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Reaves S, Arya LA, Newman DK, Wyman J, Klusaritz H, Walsh W, Brown RT, Andy UU. Reducing Falls in Older Women with Urinary Incontinence. ADVANCES IN GERIATRIC MEDICINE AND RESEARCH 2024; 5:e230011. [PMID: 38454916 PMCID: PMC10919213 DOI: 10.20900/agmr20230011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Urinary incontinence is common in older women and doubles the risk of falls in this population. The association between urinary incontinence, especially urgency urinary incontinence, and falls is multifactorial and likely the result of a complex interaction between physical, mental, social, and environmental factors. As a result of this multifactorial etiology and based on existing evidence, the integration of different fall prevention strategies including strength and resistance exercises, bladder training, and home hazard reduction have the potential to decrease the risk of falls in older women with urinary incontinence. Given the prevalence of urinary incontinence and the significant morbidity associated with falls, effective interventions to reduce fall risk in older women with urinary incontinence is of high public health significance.
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Affiliation(s)
- Simone Reaves
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - Lily A. Arya
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - Diane K. Newman
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jean Wyman
- School of Nursing, University of Minnesota, Minneapolis, MN, USA
| | - Heather Klusaritz
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA
| | - Wendy Walsh
- Department of Occupational Therapy, Saint Joseph’s University, Philadelphia, PA, USA
| | - Rebecca T. Brown
- Division of Geriatric Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Uduak U. Andy
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
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Kanis E, Gallegos P, Christman K, Vazquez D, Mullen C, Cucci MD. Impact of medication intensification on 30-day hospital readmissions in a geriatric trauma population: A multicenter cohort study. Pharmacotherapy 2024; 44:39-48. [PMID: 37926857 DOI: 10.1002/phar.2890] [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: 06/15/2023] [Revised: 09/08/2023] [Accepted: 09/29/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Fall-related injuries are a significant health issue that occur in 25% of older adults and account for a significant number of trauma-related hospitalizations. Although medication intensification may increase the risk of hospital readmissions in non-trauma patients, data on a geriatric trauma population are lacking. OBJECTIVE The primary objective was to evaluate the effect of medication intensification on 30-day hospital readmissions in geriatric patients hospitalized for fall-related injuries. METHODS This multicenter, retrospective cohort study included patients with geriatric who presented to one of three trauma centers within a large, health-system between January 1, 2018 and December 31, 2020. Patients at least 65 years old admitted with a fall-related injury were eligible for inclusion. Patients were grouped according to medication changes at discharge, which included intensified and non-intensified groups. Medication intensification included increased dose(s) or initiation of new agents. The primary outcome was the 30-day hospital readmission rate. RESULTS Of the 870 patients included (median [interquartile range, IQR] age, 82 [74-89] years, 522 (60%) female, and 220 (25%) with a previous fall), there were 471 (54%) and 399 (46%) patients in the intensified and non-intensified groups, respectively. The intensified group had a higher 30-day hospital readmission rate (21% intensified vs. 16% non-intensified, p = 0.043; number needed to harm 20) based on an unweighted analysis. According to a weighted propensity score logistic regression, medication intensification was associated with higher 30-day hospital readmissions (24% [95% confidence interval [CI] 19-31%] intensified vs. 15% [95% CI 11-20%] non-intensified, p = 0.018). These results were consistent within competing risk models accounting for death (cause-specific model: hazard ratio [HR] 1.63 [95% CI 1.07-2.49], p = 0.023; Fine-Gray model: HR 1.64 [95% CI 1.07-2.50], p = 0.022). CONCLUSIONS In a geriatric trauma population hospitalized after a fall, intensification of medications may pose an increased risk of 30-day hospital readmission.
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Affiliation(s)
- Emily Kanis
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Patrick Gallegos
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, Ohio, USA
- Department of Pharmacy Practice, Department of Internal Medicine, Northeast Ohio Medical Center, Rootstown, Ohio, USA
| | - Kailey Christman
- Department of Research, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Daniel Vazquez
- Department of Surgery, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Chanda Mullen
- Department of Research, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Michaelia D Cucci
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, Ohio, USA
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Dmochowski RR, Newman DK, Rovner ES, Zillioux J, Malik RD, Ackerman AL. Patient and Clinician Challenges with Anticholinergic Step Therapy in the Treatment of Overactive Bladder: A Narrative Review. Adv Ther 2023; 40:4741-4757. [PMID: 37725308 PMCID: PMC10567877 DOI: 10.1007/s12325-023-02625-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/21/2023] [Indexed: 09/21/2023]
Abstract
Anticholinergics have been used in the treatment of overactive bladder (OAB), but their use is limited by poor tolerability and anticholinergic-related side effects. Increasingly, providers are discontinuing anticholinergic prescribing because of growing evidence of the association of anticholinergic use with increased risk of cognitive decline and other adverse effects. Newer medications for OAB, the β3-adrenergic receptor agonists mirabegron and vibegron, do not have anticholinergic properties and are typically well tolerated; however, many insurance plans have limited patient access to these newer OAB medications by requiring step therapy, meaning less expensive anticholinergic medications must be trialed and/or failed before a β3-agonist will be covered and dispensed. Thus, many patients are unable to easily access these medications. Step therapy and other drug utilization strategies (e.g., prior authorization) are often used to manage the growing costs of pharmaceuticals, but these policies do not always follow treatment guidelines and may harm patients as a result of treatment delays, discontinuations, or related increases in adverse events. Medical professionals have called for reform of drug utilization strategies through partnerships that include clinicians and policymakers. This narrative review discusses prescribing patterns for OAB treatment and the effect of switching between drugs, as well as the costs of step therapy and prior authorization on patients and prescribers.
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Affiliation(s)
- Roger R Dmochowski
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Diane K Newman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eric S Rovner
- Department of Urology, Medical University of South Carolina, Charleston, SC, USA
| | - Jacqueline Zillioux
- Department of Urology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Rena D Malik
- Division of Urology, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - A Lenore Ackerman
- Departments of Urology and Obstetrics and Gynecology, Division of Pelvic Medicine and Reconstructive Surgery, David Geffen School of Medicine, University of California, Los Angeles, 10833 Le Conte Avenue, Box 951738, Los Angeles, CA, 90095-1738, USA.
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Huang J, Fan Y, Wang D, Deng Q, Zou X, Yu J. Efficacy and safety of vaginal electrical stimulation as an alternative or adjunct treatment for overactive bladder syndrome in women: a meta-analysis of randomized controlled trials. Int Urogynecol J 2023; 34:2345-2357. [PMID: 37368020 DOI: 10.1007/s00192-023-05546-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/08/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to evaluate the efficacy and safety of vaginal electrical stimulation (VES) as an alternative or adjunct treatment for overactive bladder (OAB) syndrome in women. METHODS Five English-language databases and four Chinese-language databases were searched to identify relevant studies. Studies comparing VES (VES alone or VES plus other interventions) with other interventions (medicines, bladder training, or PFMT) were included. Voiding diary, quality of life (QoL), and adverse events were extracted from the included studies for comparison. RESULTS Seven trials with 601 patients in total were reviewed. The results showed that when compared with other interventions, VES alone significantly improved urgency episodes (p = 0.0008) and voiding frequency (p = 0.01), but did not significantly reduce nocturia (p = 0.85), urinary incontinence episodes (p = 0.90) and number of pads (p = 0.87). When VES plus other interventions was compared with other interventions, the former significantly improved voiding frequency (p < 0.00001), nocturia (p < 0.00001), and number of pads (p = 0.03), but it did not significantly reduce urinary incontinence episodes (p = 0.24). Both VES alone (p < 0.00001) and VES plus other interventions (p = 0.003) showed significant benefit on QoL. CONCLUSIONS This study demonstrated that VES alone decreased urgency episodes and QoL better than other therapies. Although VES alone reduced voiding frequency better and VES plus other therapies decreased nocturia, number of pads, urgency episodes, and QoL better than other therapies, the results should be interpreted with caution for clinical practice because some of the RCTs included were of low quality and because of the small number of studies included.
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Affiliation(s)
- Jiapeng Huang
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
- Research Laboratory of Neurorehabilitation, Research Institute of Rehabilitation Medicine, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Ye Fan
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510120, China
| | - Dexin Wang
- Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, 510006, China
| | - Qiuying Deng
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510120, China
| | - Xu Zou
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, 510120, China.
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, 510120, China.
| | - Jin Yu
- Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, 510006, China
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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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Roitto HM, Aalto UL, Öhman H, Saarela RKT, Kautiainen H, Salminen K, Pitkälä KH. Association of medication use with falls and mortality among long-term care residents: a longitudinal cohort study. BMC Geriatr 2023; 23:375. [PMID: 37331981 DOI: 10.1186/s12877-023-04096-6] [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: 05/02/2022] [Accepted: 06/07/2023] [Indexed: 06/20/2023] Open
Abstract
BACKGROUND Falls in long-term care are common. The aim of our study was to explore how medication use is associated with incidence of falls, related consequences, and all-cause mortality among long-term care residents. METHODS Five hundred thirty two long-term care residents aged 65 years or older participated in this longitudinal cohort study in 2018-2021. Data on medication use were retrieved from medical records. Polypharmacy was defined as use of 5-10 medications and excessive polypharmacy as use of > 10 medications. The numbers of falls, injuries, fractures, and hospitalizations were collected from medical records over 12 months following baseline assessment. Participants were followed for three years for mortality. All analysis were adjusted for age, sex, Charlson Comorbidity Index, Clinical dementia rating, and mobility. RESULTS A total of 606 falls occurred during the follow-up. Falls increased significantly with the number of medications used. Fall rate was 0.84/person-years (pyrs) (95% CI 0.56 to 1.13) for the non-polypharmacy group, 1.13/pyrs (95% CI 1.01 to 1.26) for the polypharmacy group, and 1.84/pyrs (95% CI 1.60 to 2.09) for the excessive polypharmacy group. Incidence rate ratio for falls was 1.73 (95% CI 1.44 to 2.10) for opioids, 1.48 (95% CI 1.23 to 1.78) for anticholinergic medication, 0.93 (95% CI 0.70 to 1.25) for psychotropics, and 0.91 (95% CI 0.77 to 1.08) for Alzheimer medication. The three-year follow-up showed significant differences in mortality between the groups, the lowest survival rate (25%) being in the excessive polypharmacy group. CONCLUSION Polypharmacy, opioid and anticholinergic medication use predicted incidence of falls in long-term care. The use of more than 10 medications predicted all-cause mortality. Special attention should be paid to both number and type of medications when prescribing in long-term care.
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Affiliation(s)
- Hanna-Maria Roitto
- Department of Geriatrics, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
- Finnish Institute for Health and Welfare, Population Health Unit, Helsinki, Finland.
- Department of Social Services and Health Care, Helsinki, Finland.
| | - Ulla L Aalto
- Department of Geriatrics, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hanna Öhman
- Department of Geriatrics, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Hannu Kautiainen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - Karoliina Salminen
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
| | - Kaisu H Pitkälä
- Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
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Suzuki M, Yamamoto M, Shiratori T, Naito A, Nakamura M. Evaluation of trends in prescription drugs for overactive bladder in Japanese patients. Int J Urol 2023; 30:331-333. [PMID: 36479727 DOI: 10.1111/iju.15117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Motofumi Suzuki
- Department of Urology, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Masahiro Yamamoto
- Department of Urology, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Taichi Shiratori
- Department of Urology, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Akihiro Naito
- Department of Urology, Tokyo Metropolitan Bokutoh Hospital, Sumida-ku, Tokyo, Japan
| | - Masaki Nakamura
- Department of Urology, NTT Medical Center Tokyo, Shinagawa-ku, Tokyo, Japan
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Anticholinergic Use for OAB in the Older Woman: An Update. CURRENT GERIATRICS REPORTS 2023. [DOI: 10.1007/s13670-023-00380-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
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Welk B. The Differential Risk of Mortality Among Users of Overactive Bladder Anticholinergic Medications and β3 Agonists. Eur Urol Focus 2023; 9:168-171. [PMID: 35987891 DOI: 10.1016/j.euf.2022.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 07/24/2022] [Accepted: 08/04/2022] [Indexed: 11/04/2022]
Abstract
Anticholinergic overactive bladder (OAB) medications have been studied in large observational studies to determine if they are associated with a greater risk of mortality (potentially because of their effects on the heart or the brain). Studies in different populations of old adults have shown that oxybutynin is associated with a significantly higher risk of mortality of 26-58% in comparison to other OAB anticholinergic medications or β3 agonists. In general, anticholinergic OAB medications may increase the risk of mortality, and a single multicountry study showed that β3 agonist users had a 20% lower risk of mortality compared to OAB anticholinergic users. PATIENT SUMMARY: Older adults who started using a traditional type of medication for overactive bladder (oxybutynin) had a higher risk of dying compared to people who used newer types of anticholinergic medications and to people who used overactive bladder medications that work in a different way.
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Affiliation(s)
- Blayne Welk
- Department of Surgery and Epidemiology and Biostatistics, Western University, London, ON, Canada.
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Akgün Ö, Oudshoorn C, Mattace-Raso FUS, Egberts A. Anticholinergic Drug Use on Admission and the Risk of In-Hospital Falls in Older Hospitalized Patients. Clin Interv Aging 2022; 17:277-285. [PMID: 35313670 PMCID: PMC8934155 DOI: 10.2147/cia.s357818] [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: 01/11/2022] [Accepted: 03/05/2022] [Indexed: 12/01/2022] Open
Abstract
Purpose In-hospital falls, especially among older patients, are a major and underestimated problem. Several studies have suggested a possible association between anticholinergic drug use and falls, but the results are inconclusive and studies focusing on in-hospital falls are scarce. The aim of the present study was to investigate whether anticholinergic drug exposure on admission is associated with in-hospital falls. Patients and Methods This retrospective chart review study was conducted in the Erasmus MC University Medical Center, Rotterdam, the Netherlands. Patients aged 65 years and older, who were acutely admitted to the geriatric ward between 2012 and 2015, were included. Anticholinergic drug exposure was determined with the Anticholinergic Risk Scale (ARS), the Anticholinergic Cognitive Burden scale (ACB) and the list of Chew. Logistic regression was used to investigate the possible association between anticholinergic drug exposure and in-hospital falls. Analyses were adjusted for age, sex, fall history, fall as reason for admission, number of drugs on admission, use of a mobility aid and delirium. Results A total of 905 patients were included, of which 94 patients experienced one or more in-hospital falls. Each additional anticholinergic drug in use, according to the ARS, was associated with an increased odd of experiencing a fall (OR = 1.49, 95% CI: 1.06–2.10). Other measures, ie anticholinergic drug use (yes/no) and different categories of anticholinergic drug burden, measured with the ARS, ACB and list of Chew, were all not associated with in-hospital falls. Conclusion Anticholinergic drug exposure on admission is possibly not a main risk factor for in-hospital falls among older patients.
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Affiliation(s)
- Özge Akgün
- Department of Internal Medicine, Section of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Christian Oudshoorn
- Department of Internal Medicine, Section of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Francesco U S Mattace-Raso
- Department of Internal Medicine, Section of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Angelique Egberts
- Department of Internal Medicine, Section of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Franciscus Gasthuis & Vlietland, Rotterdam & Schiedam, the Netherlands
- Correspondence: Angelique Egberts, Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Room Rg-527, PO Box 2040, Rotterdam, CA, 3000, the Netherlands, Tel +31 10 70 35979, Fax +31 10 70 34768, Email
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Welk B, Etaby K, McArthur E, Chou Q. The risk of delirium and falls or fractures with the use of overactive bladder anticholinergic medications. Neurourol Urodyn 2022; 41:348-356. [PMID: 34719044 DOI: 10.1002/nau.24827] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/14/2021] [Accepted: 10/21/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To determine if OAB anticholinergics have an increased risk of delirium or falls/fractures relative to OAB beta-3 agonist medications. METHODS This was a retrospective, cohort study using linked administrative data from the universal healthcare system of Ontario, Canada. Participants were all residents >66 years of age who newly initiated an OAB medication between January 2016 and March 2020. Coprimary outcomes were evidence of a hospital visit with delirium, or for a fall/fracture. We used matching weights to make the three exposure groups (beta-3 agonist, oxybutynin, or newer OAB anticholinergics) comparable across 82 baseline characteristics. We examined both the risk during the first 30 days (logistic regression) and the risk during continuous usage (proportional hazards). RESULTS We identified 103 024 older adults who started OAB medications. With matching weights, all measured variables were similar. The 30-day incidence of delirium was 0.31%, and fall/fracture was 1.07%; there was no significantly increased risk of either delirium (oxybutynin users OR 1.28 [95% CI 0.84-1.96], newer OAB anticholinergic users OR 0.92 [95% CI 0.58-1.46]) or falls/fractures (oxybutynin users OR 1.19 [95% CI 0.95-1.49], newer OAB anticholinergic users OR 1.14 [95% CI 0.91-1.43]) compared to beta-3 agonist users. With continuous usage, there was an increased HR of delirium among users of newer anticholinergics (HR 1.13, 95% CI 1.02-1.26) and an increased HR for fall/fracture among oxybutynin users (HR 1.13, 95% CI 1.02-1.24). CONCLUSIONS Compared to beta-3 agonists, the continuous use of oxybutynin is associated with a significantly increased risk of fall/fracture, and newer OAB anticholinergics are associated with a significantly increased risk of delirium.
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Affiliation(s)
- Blayne Welk
- Department of Surgery and Epidemiology and Biostatistics, Western University, Ontario, London, Canada.,ICES, London, Ontario, Canada
| | - Khaled Etaby
- Department of Obstetrics and Gynecology, Western University, Ontario, London, Canada
| | | | - Queena Chou
- Department of Obstetrics and Gynecology, Western University, Ontario, London, Canada
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Campbell NL, Hines L, Epstein AJ, Walker D, Lockefeer A, Shiozawa A. A 12-Year Retrospective Study of the Prevalence of Anticholinergic Polypharmacy and Associated Outcomes Among Medicare Patients with Overactive Bladder in the USA. Drugs Aging 2021; 38:1075-1085. [PMID: 34746992 PMCID: PMC8651576 DOI: 10.1007/s40266-021-00901-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2021] [Indexed: 11/24/2022]
Abstract
Background and Objective Antimuscarinics, drugs with anticholinergic properties, are frequently prescribed for overactive bladder, and anticholinergic burden is associated with adverse events. The “Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults” (Poly-ACH) measure was developed by the Pharmacy Quality Alliance and is used by the Centers for Medicare and Medicaid Services. Using the Poly-ACH measure, we assessed the prevalence of anticholinergic polypharmacy among Medicare patients in the USA with overactive bladder and determined associations between polypharmacy and medical conditions, care, and spending. Methods This was a retrospective cohort study of Medicare beneficiaries with overactive bladder (coverage period: 2006–2017). Anticholinergic polypharmacy, measured by the Poly-ACH, was defined as concurrent use of two or more anticholinergics, each with two or more prescription claims on different dates of service for ≥ 30 cumulative days. Change in annual frequency of anticholinergic polypharmacy was assessed using logistic regression. Associations between anticholinergic polypharmacy over 3 years and falls, fractures, mental status, and medical care spending were assessed with longitudinal regression models. Results In total, 226,712 patients contributed 940,201 person-years of follow-up after overactive bladder diagnosis. The share of patients meeting the Poly-ACH definition was 3.3% in 2006 and 1.7% in 2017. Women and nursing home residents had higher risks of anticholinergic polypharmacy. Having 1 year or more of positive Poly-ACH status in the 3 years prior was associated with higher rates of all outcomes. Conclusions Anticholinergic polypharmacy was uncommon among older adults with overactive bladder. Prevalence was higher among women and nursing home residents, and it was associated with negative outcomes, highlighting potential longitudinal implications of anticholinergic burden. Supplementary Information The online version contains supplementary material available at 10.1007/s40266-021-00901-2.
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Affiliation(s)
- Noll L Campbell
- Purdue University College of Pharmacy, West Lafayette, IN, USA.,Indiana University Center for Aging Research, Indianapolis, IN, USA
| | - Lisa Hines
- Pharmacy Quality Alliance, Alexandria, VA, USA
| | | | - David Walker
- Medical Affairs, U.S., Astellas Pharma Global Development, Inc., 1 Astellas Way, Northbrook, IL, 60062, USA
| | - Amy Lockefeer
- Medical Affairs, U.S., Astellas Pharma Global Development, Inc., 1 Astellas Way, Northbrook, IL, 60062, USA
| | - Aki Shiozawa
- Medical Affairs, U.S., Astellas Pharma Global Development, Inc., 1 Astellas Way, Northbrook, IL, 60062, USA.
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Wilczyński K, Gorczyca M, Gołębiowska J, Szewieczek J. Anticholinergic Burden of Geriatric Ward Inpatients. MEDICINA-LITHUANIA 2021; 57:medicina57101115. [PMID: 34684152 PMCID: PMC8540218 DOI: 10.3390/medicina57101115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/06/2021] [Accepted: 10/11/2021] [Indexed: 12/03/2022]
Abstract
Background and Objectives: Anticholinergic drug use in the pharmacotherapy of elderly persons is common despite the increased risk of side effects. We examined the prevalence of anticholinergic drug use and total anticholinergic drug burden among patients admitted to an acute care geriatric ward in Poland. Materials and Methods: Cross-sectional study of 329 subjects hospitalized at the geriatric ward. Patient condition was assessed with a comprehensive geriatric assessment. The Anticholinergic Cognitive Burden (ACB) scale was used to estimate the total anticholinergic load. Results: Mean patient age was 79.61 ± 6.82 years. 40.73% of them were burdened with at least one anticholinergic drug. The clinically significant anticholinergic burden was observed in 13.98% of subjects. Patients with dementia, risk of falls, and severe disability had significantly higher total ACB scores compared to other groups. The receiver operating characteristics (ROC) curve revealed that the total ACB score ≥ 1 was significantly associated with dementia and the risk of falls. Total ACB score ≥ 2 was significantly associated with severe disability. Conclusions: Patients admitted to an acute care geriatric ward had an anticholinergic cognitive burden score comparable to other patient populations. We found associations at both low and elevated levels of anticholinergic burden with dementia and risk of falls. At elevated anticholinergic burden levels, we found associations with severe disability. Despite recommendations against the use of anticholinergics in older adults these medications are still commonly prescribed. Further study is necessary to define the characteristics of anticholinergic medication most closely associated with negative outcomes in elderly populations.
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Affiliation(s)
- Krzysztof Wilczyński
- Department of Geriatrics, Faculty of Health Sciences in Katowice, Medical University of Silesia, Ziołowa 45/47, 40-635 Katowice, Poland;
- Correspondence: ; Tel.: +48-(32)-359-8239; Fax: +48-(32)-205-9483
| | - Marta Gorczyca
- Student Scientific Interest Group, Department of Geriatrics, Faculty of Medical Sciences, Medical University of Silesia, Ziołowa 45/47, 40-635 Katowice, Poland; (M.G.); (J.G.)
| | - Jagna Gołębiowska
- Student Scientific Interest Group, Department of Geriatrics, Faculty of Medical Sciences, Medical University of Silesia, Ziołowa 45/47, 40-635 Katowice, Poland; (M.G.); (J.G.)
| | - Jan Szewieczek
- Department of Geriatrics, Faculty of Health Sciences in Katowice, Medical University of Silesia, Ziołowa 45/47, 40-635 Katowice, Poland;
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Xu XJ, Myint PK, Kioh SH, Mat S, Rajasuriar R, Kamaruzzaman SB, Tan MP. A five-year prospective evaluation of anticholinergic cognitive burden and falls in the Malaysian elders longitudinal research (MELoR) study. Arch Gerontol Geriatr 2021; 98:104535. [PMID: 34601313 DOI: 10.1016/j.archger.2021.104535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/22/2021] [Accepted: 09/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND While anticholinergic use is associated with stroke, dementia and mortality, few have evaluated its potential link with falls. To determine the relationship between anticholinergic cognitive burden (ACB) and falls over five years using the Malaysian Elders Longitudinal Research (MELoR). METHODS Community-dwelling adults aged 55 years and over were recruited through electoral roll sampling. Data obtained at baseline and follow-up (FU) at two and five years were included. Falls in the preceding 12 months were recorded. RESULTS Of the 1499 individuals (mean (SD) age= 68.9(7.5) yrs and 53.3% female) with information on baseline ACB exposure, 575(38.4%) had ACB scores of 1-2 and 117(7.8%) had ACB scores ≥3. Differences in age, ethnicity, smoking status, diabetes, hypertension, cardiovascular disease, arthritis and education existed between ACB groups. Fall occurrence differed between ACB groups at recruitment (p = 0.004) and 2-year FU (p = 0.001) but not at 5-year FU (p = 0.053). Logistic regression revealed an independent association between ACB 1-2 and falls at baseline (odds ratio, OR (95% confidence interval, CI) =1.412(1.035-1.926)) and ACB≥3 and falls at 2-yr FU (OR (95%CI) =2.098(1.032-4.263)) following adjustment for confounders. CONCLUSION Low level exposure to drugs with anticholinergic properties was associated cross-sectionally with falls, while exposure to higher levels were prospectively associated with falls at 2-year but not at 5-year FU. Future studies should determine whether avoidance of drugs with anticholinergic effects will lead to reduction in falls.
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Affiliation(s)
- Xiang Jiang Xu
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Phyo Kyaw Myint
- Ageing Clinical & Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, United Kingdom
| | - Sheng Hui Kioh
- Ageing Clinical & Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, United Kingdom; Department of Chiropractic, Centre for Complementary and Alternative Medicine (CCAM), International Medical University, Kuala Lumpur, Malaysia
| | - Sumaiyah Mat
- Physiotherapy Program, Centre for Health Ageing and Wellness, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Reena Rajasuriar
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Shahrul Bahyah Kamaruzzaman
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Maw Pin Tan
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Department of Medical Sciences, Faculty of Healthcare and Medical Sciences, Sunway University, Bandar Sunway, Selangor.
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Toepfer S, König M, Spira D, Drewelies J, Kreutz R, Bolbrinker J, Demuth I. Sex Differences in Characteristics Associated with Potentially Inappropriate Medication Use and Associations with Functional Capacity in Older Participants of the Berlin Aging Study II. Gerontology 2021; 68:664-672. [PMID: 34569530 DOI: 10.1159/000518411] [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: 12/13/2020] [Accepted: 07/04/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Medication safety is a vital aim in older adults' pharmacotherapy. Increased morbidity and vulnerability require particularly careful prescribing. Beneath avoiding unnecessary polypharmacy and prescribing omissions, physicians have to be aware of potentially inappropriate medications (PIMs) and related outcomes to optimize older adults' drug therapy, and to reduce adverse drug events. OBJECTIVE The aim of this study was to identify participants characteristics associated with PIM use and associations of PIM use with functional capacity with a focus on sex differences. METHODS Multivariable logistic regression analyses of cross-sectional Berlin Aging Study II (BASE-II) data (N = 1,382, median age 69 years, interquartile range 67-71, 51.3% women) were performed with PIM classification according to the EU(7)-PIM list. RESULTS In the overall study population, higher education was associated with lower odds of PIM use (odds ratio [OR] 0.93, confidence interval [CI] 95% 0.87-0.99, p = 0.017). Falls (OR 1.53, CI 95% 1.08-2.17, p = 0.016), frailty/prefrailty (OR 1.68, 1.17-2.41, p = 0.005), and depression (OR 2.12, CI 95% 1.32-3.41, p = 0.002) were associated with increased odds of PIM use. A better nutritional status was associated with lower odds of PIM use (OR 0.88, CI 95% 0.81-0.97, p = 0.008). In the sex-stratified analysis, higher education was associated with lower odds of PIM use in men (OR 0.90, CI 95% 0.82-0.99, p = 0.032). Frailty/prefrailty was associated with increased odds of PIM use in men (OR 2.04, CI 95% 1.18-3.54, p = 0.011) and a better nutritional status was associated with lower odds of PIM use in men (OR 0.83, CI 95% 0.72-0.96, p = 0.011). Falls in the past 12 months were related to an increased prevalence of PIM use in women (OR 1.74, CI 95% 1.10-2.75, p = 0.019). Depression was associated with a higher prevalence of PIM use in both men (OR 2.74, CI 95% 1.20-6.24, p = 0.016) and women (OR 2.06, CI 95% 1.14-3.71, p = 0.017). We did not detect sex differences regarding the overall use of drugs with anticholinergic effects, but more men than women used PIMs referring to the cardiovascular system (p = 0.036), while more women than men used PIMs referring to the genitourinary system and sex hormones (p < 0.001). CONCLUSION We found similarities, but also differences between men and women as to the associations between PIM use and participants' characteristics and functional capacity assessments. The association of lower education with PIM use may suggest that physicians' prescribing behavior is modified by patient education, a relationship that could evolve from more critical attitudes of educated patients towards medication use. We conclude that sex differences in associations of PIM use with functional capacities might be partly attributable to sex differences in drug classes used, but not with regard to anticholinergics, as these are used to a similar extent in men and women in the cohort studied here.
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Affiliation(s)
- Sarah Toepfer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Lipid Clinic at the Interdisciplinary Metabolism Center, Berlin, Germany,
| | - Maximilian König
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Lipid Clinic at the Interdisciplinary Metabolism Center, Berlin, Germany
| | - Dominik Spira
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Lipid Clinic at the Interdisciplinary Metabolism Center, Berlin, Germany
| | - Johanna Drewelies
- Humboldt-Universität zu Berlin, Department of Psychology, Berlin, Germany
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Juliane Bolbrinker
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Ilja Demuth
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Lipid Clinic at the Interdisciplinary Metabolism Center, Berlin, Germany.,Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BCRT - Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany
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Rosso AL, Marcum ZA, Zhu X, Bohnen N, Rosano C. Anticholinergic Medication Use, Dopaminergic Genotype, and Recurrent Falls. J Gerontol A Biol Sci Med Sci 2021; 77:1042-1047. [PMID: 34463739 DOI: 10.1093/gerona/glab258] [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: 06/18/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Anticholinergic medications are associated with fall risk. Higher dopaminergic signaling may provide resilience to these effects. We tested interactions between anticholinergic medication use and dopaminergic genotype on risk for recurrent falls over 10 years. METHODS Participants in the Health ABC study (n=2372, mean age=73.6; 47.8% men; 60.0% White) without disability or anticholinergic use at baseline were followed for up to 10 years for falls. Medication use was documented in 7 of 10 years. Highly anticholinergic medications were defined by Beers criteria, 2019. Recurrent falls were defined as ≥2 in the 12 months following medication assessment. Generalized estimating equations tested the association of anticholinergic use with recurrent falls in the following 12 months, adjusted for demographics, health characteristics, and anticholinergic use indicators. Effect modification by dopaminergic genotype (catechol-O-methyltransferase (COMT); Met/Met, higher dopamine signaling, n=454 vs Val carriers, lower dopamine signaling, n=1918) was tested and analyses repeated stratified by genotype. RESULTS During follow-up, 841 people reported recurrent falls. Anticholinergic use doubled the odds of recurrent falls (adjusted OR [95% CI]=2.09 (1.45, 3.03)), with suggested effect modification by COMT (p=0.1). The association was present in Val carriers (adjusted OR [95% CI]=2.16 (1.44, 3.23)) but not in Met/Met genotype (adjusted OR [95% CI]=1.70 (0.66, 4.41)). Effect sizes were stronger when excluding baseline recurrent fallers. CONCLUSION Higher dopaminergic signaling may provide protection against increased 12-month fall risk from anticholinergic use. Assessing vulnerability to the adverse effects of anticholinergic medications could help in determination of risk/benefit ratio for prescribing and deprescribing anticholinergics in older adults.
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Affiliation(s)
- Andrea L Rosso
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh
| | | | - Xiaonan Zhu
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh
| | - Nicolaas Bohnen
- Departments of Radiology and Neurology, School of Medicine, University of Michigan
| | - Caterina Rosano
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh
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Ruiz SJ, Cevallos V, Baskaran D, Mintzer MJ, Ruiz JG. The cross-sectional association of frailty with past and current exposure to strong anticholinergic drugs. Aging Clin Exp Res 2021; 33:2283-2289. [PMID: 33180283 DOI: 10.1007/s40520-020-01742-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 10/19/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Anticholinergic drugs may contribute to frailty by impairing cognitive and physical functions. Strong anticholinergic drugs in particular may have adverse effects among older adults. OBJECTIVES Determine the association between frailty and the use of strong anticholinergic drugs among older US Veterans. METHODS This is a cross-sectional study of community-dwelling Veterans 65 years and older who had determinations of frailty status. Prescription data for patients using strong anticholinergic medications (never/past/current) was obtained via electronic health records. A 31-item VA Frailty Index (VA-FI) was generated at the time of the assessment. We dichotomized the groups into non-frail (FI = < 0.21) and frail (FI ≥ 0.21) patients. We used binomial logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Frailty was the dependent variable and use of strong anticholinergic drugs was the independent variable. Multivariate adjustment was conducted for age, gender, race, ethnicity, marital status, and BMI. RESULTS Population sample consisted of 17,084 Veterans who were 71.05% Caucasian, 97.34% male, and with a mean age 75.60 (SD = 8.04) years. Among the population, 9940 (58.18%) patients had no previous use of strong anticholinergic drugs, whereas 5182 (30.33%) had past exposure and 1962 (11.49%) had current exposure. In binomial logistic regression, individuals with past (OR 3.27, 95% CI 3.03-3.54, p < 0.0005) or current (OR 4.78, 95% CI 4.30-5.31, p < 0.0005) exposure showed a higher association with frailty as compared to individuals who were never exposed. CONCLUSIONS Past and current use of strong anticholinergic drugs were associated with frailty in older Veterans. These results suggest that screening for frailty in patients with past or current exposure to strong anticholinergic medications may be necessary for proper management.
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Affiliation(s)
- Sergio J Ruiz
- Miami VA Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Veterans Successful Aging for Frail Elders (VSAFE), 1201 NW 16th Street, Miami, FL, 33125, USA
| | - Victor Cevallos
- Miami VA Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Veterans Successful Aging for Frail Elders (VSAFE), 1201 NW 16th Street, Miami, FL, 33125, USA
| | - Dhanya Baskaran
- Miami VA Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Veterans Successful Aging for Frail Elders (VSAFE), 1201 NW 16th Street, Miami, FL, 33125, USA
| | - Michael J Mintzer
- Miami VA Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Veterans Successful Aging for Frail Elders (VSAFE), 1201 NW 16th Street, Miami, FL, 33125, USA
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jorge G Ruiz
- Miami VA Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Veterans Successful Aging for Frail Elders (VSAFE), 1201 NW 16th Street, Miami, FL, 33125, USA.
- University of Miami Miller School of Medicine, Miami, FL, USA.
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Stewart C, Taylor-Rowan M, Soiza RL, Quinn TJ, Loke YK, Myint PK. Anticholinergic burden measures and older people's falls risk: a systematic prognostic review. Ther Adv Drug Saf 2021; 12:20420986211016645. [PMID: 34104401 PMCID: PMC8170331 DOI: 10.1177/20420986211016645] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/18/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Several adverse outcomes have been associated with anticholinergic burden (ACB), and these risks increase with age. Several approaches to measuring this burden are available but, to date, no comparison of their prognostic abilities has been conducted. This PROSPERO-registered systematic review (CRD42019115918) compared the evidence behind ACB measures in relation to their ability to predict risk of falling in older people. Methods Medline (OVID), EMBASE (OVID), CINAHL (EMBSCO) and PsycINFO (OVID) were searched using comprehensive search terms and a validated search filter for prognostic studies. Inclusion criteria included: participants aged 65 years and older, use of one or more ACB measure(s) as a prognostic factor, cohort or case-control in design, and reporting falls as an outcome. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. Results Eight studies reporting temporal associations between ACB and falls were included. All studies were rated high risk of bias in ⩾1 QUIPS tool categories, with five rated high risk ⩾3 categories. All studies (274,647 participants) showed some degree of association between anticholinergic score and increased risk of falls. Findings were most significant with moderate to high levels of ACB. Most studies (6/8) utilised the anticholinergic cognitive burden scale. No studies directly compared two or more ACB measures and there was variation in how falls were measured for analysis. Conclusion The evidence supports an association between moderate to high ACB and risk of falling in older people, but no conclusion can be made regarding which ACB scale offers best prognostic value in older people. Plain language summary A review of published studies to explore which anticholinergic burden scale is best at predicting the risk of falls in older people Introduction: One third of older people will experience a fall. Falls have many consequences including fractures, a loss of independence and being unable to enjoy life. Many things can increase the chances of having a fall. This includes some medications. One type of medication, known as anticholinergic medication, may increase the risk of falls. These medications are used to treat common health issues including depression and bladder problems. Anticholinergic burden is the term used to describe the total effects from taking these medications. Some people may use more than one of these medications. This would increase their anticholinergic burden. It is possible that reducing the use of these medications could reduce the risk of falls. We need to carry out studies to see if this is possible. To do this, we need to be able to measure anticholinergic burden. There are several scales available, but we do not know which is best.Methods: We wanted to answer: 'Which anticholinergic scale is best at predicting the risk of falling in older people?'. We reviewed studies that could answer this. We did this in a systematic way to capture all published studies. We restricted the search in several ways. We only included studies relevant to our question.Results: We found eight studies. We learned that people who are moderate to high users of these medications (often people who will use more than one of these medications) had a higher risk of falling. It was less clear if people who have a lower burden (often people who only use one of these medications) had an increased risk of falling. The low number of studies prevented us from determining if one scale was better than another.Conclusion: These findings suggest that we should reduce use of these medications. This could reduce the number falls and improve the well-being of older people.
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Affiliation(s)
- Carrie Stewart
- Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, Rm 1.128, Polwarth Building, Foresterhill Health Campus, Aberdeen, AB25 2ZD, UK
| | - Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Roy L Soiza
- Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Phyo Kyaw Myint
- Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, UK
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Krüger C, Schäfer I, van den Bussche H, Bickel H, Fuchs A, Gensichen J, König HH, Maier W, Mergenthal K, Riedel-Heller SG, Schön G, Weyerer S, Wiese B, von Renteln-Kruse W, Langebrake C, Scherer M. Anticholinergic drug burden according to the anticholinergic drug scale and the German anticholinergic burden and their impact on cognitive function in multimorbid elderly German people: a multicentre observational study. BMJ Open 2021; 11:e044230. [PMID: 33757948 PMCID: PMC7993236 DOI: 10.1136/bmjopen-2020-044230] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The aims of our study were to examine the anticholinergic drug use and to assess the association between anticholinergic burden and cognitive function in the multimorbid elderly patients of the MultiCare cohort. SETTING MultiCare was conducted as a longitudinal cohort study in primary care, located in eight different study centres in Germany. PARTICIPANTS 3189 patients (59.3% female). PRIMARY AND SECONDARY OUTCOME MEASURES Baseline data were used for the following analyses. Drugs were classified according to the well-established anticholinergic drug scale (ADS) and the recently published German anticholinergic burden (German ACB). Cognitive function was measured using a letter digit substitution test (LDST) and a mixed-effect multivariate linear regression was performed to calculate the influence of anticholinergic burden on the cognitive function. RESULTS Patients used 1764 anticholinergic drugs according to ADS and 2750 anticholinergics according to the German ACB score (prevalence 38.4% and 53.7%, respectively). The mean ADS score was 0.8 (±1.3), and the mean German ACB score was 1.2 (±1.6) per patient. The most common ADS anticholinergic was furosemide (5.8%) and the most common ACB anticholinergic was metformin (13.7%). The majority of the identified anticholinergics were drugs with low anticholinergic potential: 80.2% (ADS) and 73.4% (ACB), respectively. An increasing ADS and German ACB score was associated with reduced cognitive function according to the LDST (-0.26; p=0.008 and -0.24; p=0.003, respectively). CONCLUSION Multimorbid elderly patients are in a high risk for using anticholinergic drugs according to ADS and German ACB score. We especially need to gain greater awareness for the contribution of drugs with low anticholinergic potential from the cardiovascular system. As anticholinergic drug use is associated with reduced cognitive function in multimorbid elderly patients, the importance of rational prescribing and also deprescribing needs to be further evaluated. TRIAL REGISTRATION NUMBER ISRCTN89818205.
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Affiliation(s)
- Caroline Krüger
- Department of Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ingmar Schäfer
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hendrik van den Bussche
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Horst Bickel
- Department of Psychiatry, Technical University of Munich, Munich, Germany
| | - Angela Fuchs
- Institute of General Practice, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Jochen Gensichen
- Institute of General Practice and Family Medicine, Ludwig-Maximilians-Universitat Munich, Munich, Germany
- Institut for General Practice, Jena University Hospital, Jena, Germany
| | - Hans-Helmut König
- Department for Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Maier
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
| | - Karola Mergenthal
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Siegfried Weyerer
- Department of Medical Faculty Mannheim/Heidelberg, Central Institute of Mental Health, Mannheim, Germany
| | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Wolfgang von Renteln-Kruse
- Department of Research, Albertinen-Haus Zentrum fur Geriatrie und Gerontologie Medizinisch-Geriatrische Klinik, Hamburg, Germany
| | - Claudia Langebrake
- Department of Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Scherer
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Prevalence and Factors Associated with Cumulative Anticholinergic Burden Among Older Long-Stay Nursing Home Residents with Overactive Bladder. Drugs Aging 2021; 38:311-326. [PMID: 33682017 PMCID: PMC8007511 DOI: 10.1007/s40266-021-00833-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Overactive bladder (OAB), the primary cause of urinary incontinence in nursing homes, is commonly treated with anticholinergic medications; however, the elderly population is vulnerable to the adverse effects associated with anticholinergic burden. Given the relatively high prevalence of OAB among nursing home residents, it is important to understand the magnitude of anticholinergic burden in this population. OBJECTIVES The objectives of this study were to (1) examine the prevalence of cumulative anticholinergic burden among long-stay nursing home (LSNH) residents with OAB; and (2) identify the factors associated with varying levels of cumulative anticholinergic burden. METHODS This was a retrospective, cohort study using Minimum Data Set-linked Medicare claims data. Anticholinergic burden was determined based on the Anticholinergic Cognitive Burden scale and patient-specific dosing using defined daily dose. The Andersen Behavioral Model framework was used to identify the predisposing, enabling, and need factors associated with levels of anticholinergic burden. Multivariable logistic regression models were developed to determine the factors associated with levels of anticholinergic burden. RESULTS A total of 123,308 LSNH residents with OAB were identified; 87.2% had some degree of anticholinergic burden and 27.3% had high cumulative burden. Multiple factors were associated with higher levels of burden, including younger age, female sex, and non-Hispanic White ethnicity (predisposing factors); dual eligibility, Southern geographic region, and rural residence (enabling factors); and a number of comorbidities and concomitant medications (need factors). CONCLUSIONS This study revealed a high level of anticholinergic burden among LSNH residents. Multiple factors were associated with a high level of burden. There is a need to optimize the use of anticholinergics due to their significant safety concerns in the LSNH setting.
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Association of lower urinary tract symptoms and hip fracture in adults aged ≥ 50 years. PLoS One 2021; 16:e0246653. [PMID: 33657118 PMCID: PMC7928482 DOI: 10.1371/journal.pone.0246653] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/24/2021] [Indexed: 11/25/2022] Open
Abstract
Aim Lower urinary tract symptoms (LUTS) result in morbidities; however, their association with the occurrence of hip fracture is relatively unknown in the context of Asian studies. The purpose of the study was to investigate this link with the hip fracture risk in Taiwanese men and women aged 50 years and above. Materials and methods From 2000 through 2012, a population-based retrospective cohort study was conducted; claims data of 18,976 patients diagnosed with LUTS (dysuria, urinary retention, incontinence, and increased urinary frequency and urgency) were retrieved from Taiwan’s National Health Insurance Research Database. The patients were compared with 1:2 age, sex, and index year-matched controls (comparison group, n = 37,952). The incidence and hazard ratios of the hip fracture risk were calculated by the Cox proportional hazard regression models. Results The mean age was 66.2 ± 9.7 years, and the proportion of men was 58.1% in both study groups. Fractures occurred in 772 patients and 1,156 control subjects. The corresponding incidences were 7.0 and 5.0/1000 person-years. Compared to the control subjects, the patients with LUTS had an increased hip fracture risk [adjusted hazard ratio (aHR) = 1.29; 95% confidence interval (CI): 1.17–1.42]. LUTS was independently associated with an increased hip fracture risk in both men (aHR = 1.24; 95% CI: 1.08–1.42) and women (aHR = 1.34; 95% CI: 1.18–1.53) (p for interaction = 0.557). Similarly, the subgroup effect of age on hip fracture risks was not found (p for interaction = 0.665). Conclusion The study found LUTS was associated with an increased risk of hip fracture. Large-scale prospective studies in diverse populations are required to investigate causalities.
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Dmochowski RR, Thai S, Iglay K, Enemchukwu E, Tee S, Varano S, Girman C, Radican L, Mudd PN, Poole C. Increased risk of incident dementia following use of anticholinergic agents: A systematic literature review and meta-analysis. Neurourol Urodyn 2020; 40:28-37. [PMID: 33098213 PMCID: PMC7821204 DOI: 10.1002/nau.24536] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/17/2020] [Accepted: 10/01/2020] [Indexed: 12/15/2022]
Abstract
Background/rationale Long‐term treatment with anticholinergic agents may increase the risk of cognitive impairment or dementia. This systematic literature review and meta‐analysis aimed to assess the impact of ≥3 months of exposure to anticholinergics as a class on the risk of dementia, mild cognitive impairment, and change in cognitive function. The impact of anticholinergic agents specifically used to treat overactive bladder was also evaluated. Materials and Methods A systematic literature review was conducted to identify English language articles evaluating the impact of anticholinergic use for ≥3 months on dementia or cognitive function in adult patients. Databases searched included PubMed, Embase, and the Cochrane Library. Meta‐analyses were conducted using random‐effects models; 95% confidence intervals (CIs) and 95% prediction intervals (PIs) were reported. Results A total of 2122 records were identified. Out of those, 21 studies underwent qualitative synthesis and 6 reported endpoints relevant for inclusion in a meta‐analysis assessing the risk of incident dementia. The overall rate ratio for incident dementia was 1.46 (95% CI: 1.17–1.81; 95% PI: 0.70–3.04; n = 6). The risk of incident dementia increased with increasing exposure (n = 3). In addition, two studies from the meta‐analysis reported an increased risk of dementia with ≥3 months of use of bladder antimuscarinics (adjusted odds ratios ranged from 1.21 to 1.65, depending on exposure category). Conclusion Anticholinergic use for ≥3 months increased the risk of dementia on average by an estimated 46% versus nonuse. This relationship was consistent in studies assessing overactive bladder medications. The risk of developing dementia should be carefully considered in the context of potential benefit before prescribing anticholinergics.
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Affiliation(s)
- Roger R Dmochowski
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sydney Thai
- Department of Pharmacoepidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,CERobs Consulting, LLC, Chapel Hill, North Carolina, USA
| | - Kristy Iglay
- CERobs Consulting, LLC, Chapel Hill, North Carolina, USA.,Laylen Scientific Solutions, LLC, Flemington, New Jersey, USA
| | - Ekene Enemchukwu
- Department of Urology, School of Medicine, Stanford University, Stanford, California, USA
| | - Silvia Tee
- School of Medicine, Section of Geriatric Medicine - Primary Care and Population Health, Stanford University, Stanford, California, USA
| | - Susann Varano
- Clinical Research Consulting, Milford, Connecticut, USA
| | - Cynthia Girman
- Department of Pharmacoepidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,CERobs Consulting, LLC, Chapel Hill, North Carolina, USA
| | - Larry Radican
- Peloton Advantage, an Open Health Company, Parsippany, New Jersey, USA
| | - Paul N Mudd
- Clinical Development, Urovant Sciences, Inc., Durham, North Carolina, USA
| | - Charles Poole
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
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23
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Araklitis G, Baines G, da Silva AS, Robinson D, Cardozo L. Recent advances in managing overactive bladder. F1000Res 2020; 9:F1000 Faculty Rev-1125. [PMID: 32968482 PMCID: PMC7489273 DOI: 10.12688/f1000research.26607.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 12/15/2022] Open
Abstract
Overactive bladder syndrome (OAB) is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency incontinence, in the absence of urinary tract infection or other obvious pathology. In this review, we focus on recent advances in the management of OAB. We examine the evidence on the effect of anticholinergic load on OAB patients. Advances in medical treatment include a new beta-3 agonist, vibegron, which is thought to have fewer drug interactions than mirabegron. Treatment of genitourinary syndrome of the menopause with oestrogens and ospemifene have also shown promise for OAB. Botulinum toxin has been shown to be an effective treatment option. We discuss the new implantable neuromodulators that are on the market as well as selective bladder denervation and laser technology.
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Affiliation(s)
- George Araklitis
- Department of Urogynaecology, King’s College Hospital, London, UK
| | - Georgina Baines
- Department of Urogynaecology, King’s College Hospital, London, UK
| | | | - Dudley Robinson
- Department of Urogynaecology, King’s College Hospital, London, UK
| | - Linda Cardozo
- Department of Urogynaecology, King’s College Hospital, London, UK
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24
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Tan MP, Tan GJ, Mat S, Luben RN, Wareham NJ, Khaw KT, Myint PK. Use of Medications with Anticholinergic Properties and the Long-Term Risk of Hospitalization for Falls and Fractures in the EPIC-Norfolk Longitudinal Cohort Study. Drugs Aging 2020; 37:105-114. [PMID: 31808140 DOI: 10.1007/s40266-019-00731-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The consumption of medications with anticholinergic activity has been suggested to result in the adverse effects of mental confusion, visual disturbance, and muscle weakness, which may lead to falls. Existing published evidence linking anticholinergic drugs with falls, however, remains weak. This study was conducted to evaluate the relationship between anticholinergic cognitive burden (ACB) and the long-term risk of hospitalization with falls and fractures in a large population study. The dataset comprised information from 25,639 men and women (aged 40-79 years) recruited from 1993 to 1997 from Norfolk, United Kingdom into the European Prospective Investigation into Cancer (EPIC)-Norfolk study. The time to first hospital admission with a fall with or without fracture was obtained from the National Health Service hospital information system. Cox-proportional hazards analyses were conducted to adjust for confounders and competing risks. The fall hospitalization rate was 5.8% over a median follow-up of ~ 19.4 years. The unadjusted incidence rate ratio for the use of any drugs with anticholinergic properties was 1.79 (95% CI 1.66-1.93). The hazard ratios (95% CI) for ACB scores of 1, 2-3, and ≥ 4 compared with ACB = 0 for fall hospitalization were 1.20 (1.09-1.33), 1.42 (1.25-1.60), and 1.39 (1.21-1.60) after adjustment for age, gender, medical conditions, physical activity, and blood pressure. Medications with anticholinergic activity are associated with an increased risk of subsequent hospitalization with a fall over a 19-year follow-up period. The biological mechanisms underlying the long-term risk of hospitalization with a fall or fracture following baseline ACB exposure remains unclear and requires further evaluation.
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Affiliation(s)
- Maw Pin Tan
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
- Department of Medical Sciences, Faculty of Healthcare and Medical Sciences, Sunway University, Bandar Sunway, Malaysia.
| | - Guo Jeng Tan
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sumaiyah Mat
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Robert N Luben
- Clinical Gerontology Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Kay-Tee Khaw
- Clinical Gerontology Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Phyo Kyaw Myint
- Clinical Gerontology Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
- Ageing Clinical and Experimental Research (ACER) Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK.
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25
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Raju R, Linder BJ. Evaluation and Treatment of Overactive Bladder in Women. Mayo Clin Proc 2020; 95:370-377. [PMID: 32029089 DOI: 10.1016/j.mayocp.2019.11.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/28/2019] [Accepted: 11/25/2019] [Indexed: 11/23/2022]
Abstract
Overactive bladder (OAB) is a symptom complex that includes urinary urgency, frequency, urgency incontinence, and nocturia. It is highly prevalent, affecting up to 12% of the adult population, and can significantly impact quality of life. The diagnosis of OAB is made by history, physical examination, and a urinalysis to rule out underlying infection or other concerning potential etiologies. The need for additional testing is based on the initial evaluation findings, and is recommended in cases of underlying urinary tract infection, microscopic hematuria, obstructive voiding symptoms, and symptoms refractory to previous treatments. Initial management includes behavioral modification with attention to total daily fluid intake, avoidance of bladder irritants, treatment of constipation, weight loss, timed voiding, urge-suppression techniques, and pelvic floor physical therapy. Options for oral medications include antimuscarinic agents and β adrenergic agents, and can be used following or in conjunction with behavioral treatment. For patients refractory to behavioral therapy and oral medications, consideration should be given to referral to a specialist (eg, a urologist or urogynecologist) for discussion of more advanced therapies such as sacral neuromodulation, percutaneous tibial nerve stimulation, and intradetrusor injection of onabotulinumtoxinA. These more advanced treatments have favorable efficacy compared with oral agents in randomized trials, although each has a unique risk/benefit profile and shared decision-making with the individual patient is crucial. Here, we review pertinent considerations in the clinical evaluation and management of OAB in women.
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Affiliation(s)
- Rubin Raju
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN
| | - Brian J Linder
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN; Department of Urology, Mayo Clinic, Rochester, MN.
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