Relationship between anticholinergic drug use and one-year outcome among elderly people hospitalised in medical wards via emergency department: the SAFES cohort study

Association between anticholinergic drug burden and mortality in older people: a systematic review

PURPOSE

The purpose of the study is to conduct a systematic review of studies examining the association between anticholinergic burden and mortality in older individuals.

METHODS

A literature search was performed to identify relevant studies, using MEDLINE, EMBASE, PsycINFO and CENTRAL, from January 1990 to December 2018. We included studies of patients with a mean age of 65 years or older where the anticholinergic burden was estimated using anticholinergic risk assessment tools, and associations between anticholinergic load and mortality were investigated. The primary outcome of interest was the association between anticholinergic burden and mortality.

RESULTS

Twenty-seven studies were included. These were three cross-sectional, one nested case-control and 23 prospective or retrospective cohort studies. Most studies were determined to be of good quality. A total of 15 studies reported a positive correlation between anticholinergic burden and mortality, while the remaining 10 studies did not report a significant association. Eighteen out of 27 studies (80%) had a short follow-up period of 1 year or less. Among the five high-quality studies that met all the domains of the quality assessment criteria, four showed a positive association.

CONCLUSION

The variation in results could relate to the quality of the studies, follow-up period, anticholinergic risk assessment tool used and the study setting. Sixty-three percent (n = 17) of all the included studies, but almost all of the high-quality studies with an extended follow-up, reported a positive correlation between anticholinergic burden and mortality. Further high-quality research, using standardized measures and with adequate follow-up periods, is required to confirm the relationship between anticholinergic burden and mortality.

Anti-cholinergic burden and patient related clinical outcomes in an emergency general surgical setting

BACKGROUND/OBJECTIVE

The impact of medications with anti-cholinergic properties on morbidity and mortality of unselected adult patients admitted to the emergency general surgical setting has not been investigated.

METHODS

All cases were identified prospectively from unselected adult patients admitted to the emergency general surgical ward between May to July 2016 in a UK centre with a catchment population circa 500,000. Prescribed medication lists were ascertained from case notes and electronic medical records. Anti-Cholinergic Burden (ACB) was calculated from medication lists. Patients were categorised into three groups based on ACB; none (ACB score of 0); moderate (up to ACB score of two); high (ACB score more than two). The effect of increasing ACB on selected outcomes of 30- and 90-day mortality, hospital readmission within 30-days of discharge and increased length of hospital stay were examined using multivariable logistic regression models.

RESULTS

The 452 patients had a mean age (SD) of 51.7 (±20.6) years, 273 (60.4%) patients had no ACB burden, 106 (23.5%) had a ACB burden of up to two; and 73 (16.2%) had an ACB burden of > 2. Multivariable analyses showed no association between high ACB burden and 90-day (fully adjusted odds ratio [OR] 0.56 (95%CI 0.12-2.85); P = 0.48) and 30-day mortality (fully adjusted OR = 0.75 (95%CI 0.05-11.04); P = 0.84). A significant association was observed between moderate ACB burden and 30-day hospital readmission (fully adjusted OR = 2.01 (95%CI 1.09-3.71); P = 0.03).

CONCLUSIONS

Anti-cholinergic burden may be linked to hospital readmission in adults admitted to an emergency general surgical ward.

An Innovative Day Hospital Dedicated to Nursing Home Resident: A Descriptive Study of 1306 Residents Referred by their Physicians

BACKGROUND

The transfer rate of residents from nursing homes (NH) to emergency rooms is high. These transfers are often inappropriate but also potentially avoidable. Recent studies have shown that in terms of methods for training NH teams, proposals for improvement of the healthcare sector must be organized. Given this observation, Gérontopôle de Toulouse (France) opened in October 2015, a responsive day hospital dedicated to NH residents (DH NH). This day hospital is characterized by its vocation, exclusively dedicated to NH residents and its ability to provide patient care within a short period of time.

OBJECTIVES

The purpose of this day hospital is twofold: (1) decrease the rate of inappropriate transfers for NH residents by offering general practitioners and NH teams quick access to expert advice, blood tests and radiological examinations during hospitalizations and care adapted to the characteristics of NH residents; (2) potentially reduce avoidable transfers to emergency rooms and hospitalizations by taking action to prevent acute decompensation in residents, but also for the education and training of NH healthcare teams. This manuscript aims to describe the arrangements put in place and the characteristics of the residents collected after two years of activity.

DESIGN

Retrospective descriptive study.

SETTING

Gérontopôle of Toulouse, France.

PARTICIPANTS

1306 residents have been consulted at the DH NH.

MEASUREMENTS

Referring physicians (treating physicians, coordinating physician or emergency room physicians) send a standardized hospitalization request form to the day hospital by fax or email indicating the reason for the request, specialist opinion(s) desired and additional required examination(s). A gerontological assessment was conducted and anamnesis data was collected for each resident, on the very day of their coming to the DH NH.

RESULTS

In 2 years, 1306 residents from 120 NHs were sent to the DH NH. The mean age was 86.23 ± 7.05 years and the majority of patients were women (n=941, 72.22%), dependent (median ADL at 2.75, [1.25-4.5]) and malnourished (821, 63.25%). In the 3 months prior to their visit to the day hospital, 668 (57.14%) residents had been hospitalized, and one-quarter (n=336, 25.72%) had been transferred to emergency rooms. The main reasons for hospitalization included assessment of cognitive disorders (n=336, 17.52%), assistance in managing behavioral disorders (n=297, 15.48%) and bedsores and slow wound healing (n=223, 11.63%).

CONCLUSION

Our experience over a 2-year period suggests that the DH NH could be a practical response to the problem of inappropriate and avoidable transfers of NH residents to emergency rooms. This innovation could easily be utilized in other hospitals.

Anticholinergic drug exposure is associated with delirium and postdischarge institutionalization in acutely ill hospitalized older patients

Several studies investigated the possible association between anticholinergic drugs and diverse clinical outcomes in older persons, but the results are inconsistent. The aim of this study was to investigate whether anticholinergic drug exposure is associated with delirium on admission, length of hospital stay, postdischarge institutionalization and in-hospital mortality in acutely ill hospitalized older patients. In this observational chart review study, we included acutely ill patients aged 65 and older who were admitted to the geriatric ward of the Erasmus University Medical Center, Rotterdam, The Netherlands, between 2012 and 2015 (n = 905). Anticholinergic drug exposure on admission was defined as the use of anticholinergic drugs, total number of anticholinergic drugs and anticholinergic drug burden score (ADB), quantified with the Anticholinergic Risk Scale (ARS), the Anticholinergic Cognitive Burden scale (ACB) and the list of Chew et al. (Chew). Logistic regression analyses were performed to investigate possible associations between anticholinergic drug exposure and the aforementioned outcomes. Analyses were adjusted for age, sex, comorbidities, non-anticholinergic drugs and delirium, where appropriate. Moderate and high ADB measured with the ARS were associated with delirium on admission with odds ratios (OR) of 1.70 (95% confidence interval (CI) = 1.16-2.49) and 1.83 (95% CI = 1.06-3.15), respectively. High ADB measured with the ARS was also associated with postdischarge institutionalization (OR = 2.43, 95% CI = 1.24-4.75). No associations were found using the ACB and Chew. Future studies are warranted to investigate the clinical usefulness of the ARS in reducing complications in older persons.

Anticholinergic drugs and negative outcomes in the older population: from biological plausibility to clinical evidence

The use of medication with anticholinergic properties is widespread among older subjects. Many drugs of common use such as antispasmodics, bronchodilators, antiarrhythmics, antihistamines, anti-hypertensive drugs, antiparkinson agents, skeletal muscle relaxants, and psychotropic drugs have been demonstrated to have an anticholinergic activity. The most frequent adverse effects are dry mouth, nausea, vomiting, constipation, abdominal pain, urinary retention, blurred vision, tachycardia and neurologic impairment such as confusion, agitation and coma. A growing evidence from experimental studies and clinical observations suggests that drugs with anticholinergic properties can cause physical and mental impairment in the elderly population. However, the morbidity and management issues associated with unwanted anticholinergic activity are underestimated and frequently overlooked. Moreover, their possible relation with specific negative outcome in the elderly population is still not firmly established. The aim of the present review was to evaluate the relationship between the use of drugs with anticholinergic activity and negative outcomes in older persons. We searched PubMed and Cochrane combining the search terms "anticholinergic", "delirium", "cognitive impairment", "falls", "mortality" and "discontinuation". Medicines with anticholinergic properties may increase the risks of functional and cognitive decline, morbidity, institutionalization and mortality in older people. However, such evidences are still not conclusive probably due to possible confounding factors. In particular, more studies are needed to investigate the effects of discontinuation of drug with anticholinergic properties. Overall, minimizing anticholinergic burden should always be encouraged in clinical practice to improve short-term memory, confusion and delirium, quality of life and daily functioning.