Polypharmacy is associated with functional decline in Alzheimer's disease and Lewy body dementia

Impact of Polypharmacy on Symptoms and Health Outcomes in Older Adults With and Without Alzheimer's Disease and Related Dementias

BACKGROUND

There is a critical gap in understanding the symptom experience and health outcomes of older adults with and without Alzheimer's Disease and related dementias (ADRD) and polypharmacy (PPY). The primary aim of the study was to compare the number of symptoms experienced over time in older adults with and without ADRD by polypharmacy status. The secondary aim was to examine the trajectory of physical function and health outcomes over time in each group.

METHODS

This study utilized longitudinal data from the National Health and Aging Trends Study, a nationally representative sample of Medicare beneficiaries from 2016-2019. The sample was separated into four groups (N = 2,052): neither ADRD or PPY (n = 1,048), PPY only (n = 761), ADRD only (n = 116), and both ADRD and PPY(n = 127).

RESULTS

The overall sample was predominately female (57.9%), White (70.9%), aged 84 or younger (75%), married (46%), and had some college or a college degree (50%). Participants with both ADRD and PPY experienced more symptoms on average, had higher odds of falls, hospitalizations, and mortality than all other groups. Older adults with both ADRD and PPY had lower physical function, needed more assistance with activities of daily living and higher assistive device utilization compared to the other three groups.

CONCLUSIONS

Findings indicate that older adults with both ADRD and PPY experience more symptoms, negative health outcomes and physical function decline that can negatively impact their quality of life. Further research is needed to identify strategies for reducing PPY in people with ADRD.

Assessment and management of frailty in individuals living with dementia: expert recommendations for clinical practice

Frailty complicates the care of individuals with dementia, increasing their vulnerability to adverse outcomes. This Personal View presents expert recommendations for managing frailty in individuals with dementia, aimed at health-care providers, particularly those in primary care. We conducted a rapid literature review followed by a consensus process involving 18 international experts on dementia and frailty. The experts identified key areas, including diagnosis of frailty, assessment of nutritional status and nutritional management, physical activity, prevention of falls, and polypharmacy management. The recommendations emphasise early identification of frailty and a comprehensive, interdisciplinary approach to care that aims to maintain the individual's daily functioning, quality of life, and independence. The recommendations highlight the importance of tailored interventions, regular monitoring, and the integration of psychosocial support into the therapeutic approach. These recommendations address a crucial gap in existing clinical guidelines, offering practical guidance for clinicians managing frailty in individuals with dementia.

Association between Polypharmacy and Adverse Events in Patients with Alzheimer's Disease: An Analysis of the Japanese Adverse Drug Event Report Database (JADER)

Background and Objectives: Alzheimer's disease is a global health concern, with a rising prevalence among the elderly. Current pharmacological treatments, including acetylcholinesterase inhibitors (AChEIs) and N-Methyl D-Aspartate (NMDA) receptor antagonists, are associated with adverse events (AEs), particularly in the context of polypharmacy. This study aimed to investigate the relationship between Alzheimer's disease treatment combinations, the number of concomitant medications, and the occurrence of AEs. Materials and Methods: Data from the Japanese Adverse Drug Event Report database, spanning from April 2004 to June 2020, were analyzed. Patients aged 60 and older with Alzheimer's disease treated with AChEIs (donepezil, galantamine, and rivastigmine) or the NMDA receptor antagonist memantine were included. Logistic regression models were employed to assess the association between AEs and Alzheimer's disease drug combinations, as well as the number of concomitant medications. Results: Among 2653 patients, 47.7% were prescribed five or more drugs. The frequency of AEs was 6.4% for bradycardia, 4.6% for pneumonia, 3.6% for altered state of consciousness, 3.5% for seizures, 3.5% for decreased appetite, 3.5% for vomiting, 3.4% for loss of consciousness, 3.4% for fracture, 3.2% for cardiac failure, and 3.0% for falls. The combination of memantine with AChEIs was associated with a higher risk of bradycardia, whereas donepezil alone was linked to a reduced risk of fractures and falls. Polypharmacy was significantly correlated with an increased incidence of AEs, particularly altered state of consciousness, decreased appetite, vomiting, and falls. The adjusted odds ratios for using five or more drugs compared to no drugs was 10.45 for altered state of consciousness, 7.92 for decreased appetite, 4.74 for vomiting, and 5.95 for falls. Conclusions: In the treatment of Alzheimer's disease, the occurrence of AEs is associated with the number of concurrent medications, independently of the known AEs of Alzheimer's disease drugs and their combination patterns.

The relationship between anticholinergic burden and frailty in the year preceding a diagnosis of dementia with Lewy bodies

INTRODUCTION

Little is known regarding the relationship between anticholinergic medications and frailty in dementia with Lewy bodies (DLB).

METHODS

Anticholinergic Cognitive Burden Scale (ACB) and Claims-based Frailty Index scores were calculated for 12 months prior to the dementia diagnosis using electronic medical record and claims data. Logistic regression was used to estimate the association between ACB and odds of frailty.

RESULTS

Compared to controls (n = 525), a diagnosis of DLB (n = 175; adjusted odds ratio [aOR]: 15.1, 95% confidence interval [CI]: 7.0-33.9) or Alzheimer's disease (AD: n = 525; aOR = 7.7, 95% CI: 4.4-13.7) was associated with an increased odds of frailty. Patients with DLB had greater prescriptions for anticholinergic medications than patients with AD (p B < 0.001; 23%  vs 9.7%). ACB was positively correlated with frailty for all groups (r = 0.30 to 0.47, p < 0.001).

DISCUSSION

Cumulative anticholinergic burden may be a modifiable predictor of frailty among older adults, including those newly diagnosed with dementia.

Highlights

Patients with newly diagnosed dementia with Lewy bodies (DLB) are more likely to have prescriptions for anticholinergic medications relative to patients newly diagnosed with Alzheimer's disease (AD) and older adults without documented cognitive impairment.In the year prior to a documented dementia diagnosis, 74% of patients with DLB and 66% of patients with AD had evidence of frailty.Anticholinergic medication burden was associated with frailty among all older adults in the study, including those without a dementia diagnosis.

BPSD Patterns in Patients With Severe Neuropsychiatric Disturbances: Insight From the RECAGE Study

OBJECTIVE

Behavioral and psychological symptoms of dementia (BPSD) profiles vary depending on etiology in patients with mild-to-moderate BPSD. It is not known if similar differences exist in patients with severe BPSD.

METHODS

We analyzed data collected at baseline in 398 patients with severe BPSD (NPI ≥ 32) and defined diagnosis of dementia (Alzheimer's disease [AD] 297; frontotemporal dementia [FTD] 39; Lewy body disease/Parkinsonian dementia [LBD/PD] 31; and vascular dementia [VD] 31) included in the European multicenter cohort RECAGE.

RESULTS

Mean total NPI was 52.11 (18.55). LBD/PD patients demonstrated more hallucinations, more anxiety and more delusions than patients with other dementia. FTD patients had less delusions and more disinhibition than patients with other neurodegenerative disorders. These profiles overlapped partially with those reported in the literature in patients with less severe symptoms.

CONCLUSION

Patients with severe BPSD display different and specific profiles of neuropsychiatric symptoms depending on dementia etiology.

How to manage comorbidities in people with dementia: A scoping review

BACKGROUND

People with dementia experience a high prevalence of comorbidities that seriously affect patient outcomes. The aim of this study was to map the evidence and components related to comorbidity management, including interventions to facilitate and support the practice of management.

METHODS

A scoping review was conducted. In June 2022, PubMed, Web of Science, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), The National Institute of Health and Care Excellence (NICE), Open grey, and the Cochrane Library were searched to identify relevant literature. The inclusion criteria were outlined to identify studies on comorbidity management in people with dementia.

RESULTS

We found 43 items that met the inclusion criteria. The majority of the studies were published since 2010. Most research focused on medication management, health care service use and provision, and comorbidity-related monitoring and management; there were a small number of studies that involved decision-making. Only 6 studies developed interventions to support dementia care, which included comorbidity management. Studies involving the comorbidity management process were mainly based on qualitative methods, which make it difficult to quantify the impact of these processes on comorbidity management.

CONCLUSIONS

Given the serious impact of dementia on managing comorbidities, there is a need to develop systematic interventions targeting the management of comorbidities.

Assessment of clinical features and coexisting geriatric syndromes in newly diagnosed dementia with Lewy bodies: a retrospective study in a tertiary geriatrics setting in Turkey

PURPOSE

Identifying the associated clinical conditions in patients with newly diagnosed dementia with Lewy bodies (DLB) may contribute to the disease management. This study aimed to examine the clinical features and coexisting geriatric syndromes of patients with newly diagnosed DLB.

METHOD

This cross-sectional study included newly diagnosed DLB participants who were admitted to a tertiary geriatric outpatient clinic. Of the 857 patients with dementia, 116 DLB diagnoses were eligible for analysis. The core and supportive clinical features of DLB were recorded. Geriatric syndromes including polypharmacy, depression, insomnia, dependency, a history of delirium, falls, malnutrition, urinary incontinence, functional impairment, and living alone, were assessed and recorded at baseline.

RESULTS

The mean age was 79.0 ± 6.9 years, and 50.9% of the participants were female. The majority (63.8%) had mild dementia, 31.9% had moderate, and 4.3% had severe disease. Cognitive fluctuations (78.4%), visual hallucinations (77.6%), and Parkinsonism (73.3%) were the most common clinical features. Functional impairment (59.5%) and urinary incontinence (59.5%) were the leading geriatric syndromes, followed by polypharmacy (56.9%), depressive symptoms (54.7%), falls (52.6%), insomnia (49.1%), malnutrition (24.3%), and delirium (6.0%). Women had more functional impairment and depressive symptoms than men.

CONCLUSION

Although most patients had mild dementia, three-quarters of the DLB cohort had hallucinations, and nearly two-thirds were functionally impaired. The proportion of other serious health conditions also increased, indicating a high comorbidity and geriatric syndrome burden. Comprehensive geriatric assessment is strongly recommended for DLB patients from the time of diagnosis until death to reduce disability and comorbidities.

THE CLINICAL TRIAL REGISTRATION NUMBER

NCT05052450.

Functional loss and worsening geriatric assessment parameters are more common in dementia with Lewy bodies than Alzheimer's disease

BACKGROUND

The main aim of this study was to compare older patients with Alzheimer's disease (AD) to those with dementia with Lewy bodies (DLB) according to their dependency in daily living activities and comprehensive geriatric assessment parameters.

METHOD

A total of 227 AD and 123 DLB patients underwent a geriatric assessment that included comorbidities, number of drugs used, falls, urinary incontinence, hand grip strength, Mini-Nutritional Assessment (MNA), Tinetti Performance Oriented Mobility Assessment Scale, Insomnia Severity Index (ISI), and Epworth Sleepiness Scale. Basic and instrumental activities of daily living were assessed by the Barthel Index and the Lawton scale, respectively.

RESULTS

The mean age of the participants was 83.4 years, and 73% were female. There were no statistically significant differences between AD and DLB patients in age, gender, cognitive function, or comorbidities except for coronary artery disease (P < 0.05). The number of falls, drugs used, and ISI and Epworth scores were higher in patients with DLB than patients with AD (P < 0.05). DLB patients had lower MNA, Tinetti scale, and hand grip strength scores than AD patients. The ratio of patients highly dependent in basic daily activities as a whole was significantly greater in DLB than in AD (P < 0.05), but there was no significant difference in the overall levels of dependency in instrumental activities.

CONCLUSION

DLB patients are more dependent on their caregivers than AD patients. Nutritional deterioration, sleep disorders, falls, balance and gait problems, decreased muscle strength, and multiple drug use are more common in those with DLB compared to those with AD. The management of older patients with DLB may be more difficult than older patients with AD.

The association of potentially inappropriate medications, polypharmacy and anticholinergic burden with readmission and emergency room revisit after discharge: A hospital-based retrospective cohort study

AIMS

While certain drug-use indicators are known to be associated with clinical outcomes, the relationship is unclear for some highly prevalent conditions in in patients aged ≥65 years. We examine correlations between 3 drug-use indicators and postdischarge healthcare services use by older patients according to the presence of dementia, advanced age and frailty.

METHODS

This retrospective cohort study analysed data collected from hospital electronic health records between April and December 2017. Potentially inappropriate medications (PIMs) and anticholinergic burden were assessed using the 2015 Beers Criteria and anticholinergic cognitive burden scale (ACBS) score. Minor and major polypharmacy were defined as the use of 5-9 and ≥10 drugs, respectively. Outcomes were set as emergency room revisits and readmissions at 1, 3 and 6 months postdischarge. The correlation between drug-use indicators and outcomes was analysed by multivariable logistic regression.

RESULTS

The final cohort included 3061 patients for the analysis, and 2930, 2671 and 2560 patients were followed up to 1, 3 and 6 months after discharge. After controlling for confounders, all 3 drug-use indicators were significantly associated with readmission and emergency room revisits except for the relationship between PIMs and readmission within 6 months. These associations were significantly observed among patients without dementia, aged >80 years and with frailty.

CONCLUSION

PIMs, polypharmacy and anticholinergic burden are common at discharge and correlate with future use of healthcare services. In older patients, the absence of dementia, advanced age and frailty should be given extra consideration with regard to medication safety.

Sleep disturbances in Lewy body dementia: A systematic review

BACKGROUND

Lewy body dementia (LBD) refers to both dementia with Lewy bodies (DLB) and Parkinson's disease with dementia (PDD). Sleep disturbances are common in LBD, and can include poor sleep quality, excessive daytime sleepiness (EDS), and rapid eye movement behaviour disorder (RBD). Despite the high clinical prevalence of sleep disturbances in LBD, they are under-studied relative to other dementias. The aim of the present systematic review was to examine the nature of sleep disturbances in LBD, summarise the effect of treatment studies upon sleep, and highlight specific and necessary directions for future research.

METHODS

Published studies in English were located by searching PubMED and PSYCArticles databases (until 10 June 2022). The search protocol was pre-registered in PROSPERO (CRD42021293490) and performed in accordance with PRISMA guidelines.

RESULTS

Following full-text review, a final total of 70 articles were included. These included 20 studies focussing on subjective sleep, 14 on RBD, 8 on EDS, 7 on objective sleep, and 1 on circadian rhythms. The majority of the 18 treatment studies used pharmacological interventions (n = 12), had an open-label design (n = 8), and were of low-to-moderate quality. Most studies (n = 55) included only patients with DLB. Due to the heterogeneity of the studies, we reported a narrative synthesis without meta-analysis.

CONCLUSIONS

At least one form of sleep disturbance may be present in as many as 90% of people with LBD. Subjectively poor sleep quality, excessive daytime sleepiness, and RBD are more common and severe in LBD relative to other dementias.

Body mass index trajectories and associations with cognitive decline in people with Lewy body dementia and Alzheimer's disease

Background and Aims

In older adults with dementia, low body mass index (BMI) is associated with higher mortality and other adverse health outcomes. BMI or nutritional status trajectories from diagnosis have not yet been well described in dementia, especially in people with Lewy body dementia (LBD); a group that has a poorer prognosis. With this study, we aimed to evaluate the BMI trajectory in people diagnosed with mild LBD and Alzheimer's disease (AD).

Methods

The Dementia Study of Western Norway is a cohort study with annual assessments. Five-year measurements of BMI from 196 patients (LBD = 85 and AD = 111) diagnosed with mild dementia were analyzed using adjusted linear mixed-effects models.

Results

There were no differences between LBD and AD in baseline BMI, age, or mini-mental status examination (MMSE). During the follow-up, we observed a significant decrease in BMI in the LBD group across the study period (estimation [Est.]: -0.63, SE: 0.14; p < 0.001). By contrast, there was no significant change in BMI trajectory associated with AD diagnosis (Est.: 0.05, SE: 0.15; p = 0.730). Further, the introduction of an interaction term between diagnosis and time in the study showed that this difference (BMI trajectories) was significant (Est.: -0.63, SE: 0.14; p < 0.001). In addition, there was a significant interaction between MMSE total score and the follow-up time; the lower the MMSE, the lower the BMI (Est.: 0.01, SE: 0.01; p = 0.044).

Conclusion

In LBD, BMI significantly decreased with disease progression. In addition, low cognitive performance was associated with a reduction in BMI. These results highlight the importance of BMI evaluation in people with dementia, particularly patients diagnosed with LBD, and suggest that patients with LBD could be targeted for dietary intervention to maintain body weight.

Conceptualising comorbidity and multimorbidity in dementia: A scoping review and syndemic framework

Background

Older people and people with dementia experience a high prevalence of multiple health conditions. The terms 'comorbidity' and 'multimorbidity' are often used interchangeably to describe this, however there are key conceptual differences between these terms and their definitions. This has led to issues in the validity and comparability of research findings, potentially inappropriate intervention development and differences in quality of health care.

Objective

To review how the terms 'comorbidity' and 'multimorbidity' are defined within peer-reviewed dementia research and propose an operational framework.

Design

A scoping review of definitions within dementia research was carried out. Searches took place across five databases: Academic Search Premier, CINAHL Complete, MEDLINE, PsycARTICLES and PsycINFO. PRISMA-ScR guidelines were followed.

Results

Content analysis revealed five key themes, showing significant overlap and inconsistencies from both within, and between, the comorbidity and multimorbidity definitions; 1. Number of conditions; 2. Type of health conditions; 3. The co-occurrence of conditions; 4. The inclusion of an index disease (or not); 5. Use of medical language. The analysis also revealed gaps in how the underlying concepts of the definitions relate to people with dementia living with multiple health conditions.

Conclusion

This scoping review found that current definitions of comorbidity and multimorbidity are heterogeneous, reductionist and disease-focussed. Recommendations are made on the design of research studies including transparency and consistency of any terms and definitions used. A syndemic framework could be a useful tool for researchers, clinicians and policy makers to consider a more holistic picture of a person with dementia's health and wellbeing.

Intrinsic Capacity Impairment Patterns and their Associations with Unfavorable Medication Utilization: A Nationwide Population-Based Study of 37,993 Community-Dwelling Older Adults

OBJECTIVES

Our aim was to explore the patterns of intrinsic capacity (IC) impairments among community-dwelling older adults and the associations of these different patterns with excessive polypharmacy, potentially inappropriate medications, and adverse drug reactions in a nationwide population-based study.

DESIGN

A cross-sectional study included older adults from the Taiwan Integrated Care for Older People (ICOPE) program in 2020.

SETTING AND PARTICIPANTS

The study subjects comprised 38,308 adults aged 65 years and older who participated in the ICOPE Step 1 screening and assessed six domains of IC following the World Health Organization (WHO) ICOPE approach.

METHODS

Latent class analysis was adopted to identify distinct subgroups with different IC impairments patterns. The associations between different IC impairments patterns and unfavorable medication utilization, including excess polypharmacy (EPP), potentially inappropriate medications (PIMs), and adverse drug reactions (ADRs), were assessed by multivariate logistic regression models.

RESULTS

Latent class analysis identified five distinct subgroups with different IC impairment patterns: robust (latent class prevalence: 59.4%), visual impairment (17.7%), physio-cognitive decline (PCD) with sensory impairment (12.3%), depression with cognitive impairment (7.7%), and impairments in all domains (2.9%). Compared to the robust group, all other groups were at higher odds for unfavorable medication utilization. The "depression with cognitive impairment" group (EPP: aOR=4.35, 95% CI 3.52-5.39, p<0.01; PIMs: aOR=2.73, 95% CI 2.46-3.02, p<0.01) and the "impairment in all domains" group (EPP: aOR=9.02, 95% CI 7.16-11.37, p<0.01; PIMs: aOR=3.75, 95% CI 3.24-4.34, p<0.01) remained at higher odds for EPP and PIMs after adjustment.

CONCLUSIONS

We identified five distinct impairment patterns of IC, and each impairment pattern, particularly the "depression with cognitive impairment" and "impairment in all domains", was associated with higher odds of EPP and PIMs. Further longitudinal and intervention studies are needed to explore long-term outcomes of different impairment pattern and their reversibility.