, Philipp Klee-Institute for Clinical Pharmacology, University of Witten / Herdecke, Witten, Germany
| | - Kym I. E. Snell
- Centre for Prognosis Research, School of Medicine, Keele University, Staffordshire, United Kingdom
| | - Petra J. M. Elders
- Amsterdam UMC, General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Petra A. Thuermann
- HELIOS University Clinic Wuppertal, Philipp Klee-Institute for Clinical Pharmacology, University of Witten / Herdecke, Witten, Germany
| | - Norbert Donner-Banzhoff
- Department of General Practice / Family Medicine, Philipps University Marburg, Marburg, Germany
| | - Jeanet W. Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Marjan van den Akker
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
- Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
- Department of Public Health and Primary Care, Academic Centre of General Practice, KU Leuven, Leuven, Belgium
| | - Ferdinand M. Gerlach
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Sebastian Harder
- Institute of Clinical Pharmacology, Goethe University Frankfurt, Frankfurt, Germany
| | - Ulrich Thiem
- Department of Geriatrics, Immanuel Albertinen Diakonie, Albertinen-Haus, Hamburg, Germany
- University Clinic Eppendorf, Hamburg, Germany
| | - Paul P. Glasziou
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, Australia
| | - Walter E. Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christiane Muth
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
- Department of General Practice and Family Medicine, Medical Faculty East-Westphalia, University of Bielefeld, Bielefeld, Germany
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Lavrador M, Cabral AC, Veríssimo MT, Fernandez-Llimos F, Figueiredo IV, Castel-Branco MM. A Universal Pharmacological-Based List of Drugs with Anticholinergic Activity. Pharmaceutics 2023; 15:pharmaceutics15010230. [PMID: 36678858 PMCID: PMC9863833 DOI: 10.3390/pharmaceutics15010230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/01/2023] [Accepted: 01/07/2023] [Indexed: 01/12/2023] Open
Abstract
Anticholinergic burden tools have relevant pharmacological gaps that may explain their limited predictive ability for clinical outcomes. The aim of this study was to provide a universal pharmacological-based list of drugs with their documented affinity for muscarinic receptors. A comprehensive literature review was performed to identify the anticholinergic burden tools. Drugs included in these instruments were searched in four pharmacological databases, and the investigation was supplemented with PubMed. The evidence regarding the potential antagonism of the five muscarinic receptors of each drug was assessed. The proportion of drugs included in the tools with an affinity for muscarinic receptors was evaluated. A universal list of drugs with anticholinergic activity was developed based on their documented affinity for the different subtypes of muscarinic receptors and their ability to cross the blood-brain barrier. A total of 23 tools were identified, including 304 different drugs. Only 48.68%, 47.70%, 48.03%, 43.75%, and 42.76% of the drugs had an affinity to the M1, M2, M3, M4, and M5 receptor, respectively, reported in any pharmacological database. The proportion of drugs with confirmed antagonism varied among the tools (36.8% to 100%). A universal pharmacological-based list of 133 drugs is presented. It should be further validated in different clinical settings.
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Affiliation(s)
- Marta Lavrador
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR), 3000-548 Coimbra, Portugal
| | - Ana C. Cabral
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR), 3000-548 Coimbra, Portugal
| | - Manuel T. Veríssimo
- Coimbra Institute for Clinical and Biomedical Research (iCBR), 3000-548 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Fernando Fernandez-Llimos
- Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), University of Porto, 4200-450 Porto, Portugal
| | - Isabel V. Figueiredo
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR), 3000-548 Coimbra, Portugal
| | - M. Margarida Castel-Branco
- Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR), 3000-548 Coimbra, Portugal
- Correspondence: ; Tel.: +351-239-488-400
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Tristancho-Pérez Á, Villalba-Moreno Á, López-Malo de Molina MD, Santos-Ramos B, Sánchez-Fidalgo S. The Predictive Value of Anticholinergic Burden Measures in Relation to Cognitive Impairment in Older Chronic Complex Patients. J Clin Med 2022; 11:jcm11123357. [PMID: 35743428 PMCID: PMC9224688 DOI: 10.3390/jcm11123357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/16/2022] Open
Abstract
Anticholinergic burden (AB) is related to cognitive impairment (CI) and older complex chronic patients (OCCP) are more susceptible. Our objective was to evaluate the predictive value of ten anticholinergic scales to predict a potential CI due to anticholinergic pharmacotherapy in OCCP. An eight-month longitudinal multicentre study was carried out in a cohort of OCCP, in treatment with at least one anticholinergic drug and whose cognition status had been evaluated by Pfeiffer test twice for a period of 6-15 months. CI was considered when the Pfeiffer test increased 2 or more points. AB was detected using ten scales included on the Anticholinergic Burden Calculator. An ROC curve analysis was performed to assess the discriminative capacity of the scales to predict a potential CI and the cut-off point of AB that obtains better validity indicators. 415 patients were included (60.2% female, median age of 85 years (IQR = 11)). 190 patients (45.8%) manifested CI. Only the DBI (Drug Burden Index) showed statistically significant differences in the median AB between patients without CI and with CI (0.5 (1.00) vs. 0.67 (0.65), p = 0.006). At the ROC curve analysis, statistically significant values were obtained only with the DBI (AUC: 0.578 (0.523-0.633), p = 0.006). The cut-off point with the greatest validity selected for the DBI was an AB of 0.41 (moderate risk) (sensitivity = 81%, specificity = 36%, PPV = 51%). The DBI is the scale with the greatest discriminatory power to detect OCCP at risk of CI and the best cut-off point is a load value of 0.41.
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Affiliation(s)
- Ángela Tristancho-Pérez
- Pharmacy Service, Virgen del Rocío University Hospital, 41013 Seville, Spain; (Á.V.-M.); (B.S.-R.)
- Correspondence:
| | - Ángela Villalba-Moreno
- Pharmacy Service, Virgen del Rocío University Hospital, 41013 Seville, Spain; (Á.V.-M.); (B.S.-R.)
| | | | - Bernardo Santos-Ramos
- Pharmacy Service, Virgen del Rocío University Hospital, 41013 Seville, Spain; (Á.V.-M.); (B.S.-R.)
| | - Susana Sánchez-Fidalgo
- Department of Preventive Medicine and Public Health, University of Seville, 41009 Seville, Spain;
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Silva-Almodóvar A, Nahata MC. Clinical Utility of Medication-Based Risk Scores to Reduce Polypharmacy and Potentially Avoidable Healthcare Utilization. Pharmaceuticals (Basel) 2022; 15:ph15060681. [PMID: 35745600 PMCID: PMC9231366 DOI: 10.3390/ph15060681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 12/26/2022] Open
Abstract
The management of multiple chronic health conditions often requires patients to be exposed to polypharmacy to improve their health and enhance their quality of life. However, exposure to polypharmacy has been associated with an increased risk for adverse effects, drug-drug interactions, inappropriate prescribing, medication nonadherence, increased healthcare utilization such as emergency department visits and hospitalizations, and costs. Medication-based risk scores have been utilized to identify patients who may benefit from deprescribing interventions and reduce rates of inappropriate prescribing. These risk scores may also be utilized to prompt targeted discussions between patients and providers regarding medications or medication classes contributing to an individual’s risk for harm, eventually leading to the deprescribing of the offending medication(s). This opinion will describe existing medication-based risk scores in the literature, their utility in identifying patients at risk for specific adverse events, and how they may be incorporated in healthcare settings to reduce rates of potentially inappropriate polypharmacy and avoidable healthcare utilization and costs.
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Affiliation(s)
- Armando Silva-Almodóvar
- Institute of Therapeutic Innovations and Outcomes (ITIO), College of Pharmacy, Ohio State University, Columbus, OH 43210, USA;
- Tabula Rasa HealthCare, Tucson, AZ 85701, USA
| | - Milap C. Nahata
- Institute of Therapeutic Innovations and Outcomes (ITIO), College of Pharmacy, Ohio State University, Columbus, OH 43210, USA;
- College of Medicine, Ohio State University, Columbus, OH 43210, USA
- Correspondence: ; Tel.: +1-614-292-2472
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31
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Mur J, Russ TC, Cox SR, Marioni RE, Muniz‐Terrera G. Association between anticholinergic burden and dementia in UK Biobank. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2022; 8:e12290. [PMID: 35434252 PMCID: PMC9005668 DOI: 10.1002/trc2.12290] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/11/2022] [Accepted: 03/03/2022] [Indexed: 11/20/2022]
Abstract
Background Previous studies on the relationship between anticholinergic drugs and dementia have reported heterogeneous results. This variability could be due to different anticholinergic scales and differential effects of distinct classes of drugs. Methods Using Cox proportional hazards models, we computed the association between annual anticholinergic burden (AChB) and the risk of dementia in UK Biobank with linked general practitioner prescription records between the years 2000 and 2015 (n = 171,775). Results AChB according to most anticholinergic scales (standardized odds ratio range: 1.027-1.125) and the slope of the AChB trajectory (hazard ratio = 1.094; 95% confidence interval: 1.068-1.119) were predictive of dementia. However, the association between AChB and dementia held only for some classes of drugs, especially antidepressants, antiepileptics, and antidiuretics. Discussion The heterogeneity in previous findings may partially be due to different effects for different classes of drugs. Future studies should establish differences in more detail and further examine the practicality of a general measure of AChB relating to the risk of dementia.
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Affiliation(s)
- Jure Mur
- Lothian Birth Cohorts GroupDepartment of PsychologyUniversity of EdinburghEdinburghUK
- Centre for Genomic and Experimental MedicineInstitute of Genetics and Molecular MedicineUniversity of EdinburghEdinburghUK
- Alzheimer Scotland Dementia Research CentreUniversity of EdinburghEdinburghUK
| | - Tom C. Russ
- Alzheimer Scotland Dementia Research CentreUniversity of EdinburghEdinburghUK
- Edinburgh Dementia PreventionUniversity of EdinburghEdinburghUK
- Division of PsychiatryCentre for Clinical Brain ScienceUniversity of EdinburghEdinburghUK
| | - Simon R. Cox
- Lothian Birth Cohorts GroupDepartment of PsychologyUniversity of EdinburghEdinburghUK
| | - Riccardo E. Marioni
- Centre for Genomic and Experimental MedicineInstitute of Genetics and CancerUniversity of EdinburghEdinburghUK
| | - Graciela Muniz‐Terrera
- Edinburgh Dementia PreventionUniversity of EdinburghEdinburghUK
- Division of PsychiatryCentre for Clinical Brain ScienceUniversity of EdinburghEdinburghUK
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32
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Ramos H, Moreno L, Pérez-Tur J, Cháfer-Pericás C, García-Lluch G, Pardo J. CRIDECO Anticholinergic Load Scale: An Updated Anticholinergic Burden Scale. Comparison with the ACB Scale in Spanish Individuals with Subjective Memory Complaints. J Pers Med 2022; 12:jpm12020207. [PMID: 35207695 PMCID: PMC8876932 DOI: 10.3390/jpm12020207] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/30/2022] [Accepted: 01/31/2022] [Indexed: 11/30/2022] Open
Abstract
The increase in life expectancy has also been accompanied by an increase in the use of medication to treat chronic diseases. Polypharmacy is associated with medication-related problems such as the increase in the anticholinergic burden. Older people are more susceptible to anticholinergic effects on the central nervous system and this, in turn, may be related to cognitive impairment. In this paper, we develop an updated anticholinergic burden scale, the CRIDECO Anticholinergic Load Scale (CALS) via a systematic review of the literature and compare it with the currently most used Anticholinergic Burden Scale (ACB). Our new scale includes 217 different drugs with anticholinergic properties, 129 more than the ACB. Given the effect that anticholinergic medications have on cognitive performance, we then used both scales to investigate the relationship between anticholinergic burden and cognitive impairment in adult Spanish subjects with subjective memory complaint. In our population, we observed an association between cognitive impairment and the anticholinergic burden when measured by the new CALS, but not when the ACB was applied. The use of a more comprehensive and upgraded scale will allow better discrimination of the risk associated with the use of anticholinergic medications on cognitive impairment. CALS can help raise awareness among clinicians of the problems associated with the use of medications, or combinations of them, with large anticholinergic effect, and promote a better personalized pharmacological approach for each patient.
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Affiliation(s)
- Hernán Ramos
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Department of Pharmacy, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain
| | - Lucrecia Moreno
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Department of Pharmacy, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain
| | - Jordi Pérez-Tur
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Institut de Biomedicina de València-CSIC, CIBERNED, Unitat Mixta de Neurologia i Genetica, IIS La Fe, 46010 Valencia, Spain
| | - Consuelo Cháfer-Pericás
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Alzheimer Disease Research Group, Health Research Institute La Fe, 46026 Valencia, Spain
| | - Gemma García-Lluch
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Alzheimer Disease Research Group, Health Research Institute La Fe, 46026 Valencia, Spain
| | - Juan Pardo
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Embedded Systems and Artificial Intelligence Group, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain
- Correspondence:
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Broder JC, Ryan J, Shah RC, Lockery JE, Orchard SG, Gilmartin-Thomas JFM, Fravel MA, Owen AJ, Woods RL, Wolfe R, Storey E, Murray AM, Ernst ME. Anticholinergic medication burden and cognitive function in participants of the ASPREE study. Pharmacotherapy 2021; 42:134-144. [PMID: 34866212 DOI: 10.1002/phar.2652] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/29/2021] [Accepted: 10/29/2021] [Indexed: 01/24/2023]
Abstract
STUDY OBJECTIVE What is the association between anticholinergic burden and specific domains of cognitive function in older adults who are initially without major cognitive impairment? DESIGN Post-hoc analysis of longitudinal observational data from the ASPirin in Reducing Events in the Elderly (ASPREE) study. PATIENTS 19,114 participants from Australia and the United States aged 70 years and older (65 years and older for US minorities) were recruited and followed for a median of 4.7 years. At enrollment, participants were free of known cardiovascular disease, major physical disability, or dementia. MEASUREMENTS Cognitive assessments administered at baseline and biennially at follow-up visits included the Modified Mini-Mental State examination (3MS), Hopkins Verbal Learning Test-Revised (HVLT-R) delayed recall, Controlled Oral Word Association Test (COWAT), and Symbol Digit Modalities Test (SDMT). Anticholinergic burden was calculated at baseline using the Anticholinergic Cognitive Burden (ACB) scale and grouped as scores of 0 (no burden), 1-2 (low to moderate), or 3+ (high). MAIN RESULTS Linear mixed effects models were used to assess the relationship between ACB score and cognition over time. After adjusting for sex, age, education, minority status, smoking status, hypertension, diabetes, depression, chronic kidney disease, country, and frailty, participants with a high ACB score had worse performance over time for 3MS (Adjusted [Adj] B=-0.092, P=0.034), HVLT-R delayed recall (Adj B=-0.104, P<0.001), COWAT (Adj B=-0.151, P<0.001), and SDMT (Adj B=-0.129, P=0.026), than participants with an ACB score of 0. A low to moderate ACB score was also associated with worse performance over time for HVLT-R delayed recall (Adj B=-0.037, P=0.007) and COWAT (Adj B=-0.065, P=0.003), compared to those with no ACB. CONCLUSIONS Anticholinergic burden predicts worse cognitive function over time in initially dementia-free older adults, particularly for executive function (COWAT) and episodic memory (HVLT-R).
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Affiliation(s)
- Jonathan C Broder
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Joanne Ryan
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Raj C Shah
- Department of Family Medicine and Rush Alzheimer's Disease Center, Rush University, Chicago, Illinois, USA
| | - Jessica E Lockery
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Translational Immunology and Nanotechnology Research Program, RMIT University, Bundoora, Victoria, Australia
| | - Suzanne G Orchard
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Julia F-M Gilmartin-Thomas
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- College of Health and Biomedicine & Institute for Health and Sport, Victoria University, Melbourne, Victoria, Australia
- Australian Institute for Musculoskeletal Science, St Albans, Victoria, Australia
| | - Michelle A Fravel
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Iowa, Iowa City, Iowa, USA
| | - Alice J Owen
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Robyn L Woods
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rory Wolfe
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Elsdon Storey
- Department of Epidemiology & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anne M Murray
- Berman Center for Outcomes and Clinical Research, Hennepin Health Research Institute, Minneapolis, Minnesota, USA
- Division of Geriatrics, Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | - Michael E Ernst
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Iowa, Iowa City, Iowa, USA
- Department of Family Medicine, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
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Nagai J, Ishikawa Y. Analysis of anticholinergic adverse effects using two large databases: The US Food and Drug Administration Adverse Event Reporting System database and the Japanese Adverse Drug Event Report database. PLoS One 2021; 16:e0260980. [PMID: 34855908 PMCID: PMC8638968 DOI: 10.1371/journal.pone.0260980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/21/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Anticholinergic adverse effects (AEs) are a problem for elderly people. This study aimed to answer the following questions. First, is an analysis of anticholinergic AEs using spontaneous adverse drug event databases possible? Second, what is the main drug suspected of inducing anticholinergic AEs in the databases? Third, do database differences yield different results? METHODS We used two databases: the US Food and Drug Administration Adverse Event Reporting System database (FAERS) and the Japanese Adverse Drug Event Report database (JADER) recorded from 2004 to 2020. We defined three types of anticholinergic AEs: central nervous system (CNS) AEs, peripheral nervous system (PNS) AEs, and a combination of these AEs. We counted the number of cases and evaluated the ratio of drug-anticholinergic AE pairs between FAERS and JADER. We computed reporting odds ratios (RORs) and assessed the drugs using Beers Criteria®. RESULTS Constipation was the most reported AE in FAERS. The ratio of drug-anticholinergic AE pairs was statistically significantly larger in FAERS than JADER. Overactive bladder agents were suspected drugs common to both databases. Other drugs differed between the two databases. CNS AEs were associated with antidementia drugs in FAERS and opioids in JADER. In the assessment using Beers Criteria®, signals were detected for almost all drugs. Between the two databases, a significantly higher positive correlation was observed for PNS AEs (correlation coefficient 0.85, P = 0.0001). The ROR was significantly greater in JADER. CONCLUSIONS There are many methods to investigate AEs. This study shows that the analysis of anticholinergic AEs using spontaneous adverse drug event databases is possible. From this analysis, various suspected drugs were detected. In particular, FAERS had many cases. The differences in the results between the two databases may reflect differences in the reporting countries. Further study of the relationship between drugs and CNS AEs should be conducted.
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Affiliation(s)
- Junko Nagai
- The Office of Institutional Research, Meiji Pharmaceutical University, Kiyose, Tokyo, Japan
- * E-mail:
| | - Yoichi Ishikawa
- Division of Clinical Pharmacy, Department of Pediatric Pharmaceutical Sciences, Education and Research Center for Pharmacy, Meiji Pharmaceutical University, Kiyose, Tokyo, Japan
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35
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Kakkar M, Barmak AB, Arany S. Anticholinergic medication and dental caries status in middle-aged xerostomia patients-a retrospective study. J Dent Sci 2021; 17:1206-1211. [PMID: 35784170 PMCID: PMC9236892 DOI: 10.1016/j.jds.2021.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/16/2021] [Indexed: 11/30/2022] Open
Abstract
Background/purpose Xerostomia is the most frequent side effect of anticholinergic (AC) medications, which block the cholinergic neurotransmission of saliva secretion. As the most significant increase in AC medications’ usage reported in middle-aged adults, we aimed to explore whether the level of exposure to AC medication show association with the severity of caries status of middle-aged individuals who complained about medication-induced xerostomia. Materials and methods Our retrospective study included 414 individuals (between 45 and 64 years) with self-reported xerostomia. We determined caries status by the Decayed, Missing, or Filled Teeth (DMFT) index and quantified the level of AC drug exposure by the AC Drug Scale (ADS), verified through electronic medication records. Statistical analyses were performed using chi-square and ANOVA tests. Covariates were age, gender, smoking, edentulism, comorbidities, polypharmacy, number, and the type of AC medications. Results In total, 54% of patients were taking five or more AC drugs. The mean number of anticholinergics was 5.41 (±3.44), most frequently antidepressants and antipsychotics, among all medications 10.63 (±5.79). Higher ADS scores were associated (p = 0.006) with a higher number of missing teeth. Multiple linear regression model showed that the number of AC medications, age, and smoking status are associated with DMFT (mean of 18.7 ± 8.96) scores. Conclusion Caries status of middle-aged xerostomia patients was found to be reflective of the level of AC exposure from medications. Our finding emphasizes the importance of assessing AC medication burden in affected dental patients to improve clinical prevention strategies and guide interdisciplinary treatment plans.
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Affiliation(s)
- Mayank Kakkar
- Department of Dentistry, Eastman Institute of Oral Health, University of Rochester, NY, USA
- Complex Care Center Clinic, University of Rochester Medical Center, NY, USA
| | - Abdul Basir Barmak
- Department of Dentistry, Eastman Institute of Oral Health, University of Rochester, NY, USA
| | - Szilvia Arany
- Department of Dentistry, Eastman Institute of Oral Health, University of Rochester, NY, USA
- Specialty Care Clinic, Eastman Institute of Oral Health, University of Rochester, NY, USA
- Corresponding author. Specialty Care, Department of Dentistry, Eastman Institute for Oral Health, University of Rochester, 625 Elmwood Avenue, Rochester, 14620, NY, USA.
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Lisibach A, Gallucci G, Beeler PE, Csajka C, Lutters M. High anticholinergic burden at admission associated with in-hospital mortality in older patients: A comparison of 19 different anticholinergic burden scales. Basic Clin Pharmacol Toxicol 2021; 130:288-300. [PMID: 34837340 PMCID: PMC9299782 DOI: 10.1111/bcpt.13692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/10/2021] [Accepted: 11/18/2021] [Indexed: 01/16/2023]
Abstract
Although no gold standard exists to assess a patient's anticholinergic burden, a review identified 19 anticholinergic burden scales (ABSs). No study has yet evaluated whether a high anticholinergic burden measured with all 19 ABSs is associated with in‐hospital mortality and length of stay (LOS). We conducted a cohort study at a Swiss tertiary teaching hospital using patients' electronic health record data from 2015–2018. Included were patients aged ≥65 years, hospitalised ≥48 h without stays and >24 h in intensive care. Patients' cumulative anticholinergic burden score was classified using a binary (<3: low, ≥3: high) and categorical approach (0: no, 0.5–3: low, ≥3: high). In‐hospital mortality and LOS were analysed using multivariable logistic and linear regression, respectively. We included 27,092 patients (mean age 78.0 ± 7.5 years, median LOS 6 days). Of them, 913 died. Depending on the evaluated ABS, 1370 to 17,035 patients were exposed to anticholinergics. Patients with a high burden measured by all 19 ABSs were associated with a 1.32‐ to 3.03‐fold increase in in‐hospital mortality compared with those with no/low burden. We obtained similar results for LOS. To conclude, discontinuing drugs with anticholinergic properties (score ≥3) at admission might be a targeted intervention to decrease in‐hospital mortality and LOS.
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Affiliation(s)
- Angela Lisibach
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland.,Center for Research and Innovation in Clinical Pharmaceutical Sciences, University Hospital and University of Lausanne, Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Lausanne, Switzerland
| | - Giulia Gallucci
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
| | - Patrick E Beeler
- Division of Occupational and Environmental Medicine, Epidemiology, Biostatistics and Prevention Institute, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, University Hospital and University of Lausanne, Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Lausanne, Switzerland
| | - Monika Lutters
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland.,Swiss Federal Institute of Technology, Zurich, Switzerland
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Welk B, Richardson K, Panicker JN. The cognitive effect of anticholinergics for patients with overactive bladder. Nat Rev Urol 2021; 18:686-700. [PMID: 34429535 DOI: 10.1038/s41585-021-00504-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 02/07/2023]
Abstract
Overactive bladder (OAB) is often treated with medications that block the cholinergic receptors in the bladder (known as anticholinergics). The effect of this medication class on cognition and risk of dementia has been increasingly studied over the past 40 years after initial studies suggested that the anticholinergic medication class could affect memory. Short-term randomized clinical trials demonstrated that the administration of the anticholinergic oxybutynin leads to impaired memory and attention, and large, population-based studies showed associations between several different anticholinergic medications and dementia. However, trials involving anticholinergics other than oxybutynin have not shown such substantial effects on short-term cognitive function. This discordance in results between short-term cognitive safety of OAB anticholinergics and the long-term increased dementia risk could be explained by the high proportion of patients using oxybutynin in the OAB subgroups of the dementia studies, or a study duration that was too short in the prospective clinical trials on cognition with other OAB anticholinergics. Notably, all studies must be interpreted in the context of potential confounding factors, such as when prodromal urinary symptoms associated with the early stages of dementia lead to an increase in OAB medication use, rather than the use of OAB medication causing dementia. In patients with potential risk factors for cognitive impairment, the cautious use of selected OAB anticholinergic agents with favourable physicochemical and pharmacokinetic properties and clinical trial evidence of cognitive safety might be appropriate.
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Affiliation(s)
- Blayne Welk
- Department of Surgery and Epidemiology & Biostatistics, Western University, London, Ontario, Canada.
| | | | - Jalesh N Panicker
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery, and UCL Queen Square Institute of Neurology, Faculty of Brain Sciences, University College London, London, UK
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Mills J. Nurses Must Consider the Impact of Anticholinergic Medications in Schizophrenia Spectrum Disorders. Issues Ment Health Nurs 2021; 42:887-889. [PMID: 34415828 DOI: 10.1080/01612840.2021.1964828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Jeremy Mills
- Peninsula, a Division of Parkwest Medical Center, Knoxville, Tennessee, USA
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Sørensen SR, Frederiksen JD, Anru PL, Masud T, Petrovic M, Rosholm JU, Ryg J. Use of Drugs with Anticholinergic Properties at Hospital Admission Associated with Mortality in Older Patients: A Danish Nationwide Register-Based Cohort Study. Drugs Real World Outcomes 2021; 9:129-140. [PMID: 34414558 PMCID: PMC8844340 DOI: 10.1007/s40801-021-00270-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Use of drugs with anticholinergic properties (DAP) has a negative impact on older people. OBJECTIVE Our aim was to examine the association between DAP at hospital admission and mortality in older patients. PATIENTS AND METHODS We performed a nationwide population-based cohort study including patients aged ≥ 65 years admitted to Danish geriatric medicine departments during 2005-2014. National health registers were used to link with individual-level data. Patients were followed to emigration, death, or study termination (31 December 2015). DAP was defined as medications included in the anticholinergic cognitive burden (ACB) scale, which assigns each DAP a score between 1 and 3. The individual ACB score was calculated and the number of DAP counted. We used Cox proportional-hazard regressions to estimate the crude and adjusted hazard ratios adjusting for age, activities of daily living, marital status, index admission period, BMI, and prior hospitalizations (model 1), and additionally Charlson Comorbidity Index (model 2). RESULTS We included 74,589 patients aged (median [IQR]) 83 (77-88) years. Use of one or more DAP (62.5%) was associated with increased mortality compared with those with no use (p < 0.001). In the fully adjusted model 2, compared with no use, higher mortality risks (HR [95% CI]) were seen with ACB score of 2 and number of DAP ≥ 5 for 30-day (1.46 [1.32-1.61] and 1.46 [1.09-1.95]), 1-year (1.34 [1.28-1.41] and 1.48 [1.29-1.70]), and overall mortality (1.27 [1.23-1.31] and 1.44 [1.31-1.59]), respectively. CONCLUSIONS Use of DAP at hospital admission is associated with short- and long-term mortality in geriatric patients. Deprescribing studies are warranted to study whether the impact on mortality can be attenuated.
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Affiliation(s)
- Søren Ramsdal Sørensen
- Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jeppe Dalskov Frederiksen
- Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Pavithra Laxsen Anru
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
| | - Tahir Masud
- Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Geriatric Department, Nottingham University Hospital, Nottingham, UK
| | - Mirko Petrovic
- Deaprtment of Geriatrics, Ghent University Hospital, Ghent, Belgium
| | - Jens-Ulrik Rosholm
- Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark.
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
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Hilmer SN, Mach J. Translational Gerontology Research to Understand the Effects of Medications in Older Adults. J Gerontol A Biol Sci Med Sci 2021; 76:1007-1009. [PMID: 34021315 DOI: 10.1093/gerona/glab031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sarah N Hilmer
- Laboratory of Ageing and Pharmacology, Kolling Institute, Royal North Shore Hospital and Faculty of Medicine and Health, University of Sydney, St Leonards, New South Wales, Australia
| | - John Mach
- Laboratory of Ageing and Pharmacology, Kolling Institute, Royal North Shore Hospital and Faculty of Medicine and Health, University of Sydney, St Leonards, New South Wales, Australia
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Taylor-Rowan M, Edwards S, Noel-Storr AH, McCleery J, Myint PK, Soiza R, Stewart C, Loke YK, Quinn TJ. Anticholinergic burden (prognostic factor) for prediction of dementia or cognitive decline in older adults with no known cognitive syndrome. Cochrane Database Syst Rev 2021; 5:CD013540. [PMID: 34097766 PMCID: PMC8169439 DOI: 10.1002/14651858.cd013540.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Medications with anticholinergic properties are commonly prescribed to older adults. The cumulative anticholinergic effect of all the medications a person takes is referred to as the 'anticholinergic burden' because of its potential to cause adverse effects. It is possible that high anticholinergic burden may be a risk factor for development of cognitive decline or dementia. There are various scales available to measure anticholinergic burden but agreement between them is often poor. OBJECTIVES To assess whether anticholinergic burden, as defined at the level of each individual scale, is a prognostic factor for future cognitive decline or dementia in cognitively unimpaired older adults. SEARCH METHODS We searched the following databases from inception to 24 March 2021: MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), CINAHL (EBSCOhost), and ISI Web of Science Core Collection (ISI Web of Science). SELECTION CRITERIA We included prospective and retrospective longitudinal cohort and case-control observational studies with a minimum of one year' follow-up that examined the association between an anticholinergic burden measurement scale and future cognitive decline or dementia in cognitively unimpaired older adults. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, and undertook data extraction, assessment of risk of bias, and GRADE assessment. We extracted odds ratios (OR) and hazard ratios, with 95% confidence intervals (CI), and linear data on the association between anticholinergic burden and cognitive decline or dementia. We intended to pool each metric separately; however, only OR-based data were suitable for pooling via a random-effects meta-analysis. We initially established adjusted and unadjusted pooled rates for each available anticholinergic scale; then, as an exploratory analysis, established pooled rates on the prespecified association across scales. We examined variability based on severity of anticholinergic burden. MAIN RESULTS We identified 25 studies that met our inclusion criteria (968,428 older adults). Twenty studies were conducted in the community care setting, two in primary care clinics, and three in secondary care settings. Eight studies (320,906 participants) provided suitable data for meta-analysis. The Anticholinergic Cognitive Burden scale (ACB scale) was the only scale with sufficient data for 'scale-based' meta-analysis. Unadjusted ORs suggested an increased risk for cognitive decline or dementia in older adults with an anticholinergic burden (OR 1.47, 95% CI 1.09 to 1.96) and adjusted ORs similarly suggested an increased risk for anticholinergic burden, defined according to the ACB scale (OR 2.63, 95% CI 1.09 to 6.29). Exploratory analysis combining adjusted ORs across available scales supported these results (OR 2.16, 95% CI 1.38 to 3.38), and there was evidence of variability in risk based on severity of anticholinergic burden (ACB scale 1: OR 2.18, 95% CI 1.11 to 4.29; ACB scale 2: OR 2.71, 95% CI 2.01 to 3.56; ACB scale 3: OR 3.27, 95% CI 1.41 to 7.61); however, overall GRADE evaluation of certainty of the evidence was low. AUTHORS' CONCLUSIONS There is low-certainty evidence that older adults without cognitive impairment who take medications with anticholinergic effects may be at increased risk of cognitive decline or dementia.
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Affiliation(s)
- Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | | | | | - Phyo K Myint
- Division of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Roy Soiza
- Department of General Internal Medicine, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | | | - Yoon Kong Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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