Anticholinergic drugs and the risk of dementia: A systematic review and meta-analysis

Tiotropium Initiation and Dementia Risk in Chronic Obstructive Pulmonary Disease

Importance

Long-acting muscarinic antagonists (LAMAs), such as tiotropium, are inhaled anticholinergic bronchodilators. However, there is limited clinical evidence examining whether LAMAs may have clinically meaningful central anticholinergic effects, such as increased dementia risk.

Objective

To determine the association between tiotropium initiation and dementia risk in older adults with chronic obstructive pulmonary disease (COPD).

Design, Setting, and Participants

This population-based, active-comparator, new-user cohort study used linkable administrative databases from Ontario, Canada, with a target trial emulation framework. The cohort included new users of tiotropium monotherapy or a long-acting β2-agonist plus inhaled corticosteroid (LABA-ICS) who were 66 years or older with COPD and without dementia, from September 4, 2004, to February 29, 2012. The follow-up period was up to 10 years from treatment initiation. Analyses were conducted from May 13, 2024, to March 6, 2025.

Exposures

Tiotropium monotherapy initiators were compared with LABA-ICS initiators. The primary analysis used an intention-to-treat exposure definition.

Main Outcomes and Measures

Incident dementia was determined using a validated algorithm. A 1-year lag time was implemented to mitigate reverse causality and to account for disease latency. Cause-specific hazard ratios (HRs) with death as a competing risk were obtained from Cox models with propensity score fine stratification weights. Weighted incidence rate differences (IRDs) per 1000 person-years were calculated.

Results

Among 30 960 tiotropium monotherapy initiators and 19 530 LABA-ICS initiators, the mean (SD) age was 75.1 (6.7) years and 46.7% were female. Over a median (IQR) follow-up period of 7.59 (3.91-10.0) years from treatment initiation, tiotropium monotherapy vs LABA-ICS initiation was associated with a small increase in dementia risk per 1000 person-years (incidence rates, 29.6 [95% CI, 28.8-30.4] vs 27.4 [95% CI, 26.4-28.3]; IRD, 2.3 [95% CI, 1.0-3.5]; HR, 1.09 [95% CI, 1.04-1.14]). The secondary as-treated analysis showed no significant association per 1000 person-years (incidence rates, 24.1 [95% CI, 22.2-26.0] vs 21.4 [95% CI, 18.5-24.3]; IRD, 2.7 [95% CI, -0.8 to 6.1]; HR, 1.11 [95% CI, 0.93-1.32]).

Conclusions and Relevance

In this cohort study, among older adults with COPD, the small absolute rate increase in incident dementia associated with tiotropium monotherapy vs LABA-ICS was of questionable clinical importance, particularly when weighed against the established clinical benefits of tiotropium.

Anticholinergic burden quantified using the Japanese risk scale as a predictor of frailty and sarcopenia among community-dwelling older adults: A 9-year Kashiwa cohort study

AIM

Given the adverse effects of anticholinergic drugs and the necessity for medication evaluation tools in the aging population, a comprehensive scale to assess the total anticholinergic burden in Japan was developed. We examined the longitudinal association between the anticholinergic burden, quantified using the Japanese Anticholinergic Drug Risk Scale, and the development of frailty and sarcopenia in older adults.

METHODS

In this longitudinal population-based cohort study, 2044 older residents without long-term care needs were randomly selected from a community in Kashiwa, Japan. Baseline data were collected in 2012, with follow-ups in 2013, 2014, 2016, 2018, and 2021. Medications were identified through interviews and assessed with the Screening Tool for Older Persons' Appropriate Prescriptions for the Japanese. The anticholinergic burden was quantified using the Japanese Anticholinergic Risk Scale. We evaluated new-onset frailty and sarcopenia using the Cardiovascular Health Study Index and Asian Working Group for Sarcopenia 2019 criteria, respectively.

RESULTS

Of the 1549 participants without sarcopenia or frailty at baseline (age 72.5 ± 5.5 years; 49.1% women; median follow-up 6.0 years), 274 and 230 developed new-onset frailty and sarcopenia, respectively, during follow-up. After adjusting for potential confounders, an anticholinergic burden score ≥3 was strongly associated with new-onset frailty and sarcopenia (adjusted hazard ratio [95% confidence interval]: 2.45 [1.52-3.94] and 2.01 [1.20-3.35], respectively).

CONCLUSIONS

Anticholinergic burden is a predictor of frailty and sarcopenia in community-dwelling older adults. Effective evaluation and management of anticholinergic burden using the Japanese Anticholinergic Drug Risk Scale are crucial for promoting healthy aging and mitigating adverse health outcomes. Geriatr Gerontol Int 2025; 25: 520-527.

Effect of different durations of treatment with antihypertensive drugs with anticholinergic effects on the risk of dementia: a target trial emulation study

Studying the effect of duration of treatment on prognostic outcomes using real-world data is challenging because only people who survive for a long time can receive a treatment for a long time. Specifying a target trial helps overcome such challenge. We aimed to estimate the effect of different durations of treatment with antihypertensive drugs with anticholinergic properties (AC AHT) on the risk of vascular dementia and Alzheimer's disease by emulating a target trial using the UK CPRD GOLD database (2001-2017). Comparing treatment for 3-6 years vs ≤3 years yielded null results for both types of dementia. Comparing a longer duration of treatment, >6 years vs ≤3 years, yielded a 10-year risk ratio of 0.69 (95% CI, 0.54-0.90) for vascular dementia and 0.91 (95% CI, 0.77-1.10) for Alzheimer's disease. For illustration, we performed an analysis that failed to emulate a target trial by assigning exposure categories using postbaseline information, obtaining implausible beneficial estimates. Our findings indicate a modest benefit of longer duration of treatment with AC AHT on vascular dementia and highlight the value of the target trial emulation to avoid selection bias in the evaluation of the effect of different durations of treatment. This article is part of a Special Collection on Pharmacoepidemiology.

Pregnancy with multiple high-risk factors: a systematic review and meta-analysis

Background

A wide spectrum of high-risk factors in pregnancy can lead to adverse pregnancy outcomes or short- or long-term health effects. Despite this, there has been no synthesis of findings on the measurement, potential causes, and health outcomes of multiple high-risk factors in pregnancy (MHFP). We aimed to address this gap by summarising the existing research on this topic.

Methods

We retrieved studies published up to 3 June 2024 through systematic database searches and used a narrative synthesis approach to summarise the measurement, patterns, causes, and outcomes of MHFP. We also estimated the pooled MHFP prevalence through meta-analysis with a random effects model and performed subgroup analyses and meta-regression to examine potential sources of between-study heterogeneity.

Results

We included 83 observational studies published between 2010 and 2024, of which 72% were from high-income countries. These studied factors can be grouped into four categories: physical conditions, mental conditions, sociobehavioural problems, and pregnancy history. We identified 16 MHFP patterns, among which co-existing multiple physical conditions were the most common pattern. The overall pooled prevalence of MHFP was 12% (95% confidence interval (CI) = 12-13), with an increasing trend and relatively higher levels in low- and middle-income countries (LMICs). We observed heterogeneity in the measurement of MHFP across the studies, possibly due to the number of risk factors in the definition of MHFP. About 78% of included studies investigated MHFP-associated health outcomes for women and offspring, with only two studies examining long-term maternal or offspring outcomes later in life.

Conclusions

Research into MHFP has been emerging over the past decade, but is far from complete. The burden of MHFP is increasing worldwide, particularly LMICs. Maternal healthcare systems must shift to a multidisciplinary and integrated framework so as to better design and implement prevention and intervention programmes and sustain the healthy development of the next generation.

Registration

PROSPERO: CRD42022358889.

Effects of osteoporosis treatment and multicomponent integrated care on intrinsic capacity and happiness among rural community-dwelling older adults: the Healthy Longevity and Ageing in Place (HOPE) randomised controlled trial

BACKGROUND

Monitoring and improving intrinsic capacity (IC) and well-being are essential for older adults to maintain functional abilities. However, evidence of effective interventions to improve IC and happiness is scarce. This study examined the effects of multicomponent interventions in the Healthy Longevity and Ageing in Place (HOPE) randomised controlled trial on IC and happiness among rural community-dwelling older adults.

METHODS

This cluster randomised trial was conducted in rural communities in Taiwan (NCT05104034). Participants aged ≥50 were enrolled from September 2021 to April 2022 and randomly assigned by community level to one of three groups: multicomponent integrated care (MIC), osteoporosis care (OC) and usual care (UC). MIC included osteoporosis, sarcopenia and polypharmacy care, along with exercise and nutritional support. OC was a resource-conservative, focusing on osteoporosis screening and treatment alone. IC and happiness were measured at baseline and 12 months after follow-up. IC was assessed across cognition, locomotion, vitality, sensory and psychological domains per World Health Organization Integrated Care for Older People (ICOPE) guidelines. Happiness was measured using the 10-item Chinese Happiness Inventory. Generalised estimating equations were used to estimate the effect of the intervention.

RESULTS

567 residents were recruited from 30 congregate meal service centres. Mean IC score increased across all the groups, though the happiness score decreased. Compared to UC, the MIC group exhibited a significantly greater improvement in IC scores (adjusted estimate = 0.30, standard error (SE) = 0.11, P = .01), whereas OC did not show significant effects. Smaller reductions in happiness scores were observed in both the MIC (adjusted estimate = 1.46, SE = 0.48, P = .003) and OC groups (adjusted estimate = 0.95, SE = 0.48, P = .05).

CONCLUSION

MIC, including osteoporosis and pharmaceutical care, along with exercise and nutritional support, is an effective strategy to enhance IC and happiness compared to osteoporosis treatment alone and UC. This underscores the importance of comprehensive strategies for promoting healthy ageing in rural communities.

Drug-induced dementia: a pharmacovigilance analysis of the FAERS database

BACKGROUND

Dementia is a global public health challenge. Certain medications, such as anticholinergics and benzodiazepines, have been linked to an increased dementia risk. However, most studies focused on a limited range of drugs, lacking a comprehensive overview. This article addressed this gap by analyzing drugs associated with dementia using data from the FDA Adverse Event Reporting System (FAERS).

RESEARCH DESIGN AND METHODS

The FAERS database was queried using Open Vigil 2.1 to extract reports of drug-induced dementia events from January 2004 to September 2023. Signal detection was performed using Reporting Odds Ratio (ROR) and Proportional Reporting Ratio methods.

RESULTS

We analyzed 21,509 reports. There were 163 drugs positively associated with dementia, including neurological drugs (51 drugs, 31.3%), cardiovascular drugs (25 drugs, 15.3%), alimentary tract/metabolism drugs (24 drugs, 14.7%) and genito urinary system/sex hormones drugs (15 drugs, 9.2%). Besides neurological drugs, the drugs with the highest number of reports were apixaban, valsartan and atorvastatin.

CONCLUSION

We found that tamsulosin, alfuzosin, and megestrol may be associated with an increased risk of dementia, and further research is required to clarify these relationships. In clinical practice, it is important to monitor the cognitive status of patients when using drugs that may increase the risk of dementia.

Associations of posttraumatic stress disorder symptoms with amyloid burden in cognitively normal older adults

Background

Posttraumatic stress disorder (PTSD) is associated with the development of dementia. However, the link between PTSD and preclinical Alzheimer's disease pathology (amyloid β [Aβ]) remains controversial. Moreover, the correlation between the severity of PTSD with Aβ levels remains unknown.

Methods

This cross-sectional study sought to investigate the associations of PTSD symptoms with global and regional brain Aβ burden. To this end, data were obtained from participants in the Anti-Amyloid Treatment in Asymptomatic Alzheimer's Disease (A4) Study. In addition, we explored the association between the severity of PTSD symptoms and Aβ levels.

Results

A total of 4,228 participants aged 65 to 85 years were included in the final analysis. The results showed that PTSD symptoms were significantly associated with higher global Aβ levels (1.15 ± 0.20 vs. 1.09 ± 0.19; β = 0.056; p < 0.001), after adjusting for covariates. The association between PTSD symptoms and Aβ levels was not affected by sex, age, ApoE genotype, or psychiatric diseases. Similarly, PTSD symptoms were significantly associated with Aβ levels in all subregions, including the anterior cingulate, posterior cingulate, parietal cortex, precuneus, temporal cortex, and frontal cortex. In addition, the group with severe PTSD symptoms (1.22 ± 0.24) exhibited higher global Aβ levels than the groups with moderate (1.14 ± 0.19) or mild (1.12 ± 0.20) symptoms or the control (1.08 ± 0.18), with p < 0.001.

Conclusion

The findings imply a close relationship between PTSD and brain Aβ levels, irrespective of sex, age, ApoE genotype, or psychiatric diseases. More well-designed studies are needed to further explore the relationship and mechanism underlying the association between PTSD and Aβ burden.

Medication Exposure and Risk of Dementia and Alzheimer's Disease

Alzheimer's disease (AD), a complex neurodegenerative disease (ND), is the most predominant cause of dementia among the elderly. Generally, elderly people have multiple chronic health conditions, like hypertension, arthritis, diabetes, insomnia, bowel problems, and depression. Although prescribed medications have beneficial therapeutic compositions, some may have side effects that could hinder cognitive function or worsen cognitive decline. Hence, we should evaluate those medications to guarantee their safety. In the present mechanistic review, we discussed frequently used categories of medication (analgesics, anticholinergics, benzodiazepines, proton pump inhibitors, and statins), concerning their possible involvement in increasing AD and dementia risks. This review summarized the results of various observational studies, meta-analyses, randomized case-control studies, and systematic reviews. As the results were contradictory, it was difficult to ascertain the clear associations between medication usage and increased risks of dementia or AD. The blood-based biomarkers (BBMs) offer a low-cost and accessible alternative for early diagnosis of AD. Systematic reviews combined with meta-analysis would be crucial tools for accurately assessing and summarizing the efficacy of health interventions, yet randomized clinical trials have always been the best way to help with clinical care decisions. Thus, an open discussion is necessary to help individuals determine whether the advantages of utilizing medications outweigh the possible drawbacks.

Algorithms for the first-line management of bladder, bowel and sexual dysfunction in multiple sclerosis: Present and future

INTRODUCTION

Neurogenic lower urinary tract (NLUTD), bowel (NBD), and sexual dysfunction (SD) are commonly observed in patients with (pw) multiple sclerosis (MS) and diminish the patients' quality of life (QoL). This systematic review aim to evaluate and discuss the current algorithms for the management of these issues.

METHODS

A systematic review was conducted on the PubMed in June 2024. The primary search criterion was the presence of the term 'algorithm/s' or 'management/ing' in the title and/or abstract, followed by the MeSH term 'multiple sclerosis' and a combination of free-text keywords referring to NLUTD, NBD or SD.

RESULTS

Fifteen articles regarding NLUTD were considered eligible, only one regarding SD while none addressed NBD.

DISCUSSION

Numerous studies emphasize the profound impact of urinary and bowel symptoms on the QoL and morbidity in pwMS. Few algorithms addressing NLUTD are designed for first-line physicians and addresses the key priorities in MS care. Specific approaches to NBD management in pwMS are lacking. Screening for SD requires a structured assessment to deliver appropriate solutions.

CONCLUSION

NLUTD, NBD, and SD are underdiagnosed and undertreated. The implementation of straightforward algorithms for first-line physicians could enhance the management of these common issues, improve the QoL, reduce costs, and ensure appropriate referral to specialists.

The AUA/SUFU guideline on the diagnosis and treatment of idiopathic overactive bladder

PURPOSE

The purpose of this guideline is to provide evidence-based guidance to clinicians of all specialties on the evaluation, management, and treatment of idiopathic overactive bladder (OAB). The guideline informs the reader on valid diagnostic processes and provides an approach to selecting treatment options for patients with OAB through the shared decision-making process, which will maximize symptom control and quality of life, while minimizing adverse events and burden of disease.

METHODS

An electronic search employing OVID was used to systematically search the MEDLINE and EMBASE databases, as well as the Cochrane Library, for systematic reviews and primary studies evaluating diagnosis and treatment of OAB from January 2013 to November 2023. Criteria for inclusion and exclusion of studies were based on the Key Questions and the populations, interventions, comparators, outcomes, timing, types of studies and settings (PICOTS) of interest. Following the study selection process, 159 studies were included and were used to inform evidence-based recommendation statements.

RESULTS

This guideline produced 33 statements that cover the evaluation and diagnosis of the patient with symptoms suggestive of OAB; the treatment options for patients with OAB, including Noninvasive therapies, pharmacotherapy, minimally invasive therapies, invasive therapies, and indwelling catheters; and the management of patients with BPH and OAB.

CONCLUSION

Once the diagnosis of OAB is made, the clinician and the patient with OAB have a variety of treatment options to choose from and should, through shared decision-making, formulate a personalized treatment approach taking into account evidence-based recommendations as well as patient values and preferences.

Risk of dementia associated with the use of anticholinergic medications: a review of recent literature

PURPOSE OF REVIEW

While there is an established association between the use of anticholinergic medications and its effects on cognition, the extent of this impact remains unclear. We outline recent studies addressing this topic.

RECENT FINDINGS

We describe a series of recent articles discussing the risk of dementia associated with anticholinergic medication use in general, with further focus on the risk of overactive bladder (OAB) anticholinergic use, detailing short & long-term use effects, risk variation based on age and gender, and reporting alternative treatment options.

SUMMARY

Anticholinergic medication use bears an increased risk of dementia development, and accelerated cognitive decline in individuals with preexisting dementia, with the risk being related to the medications dosages, length of exposure, and pharmacological profile. β3-adrenoceptor agonists have proven to be a potent alternative for OAB anticholinergics, owing to its safe profile in regards of no clear effects on cognitive function, and having similar efficacy in OAB treatment.

Understanding the medication regimens associated with anticholinergic burden in older people's mental health services in the UK

BACKGROUND

Medications with anticholinergic properties are associated with a range of adverse effects that tend to be worse in older people.

AIMS

To investigate medication regimens with high anticholinergic burden, prescribed for older adults under the care of mental health services.

METHOD

Clinical audit of prescribing practice, using a standardised data collection tool.

RESULTS

Fifty-seven trusts/healthcare organisations submitted data on medicines prescribed for 7915 patients: two-thirds (66%) were prescribed medication with anticholinergic properties, while just under a quarter (23%) had a medication regimen with high anticholinergic burden (total score ≥3 on the anticholinergic effect on cognition (AEC) scale). Some 16% of patients with a diagnosis of dementia or mild cognitive impairment were prescribed medication regimens with a high anticholinergic burden, compared with 35% of those without such diagnoses. A high anticholinergic burden was mostly because of combinations of commonly prescribed psychotropic medications, principally antidepressant and antipsychotic medications with individual AEC scores of 1 or 2.

CONCLUSIONS

Adults under the care of older people's mental health services are commonly prescribed multiple medications for psychiatric and physical disorders; these medication regimens can have a high anticholinergic burden, often an inadvertent consequence of the co-prescription of medications with modest anticholinergic activity. Prescribers for older adults should assess the anticholinergic burden of medication regimens, assiduously check for adverse anticholinergic effects and consider alternative medications with less anticholinergic effect where indicated. The use of a scale, such as the AEC, which identifies the level of central anticholinergic activity of relevant medications, can be a helpful clinical guide.

Advances in Outpatient Therapies and Treatment of Benign Prostatic Hyperplasia: A Comprehensive Review for Men's Health

Benign prostate hyperplasia (BPH) affects a large number of men and can be treated with behavioral, medical, or surgical treatments. The newest addition to medical therapy is β3-agonists for overactive lower urinary tract symptoms. Multiple new surgical treatments have become available in the past decade, including several clinic-based minimally invasive surgical techniques (eg, UroLift, Rezum, Optilume BPH), OR treatments (eg, Aquablation, single port robotics), and prostate artery embolization. The growth of options allows providers to better tailor BPH treatment to the specific disease factors and patient preferences.

Medication burden and anticholinergic use are associated with overt HE in individuals with cirrhosis

BACKGROUND

Polypharmacy and anticholinergic medications are associated with cognitive decline in elderly populations. Although several medications have been associated with HE, associations between medication burden, anticholinergics, and HE have not been explored. We examined medication burden and anticholinergics in patients with cirrhosis and their associations with HE-related hospitalization.

METHODS

We conducted a retrospective cohort study of patients aged 18-80 with cirrhosis seen in hepatology clinics during 2019. The number of chronic medications (medication burden) and anticholinergic use were recorded. The primary outcome was HE-related hospitalization.

RESULTS

A total of 1039 patients were followed for a median of 840 days. Thirty-seven percent had a history of HE, and 9.8% had an HE-related hospitalization during follow-up. The mean number of chronic medications was 6.1 ± 4.3. Increasing medication burden was associated with HE-related hospitalizations in univariable (HR: 1.09, 95% CI: 1.05-1.12) and multivariable (HR: 1.07, 95% CI: 1.03-1.11) models. This relationship was maintained in those with baseline HE but not in those without baseline HE. Twenty-one percent were taking an anticholinergic medication. Anticholinergic exposure was associated with increased HE-related hospitalizations in both univariable (HR: 1.68, 95% CI: 1.09-2.57) and multivariable (HR: 1.71, 95% CI: 1.11-2.63) models. This relationship was maintained in those with baseline HE but not in those without baseline HE.

CONCLUSIONS

Anticholinergic use and medication burden are both associated with HE-related hospitalizations, particularly in those with a history of HE. Special considerations to limit anticholinergics and minimize overall medication burden should be tested for potential benefit in this population.

What is the best first choice oral drug therapy for OAB?

AIMS

The management of overactive bladder (OAB) involves lifestyle changes and conservative measures in the first instance with the use of liquid/dietary advice, weight loss, and bladder training. Thereafter oral pharmacotherapy is instigated in symptomatic patients. Antimuscarinics and beta 3 agonists form the main classes of drug therapy in this field. Views on what is the best first line OAB treatment is changing based on recent evidence and adverse event profiles of these medications.

METHODS

At the ICI-RS meeting 2023, Bristol, UK this topic was discussed and debated as a proposal. The following article summarizes the concepts presented that day as well as the interactive discussion that took place thereafter.

RESULTS

OAB guidelines are moving in many circumstances to an either antimuscarinic or beta 3 agonist approach based on patient factors. Several studies have raised concerns on the long-term impact of antimuscarinics, in relation to cognition, dementia, cardiovascular events, and mortality all related to antimuscarinic load. Neither antimuscarinics nor beta 3 agonists have good persistence and adherence rates in the medium to long term. Several barriers also exist to prescribing including guidelines recommending utilizing drugs with the lowest acquisition cost and "step therapy." A newer approach to managing OAB is personalized therapy in view of the many possible etiological factors and phenotypes. These concepts are highlighted in this article.

CONCLUSIONS

Current oral pharmacotherapy in managing OAB is limited by adverse events, adherence and persistence problems. Both antimuscarinics and beta 3 agonists are efficacious but most clinical trials demonstrate significant placebo effects in this field. Personalizing treatment to the individual seems a logical approach to OAB. There is a need for better treatments and further studies are required of existing treatments with high quality longer term outcomes.

Dementia, comorbidity and multimorbidity

Many people living with dementia will also have multimorbidity comprising several other intercurrent, long-term and comorbid conditions. This article examines the relationship between such conditions in the context of dementia, giving an overview of the literature, including prevalence and some of the common conditions that can coexist with dementia. The theory and evidence-base will be tied together using a case study approach, to illustrate the complexity of managing comorbid conditions and multimorbidity alongside dementia, and explore some of the approaches that can be used by community nurses to support the overall health of people living with dementia that they work with.

Cross-cultural adaptation and validation of the Australian National University Alzheimer Disease Risk Index (ANU-ADRI) for Chinese community-dwelling residents: A cross-sectional Study

OBJECTIVE

To cross-culturally adapt the Australian National University Alzheimer Disease Risk Index (ANU-ADRI) and verify the reliability and validity of its cognitive activity domain.

METHODS

According to Beaton's guidelines, the ANU-ADRI was were translated into Chinese. The psychometric properties of ANU-ADRI its cognitive activity was conducted among community-dwelling residents (n = 442) in Changchun, Harbin and Hegang from December 2021 to July 2023.

RESULTS

The Chinese version of the ANU-ADRI had good content validity and face validity. Exploratory factor analysis of cognitive activity revealed a 3-factor structure, with a cumulative variance contribution rate of 64.124 %. Confirmatory factor analysis revealed a good model fit (x2/df = 1.664, RMSEA = 0.055, RMR = 0.090, GFI = 0.942, CFI = 0.919, IFI = 0.921, TLI = 0.902, and NFI = 0.824). The internal consistency (Cronbach's α = 0.807) and test-retest reliability (ICC = 0.787) were considered satisfactory.

CONCLUSION

The ANU-ADRI showed acceptable reliability and validity for assessing risk factors for Alzheimer's disease among middle-aged and elderly community-dwelling residents.

The AUA/SUFU Guideline on the Diagnosis and Treatment of Idiopathic Overactive Bladder

PURPOSE

The purpose of this guideline is to provide evidence-based guidance to clinicians of all specialties on the evaluation, management, and treatment of idiopathic overactive bladder (OAB). The guideline informs the reader on valid diagnostic processes and provides an approach to selecting treatment options for patients with OAB through the shared decision-making process, which will maximize symptom control and quality of life, while minimizing adverse events and burden of disease.

METHODS

An electronic search employing OVID was used to systematically search the MEDLINE and EMBASE databases, as well as the Cochrane Library, for systematic reviews and primary studies evaluating diagnosis and treatment of OAB from January 2013 to November 2023. Criteria for inclusion and exclusion of studies were based on the Key Questions and the populations, interventions, comparators, outcomes, timing, types of studies and settings (PICOTS) of interest. Following the study selection process, 159 studies were included and were used to inform evidence-based recommendation statements.

RESULTS

This guideline produced 33 statements that cover the evaluation and diagnosis of the patient with symptoms suggestive of OAB; the treatment options for patients with OAB, including non-invasive therapies, pharmacotherapy, minimally invasive therapies, invasive therapies, and indwelling catheters; and the management of patients with BPH and OAB.

CONCLUSION

Once the diagnosis of OAB is made, the clinician and the patient with OAB have a variety of treatment options to choose from and should, through shared decision-making, formulate a personalized treatment approach taking into account evidence-based recommendations as well as patient values and preferences.

Sedative load and anticholinergic burden among older adults in Slovenia over a decade: Potential for optimization of pharmacotherapy

This study investigates the 10-year trend in the sedative and anticholinergic burden among older adults in Slovenia, with the aim of identifying opportunities to optimize pharmacotherapy in this population. A retrospective drug utilization analysis was conducted based on a national anonymized database of dispensed prescriptions from 2009 to 2019. The study employed the sedative load model and the anticholinergic cognitive burden scale to assess the sedative and anti cholinergic burden, respectively. The findings indicate that in 2019, 45.6 % and 40.8 % of older adults (≥ 65 years) used sedative and anticholinergic medications, respectively. A high sedative load and a clinically significant anticholinergic burden were observed in a considerable proportion of older adults (13.2 % and 11.2 %, respectively, in 2019). The age-standardized prevalence of sedative load and anti-cholinergic burden significantly decreased over the 10-year study period by 5.6 % and 1.7 %, respectively (absolute difference), while the prevalence of clinically significant anticholinergic burden remained stable. Notably, the age groups 85-89 years and above 90 years had an increase in the proportion of individuals with a clinically significant anticholinergic burden over the years. These results emphasize the need for targeted interventions, particularly in the oldest age groups, to promote safe and effective medication use among older adults.

A study protocol for identifying aging trajectories toward chronic neurodegenerative diseases by means of Marche regional administrative databases - TREND project

Background

People are living longer but an increasing number of older people experience chronicity and disability in the latest years of their life. The Marche region is one of the Italian regions where people live the longest lives; therefore, the number of people with age-related chronic diseases is expected to be at least similar, if not higher, compared to the rest of Italy. The identification of the aging trajectories is of huge interest in the arena of public health. Administrative healthcare databases represent valuable reservoirs for reconstructing the trajectories of aging. Here, we present the protocol for a study (TREND project) aimed to integrate existing administrative databases into a Marche regional dataset in order to estimate the prevalence and incidence rates of age-related neurodegenerative diseases (ND), with a specific focus on Parkinsonism and Dementia.

Methods

The TREND Project is a retrospective cross-sectional study. The source population includes permanent residents in the Marche region aged 40 years and older. A minimal dataset has been built up linking data on drug prescriptions, outpatient services, and diagnosis for hospital admission, from 2014 to 2021 in the Marche Region. Data on clinical outcomes (re-hospitalization, mortality, comorbidities), and therapeutic approaches (drugs and medicines) have been integrated with state-of-the-art statistical methods to define patients into different risk clusters and to analyze the aging trend by assessing the Comorbidity Index (CI) as a proxy for chronicity.

Discussion

Our research contributes to the integration of existing administrative databases on ND to create a Marche regional ND database, support regional health policy, and better understand patients' needs and their aging trajectories. This approach could be implemented also at the National level. Moreover, by linking different administrative data sources, this study sheds light on important issues related to ND, such as early-onset dementia; ethical aspects such as anticipated wills; problems of dementia in patients still in the job market, etc. The results of this study will contribute to the successful implementation of integrated care for patients affected by ND at regional or national levels.

[Translated article] Topical Anticholinergics in the Management of Focal Hyperhidrosis in Adults and Children. A Narrative Review

Hyperhidrosis, or excessive sweating, is characterized by overactivity of the eccrine sweat glands, usually associated with dysfunction of the autonomic nervous system. Primary focal hyperhidrosis is the most common form and can affect the axillae, palms, soles, and/or face, often leading to significantly impaired quality of life and social functioning. Treatment is complex. Topical antiperspirants are normally recommended as the first-line treatment for mild hyperhidrosis. Multiple clinical trials and prospective studies support the efficacy and tolerability of oral and topical anticholinergics in the management of hyperhidrosis. Topical glycopyrronium, which has been investigated in at least 8 clinical trials enrolling more than 2000 patients, is probably the first-line pharmacological treatment for axillary hyperhidrosis in patients with moderate to severe disease poorly controlled with topical antiperspirants. Second-line treatments include botulinum toxin injections, microwave treatment, and oral anticholinergics. We review the use of topical anticholinergics in the management of focal hyperhidrosis in adults and children.

Increased anticholinergic medication use in middle-aged and older autistic adults and its associations with self-reported memory difficulties and cognitive decline

Many commonly used prescription and over-the-counter medicines have potent anticholinergic (AC) effects. Among older adults, AC medications are associated with cognitive impairment and risk for cognitive disorders, including Alzheimer's disease. Collectively, the impact of AC medications is known as anticholinergic cognitive burden (ACB). Because of the high rates of co-occurring medical and psychiatric conditions, autistic adults may have high AC exposure and, thus, may experience elevated ACB. However, no research has characterized AC exposure or examined its associations with cognitive outcomes in autistic adults. Autistic adults (40-83 years) recruited via Simons Powering Autism Research's (SPARK) Research Match service self-reported their medication use (N = 415) and memory complaints (N = 382) at Time (T)1. At T2, 2 years later, a subset of T1 participants (N = 197) self-reported on decline in cognition. Medications were coded using two scales of AC potency. A high proportion (48.2%-62.9%, depending upon the AC potency scale) of autistic adults reported taking at least one medication with AC effects, and 20.5% to 26.5% of autistic adults reported clinically-relevant levels of AC medication (potency ≥3). After controlling for birth-sex, and age, hierarchical linear regression models showed total ACB scores and AC potency values of ≥3 predicted greater memory complaints. Logistic regression models showed that AC medicines at T1 were associated with self-reported cognitive decline at follow-up 2 years later. Understanding AC medications-including potentially earlier AC polypharmacy-and their impacts on cognition (e.g., dementia risk) in autistic adults is warranted.

Topical Anticholinergics in the Management of Focal Hyperhidrosis in Adults and Children. A Narrative Review

Hyperhidrosis, or excessive sweating, is characterized by overactivity of the eccrine sweat glands, usually associated with dysfunction of the autonomic nervous system. Primary focal hyperhidrosis is the most common form and can affect the axillae, palms, soles, and/or face, often leading to significantly impaired quality of life and social functioning. Treatment is complex. Topical antiperspirants are normally recommended as the first-line treatment for mild hyperhidrosis. Multiple clinical trials and prospective studies support the efficacy and tolerability of oral and topical anticholinergics in the management of hyperhidrosis. Topical glycopyrronium, which has been investigated in at least 8 clinical trials enrolling more than 2000 patients, is probably the first-line pharmacological treatment for axillary hyperhidrosis in patients with moderate to severe disease poorly controlled with topical antiperspirants. Second-line treatments include botulinum toxin injections, microwave treatment, and oral anticholinergics. We review the use of topical anticholinergics in the management of focal hyperhidrosis in adults and children.

Resolving a paradox: antidepressants, neuroinflammation, and neurodegeneration

Depression is a known risk factor for dementia. Antidepressants are the most commonly used treatment for this condition, and are effective in at least half to two-thirds of cases. Extensive evidence from in vitro and animal models suggests that antidepressants have anti-inflammatory and neuroprotective properties. These effects have been shown to reduce the oxidative damage, amyloid aggregation, and expression of pro-inflammatory genes associated with animal models of neurodegenerative disorders. However, longitudinal research in humans has shown that antidepressants do not protect against dementia, and may even be associated with a risk of cognitive deterioration over time in older adults. The contrast between two sets of findings represents a paradox of significant clinical and public health significance, particularly when treating depression in late life. This review paper attempts to resolve this paradox by critically reviewing the medium- and long-term effects of antidepressants on peripheral immune-inflammatory responses, infection risk, gut microbiota, and neuroendocrine responses to stress, and how these effects may influence the risk of neurodegeneration. Briefly stated, it is possible that the peripheral actions of antidepressant medications may antagonize their beneficial effects against neuroinflammation. The implications of these findings are then explored with a particular focus on the development and testing of multimodal neuroprotective and anti-inflammatory treatments that could reduce the risk of Alzheimer’s and related dementias in patients suffering from depression.

Investigation of mechanisms of action involved in the antidepressant-like effect of Trans,trans-farnesol in mice

This study aimed to investigate, through in vivo and biochemical methodologies, the effect of trans,trans-farnesol (12.5, 25, 50 or 100 mg/kg, p.o.) acute administration, adopting different behavioral and neurochemical parameters associated with an acute induced-depression model in mice. The initial results showed that, the oral treatment with trans,trans-farnesol, at the dose of 100 mg/kg induced a possible antidepressant-like effect in animals subjected to forced swim test (FST) and reserpine-induced akinesia. In addition, it was observed that the compound in question has an effect size and properties similar to imipramine (prototype of tricyclic antidepressants), but devoid of proconvulsant adverse effect. In biochemical assays, the pretreatment with trans,trans-farnesol, at a dose of 100 mg/kg (p.o.), decreased the hippocampal concentration of thiobarbituric acid reactive substances (TBARS) and restored striatal levels of noradrenaline and serotonin in mice subjected to FST. Altogether, these results suggest that trans,trans-farnesol showed a significant antidepressant-like effect, which seems to be mediated by the antagonism of muscarinic cholinergic receptors, reduction of oxidative stress and the modulation of noradrenaline and serotonin content in the central nervous system.

Association of anticholinergic drug exposure with the risk of dementia among older adults in Japan: The LIFE Study

OBJECTIVES

Several studies have investigated that anticholinergic drugs cause cognitive impairment. However, the risk of dementia associated with anticholinergics has not been extensively investigated in the super-aging society of Japan. We conducted this study to assess the association between anticholinergic drugs and the risk of dementia in older adults in Japan.

METHODS

This nested case-control study used data from the Longevity Improvement & Fair Evidence Study, which includes claim data in Japan from 2014 to 2020. We included 66,478 cases of diagnosed dementia and 328,919 matched controls aged ≥65 years, matched by age, sex, municipality, and cohort entry year. Primary exposure was the total cumulative anticholinergic drugs prescribed from cohort entry date to event date or matched index date, which was the total standardized daily doses for each patient, calculated by adding the total dose of different types of anticholinergic drugs in each prescription, divided by the World Health Organization-defined daily dose values. Odds ratios for dementia associated with cumulative exposure to anticholinergic drugs were calculated using conditional logistic regression adjusted for confounding variables.

RESULTS

The mean (standard deviation) age at index date was 84.3 (6.9), and the percentage of women was 62.1%. From cohort entry date to event date or matched index date, 18.8% of the case patients and 13.7% of the controls were prescribed at least one anticholinergic drug. In the multivariable-adjusted model, individuals with anticholinergic drugs prescribed had significantly higher odds of being diagnosed with dementia (adjusted odds ratio, 1.50 [95% confidence interval, 1.47-1.54]). Among specific types of anticholinergic drugs, a significant increase in risk was observed with the use of antidepressants, antiparkinsonian drugs, antipsychotics, and bladder antimuscarinics in a fully multivariable-adjusted model.

CONCLUSIONS

Several types of anticholinergic drugs used by older adults in Japan are associated with an increased risk of dementia. These findings suggest that the underlying risks should be considered alongside the benefits of prescribing anticholinergic drugs to this population.

Novel Anthranilic Acid Hybrids-An Alternative Weapon against Inflammatory Diseases

Anti-inflammatory drugs are used to relieve pain, fever, and inflammation while protecting the cardiovascular system. However, the side effects of currently available medications have limited their usage. Due to these adverse effects, there is a significant need for new drugs. The current trend of research has shifted towards the synthesis of novel anthranilic acid hybrids as anti-inflammatory agents. Phenyl- or benzyl-substituted hybrids exerted very good anti-inflammatory effects in preventing albumin denaturation. To confirm their anti-inflammatory effects, additional ex vivo tests were conducted. These immunohistochemical studies explicated the same compounds with better anti-inflammatory potential. To determine the binding affinity and interaction mode, as well as to explain the anti-inflammatory activities, the molecular docking simulation of the compounds was investigated against human serum albumin. The biological evaluation of the compounds was completed, assessing their antimicrobial activity and spasmolytic effect. Based on the experimental data, we can conclude that a collection of novel hybrids was successfully synthesized, and they can be considered anti-inflammatory drug candidates-alternatives to current therapeutics.

Optimizing treatment for older adults with depression

This review presents a comprehensive guide for optimizing medication management in older adults with depression within an outpatient setting. Medication optimization involves tailoring the antidepressant strategy to the individual, ensuring the administration of appropriate medications at optimal dosages. In the case of older adults, this process necessitates not only adjusting or changing antidepressants but also addressing the concurrent use of inappropriate medications, many of which have cognitive side effects. This review outlines various strategies for medication optimization in late-life depression: (1) Utilizing the full dose range of a medication to maximize therapeutic benefits and strive for remission. (2) Transitioning to alternative classes (such as a serotonin and norepinephrine reuptake inhibitor [SNRI], bupropion, or mirtazapine) when first-line treatment with selective serotonin reuptake inhibitors [SSRIs] proves inadequate. (3) Exploring augmentation strategies like aripiprazole for treatment-resistant depression. (4) Implementing measurement-based care to help adjust treatment. (5) Sustaining an effective antidepressant strategy for at least 1 year following depression remission, with longer durations for recurrent episodes or severe presentations. (6) Safely discontinuing anticholinergic medications and benzodiazepines by employing a tapering method when necessary, coupled with counseling about the benefits of stopping them. Additionally, this article explores favorable medications for depression, as well as alternatives for managing anxiety, insomnia, allergy, overactive bladder, psychosis, and muscle spasm in order to avoid potent anticholinergics and benzodiazepines.

The Impact of Sex-Specific Survival on the Incidence of Dementia in Parkinson's Disease

OBJECTIVE

The aim of our study is to analyze sex-specific patterns of Parkinson's disease dementia (PDD) incidence. We are investigating the extent to which sex differences in survival after initial Parkinson's disease (PD) diagnosis influence differences in PDD risk among PD patients.

METHODS

We used a random sample of German longitudinal health claims data of persons ages 50+ (2004-2019; n = 250,000) and identified new PD cases ages 65+ who were followed-up for a PDD diagnosis or death between 2006 and 2017. We performed Cox and competing-risk regression models, with death as competing event, to calculate PDD hazard ratios (HR) adjusted for age at PD onset, PD severity as measured by the modified Hoehn and Yahr (HY) scale, comorbidities, and medications.

RESULTS

Of 2195 new PD cases, 602 people died before PDD and 750 people developed PDD by the end of 2017. The adjusted risk of PDD differs by sex, with men having a higher PDD risk than women. When accounting for death, men and women do not differ in their PDD risk (HR = 1.02, P = 0.770). Sex-specific analyses showed significant age and severity effects in women (age: HR = 1.05, P < 0.001; HY 3-5 vs. 0-2.5: HR = 1.46, P = 0.011), but not in men.

CONCLUSION

Older age at first PD diagnosis and higher disease severity increase PDD risk, but this association is attenuated for PD men when controlling for death. This implies that the most frail PD men die rapidly before receiving a dementia diagnosis, whereas women with PD survive at higher rates, regardless of their age at onset and disease severity. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Benzodiazepine Use and the Risk of Dementia in the Elderly Population: An Umbrella Review of Meta-Analyses

The prevalence of dementia among the elderly is high, and it is the leading cause of death globally. However, the relationship between benzodiazepine use and dementia risk has produced inconsistent results, necessitating an updated review of the evidence. To address this, we conducted an umbrella review of meta-analyses to summarize the available evidence on the association between benzodiazepine use and dementia risk and evaluate its credibility. We systematically evaluated the meta-analyses of observational studies that examined the connection between benzodiazepine use and dementia risk. For each meta-analysis, we collected the overall effect size, heterogeneity, risk of bias, and year of the most recent article and graded the evidence based on pre-specified criteria. We also used AMSTAR, a measurement tool to evaluate systematic reviews, to assess the methodological quality of each study. Our review included five meta-analyses encompassing 30 studies, and the effect size of the association between benzodiazepine use and dementia risk ranged from 1.38 to 1.78. Nonetheless, the evidence supporting this relationship was weak, and the methodological quality of the studies included was low. In conclusion, our findings revealed limited evidence of a link between benzodiazepine use and dementia risk, and more research is required to determine a causal connection. Physicians should only prescribe benzodiazepine for appropriate indications.

Anticholinergic action is rarely a good thing

The evidence for the risks associated with anticholinergic agents has grown considerably in the last two decades. Not only are they associated with causing peripheral side effects such as dry mouth, blurred vision and constipation, but they can also cause central effects such as cognitive impairment; and more recently, they have consistently been linked with an increased risk of dementia and death in older people. This paper reviews the evidence for the associations of anticholinergic agents and the risk of dementia and increased mortality in dementia.

The Prognostic Utility of Anticholinergic Burden Scales: An Integrative Review and Gap Analysis

BACKGROUND

Anticholinergic drugs are commonly prescribed, especially to older adults. Anticholinergic burden scales (ABS) have been used to evaluate the cumulative effects of multiple anticholinergics. However, studies have shown inconsistent results regarding the association between anticholinergic burden assessed with ABS and adverse clinical outcomes such as cognitive impairment, functional decline, and frailty. This review aims to identify gaps in research on the development, validation, and evaluation of ABS, and provide recommendations for future studies.

METHOD

A comprehensive search of five databases (MEDLINE, Embase, PsychInfo, CINAHL, CENTRAL) was conducted for relevant studies published from inception until 25 May 2023. Two reviewers screened for eligibility and assessed the quality of studies using different tools based on the study design and stage of the review framework. Research evidence was evaluated, and gaps were identified and grouped into evidence, knowledge, and methodological gaps, using evidence tables to summarize data.

RESULTS

Several evidence, knowledge, and methodological gaps in existing development, validation, and evaluation studies of ABS were identified. There is no universally accepted scale, and there is a need to define a clinically relevant threshold for measuring total anticholinergic burden. The current evidence has limitations, underrepresenting low- and middle-income countries, younger individuals, and populations with cognitive disabilities. The impact of anticholinergic burden on frailty is also understudied. Existing evaluation studies provide limited evidence on the benefit of reducing anticholinergic burden on clinical outcomes or the safety of anticholinergic deprescribing. There is also uncertainty regarding optimal reduction, clinically significant anticholinergic burden thresholds, and cost effectiveness.

CONCLUSIONS

Future research recommendations to bridge knowledge gaps include developing a risk assessment framework, refining ABS scales, establishing a standardized consensus scale, and creating a longitudinal measure of cumulative anticholinergic risk. Strategies to minimize bias, consider frailty, and promote multidisciplinary and multinational collaborations are also necessary to improve patient outcomes.

Managing drugs with anticholinergic activity

Over the past two decades, considerable data have emerged on an association between drugs with anticholinergic activity and serious adverse effects in older people. Well-recognised anticholinergic adverse effects include dry mouth, blurred vision, constipation and urinary retention. Of particular concern is the potential impact on cognitive function with several studies showing that long-term use of medicines with anticholinergic activity is associated with worsening of cognitive function, increased incidence of dementia and increased mortality. This article gives an overview of the evidence, discusses some of the tools used to identify high-risk drugs and highlights issues to consider when prescribing drugs with anticholinergic activity with a view to reducing potential risks in older people and those at highest risk of cognitive impairment.

Post Hoc Analyses of a Randomized Controlled Trial for the Effect of Pharmacist Deprescribing Intervention on the Anticholinergic Burden in Frail Community-Dwelling Older Adults

OBJECTIVES

Anticholinergic burden is detrimental to cognitive health. Multiple studies found that a high anticholinergic burden is associated with an increased risk for dementia, changes to the brain structure, function, and cognitive decline. We performed a post hoc analysis of a randomized controlled deprescribing trial. We compared the effect of the intervention on baseline anticholinergic burden across the treatment and control groups and the time of recruitment before and after a lockdown due to the COVID pandemic with subgroup analyses by baseline frailty index.

DESIGN

Randomized controlled trial.

SETTINGS AND PARTICIPANTS

We analyzed data from a de-prescribing trial of older adults (>65 years) previously conducted in New Zealand that was focused on reducing the Drug Burden Index (DBI).

METHODS

We used the anticholinergic cognitive burden (ACB) to quantify the impact of the intervention on reducing the anticholinergic burden. Participants not taking anticholinergics at the start of the trial were excluded. The primary outcome for this subgroup analysis was a change in ACB, measured with the ĝ_Hedges statistic describing the difference in standard deviation units of this change between intervention and control. For this analysis, the trial participants were stratified into low, medium, and high frailty and timing into prior- and post-lockdown (public health measures for COVID-19).

RESULTS

Among the 295 participants in this analysis, the median (IQR) age was 79 (74, 85), and 67% were women. For the primary outcome ĝ_Hedges = -0.04 (95% CI -0.26 to 0.19) with a -0.23 mean reduction in ACB in the intervention arm and -0.19 in the control arm. Before lockdown ĝ_Hedges = -0.38 (95% CI -0.84 to 0.04) and post-lockdown ĝ_Hedges = 0.07 (95% CI -0.19 to 0.33). The mean change in ACB for each of the frailty strata was as follows: low frailty (-0.02; 95% CI -0.65 to 0.18); medium frailty (0.05; 95% CI -0.28 to 0.38); high frailty (0.08; 95% CI -0.40 to 0.56).

CONCLUSIONS AND IMPLICATIONS

The study did not provide evidence for the effect of pharmacist deprescribing intervention on reducing the anticholinergic burden. However, this post hoc analysis examined the impact of COVID on the effectiveness of the intervention, and further research in this area may be warranted.

Adherence to Overactive Bladder Syndrome Treatments Recent Developments and Future Perspectives

Overactive bladder (OAB) is a common and distressing condition which is known to have a significant effect on Health-Related Quality of Life (HRQoL). Whilst all patients complaining of overactive bladder symptoms will, in theory, initially benefit from conservative measures, many will require pharmacological therapy. Antimuscarinics currently remain the most commonly used drugs to treat OAB although compliance and persistence can be poor due to concerns regarding adverse events and lack of efficacy. This review will explore the common management strategies for OAB with a particular focus on patient adherence to therapy including compliance and persistence. The role of antimuscarinics and the B3-agonist, mirabegron, will be considered along with barriers to their efficacy and adoption. For those patients in whom conservative and pharmacological treatment proves ineffective or is unsuitable, the management of refractory OAB will also be considered. In addition, the role of current and future developments will be examined.

[Polypharmacy in nursing homes: options to improve drug therapy safety]

Patients in need of care usually suffer from multiple chronic conditions and therefore receive a high number of drugs. Polypharmacy involves multiple risks, for example, drug-drug and drug-disease interactions, adverse effects and potentially inappropriate medication (PIM), more hospital admissions, and increased mortality.Residents in long-term care facilities are particularly sensitive to adverse drug reactions because of age-related changes, frailty, and the high prevalence of dementia. Numerous drugs have side effects that lead to sedation, particularly in old age, and increase the risk of falls. In addition, anticholinergic effects negatively modify cognition. These PIMs are frequently prescribed to nursing home residents.The medication process in long-term care facilities is complex and requires numerous coordinated processes. In addition to the correct administration, the nursing staff have other important tasks such as monitoring the effects and potential adverse drug reactions and communicating their observations to the prescribing physicians and home-supplying pharmacists. The nursing staff therefore play a crucial role in the prescription of psychotropic drugs and contribute to the medication quality for nursing home residents. National and international studies indicate that improvements of polypharmacy and drug therapy safety in nursing homes can only be achieved by interprofessional collaboration.

[Guidelines on the urological management of the adult patient with spinal dysraphism (spina bifida)]

INTRODUCTION

Improved life expectancy and prenatal screening have changed the demographics of spina bifida (spinal dysraphism) which has presently become a disease of adulthood. Urinary disorders affect almost all patients with spinal dysraphism and are still the leading cause of mortality in these patients. The aim of this work was to establish recommendations for urological management that take into account the specificities of the spina bifida population.

MATERIALS AND METHODS

National Diagnosis and Management Guidelines (PNDS) were drafted within the framework of the French Rare Diseases Plan at the initiative of the Centre de Référence Maladies Rares Spina Bifida - Dysraphismes of Rennes University Hospital. It is a collaborative work involving experts from different specialties, mainly urologists and rehabilitation physicians. We conducted a systematic search of the literature in French and English in the various fields covered by these recommendations in the MEDLINE database. In accordance with the methodology recommended by the authorities (Guide_methodologique_pnds.pdf, 2006), proposed recommendations were drafted on the basis of this literature review and then submitted to a review group until a consensus was reached.

RESULTS

Bladder dysfunctions induced by spinal dysraphism are multiple and varied and evolve over time. Management must be individually adapted and take into account all the patient's problems, and is therefore necessarily multi-disciplinary. Self-catheterisation is the appropriate micturition method for more than half of the patients and must sometimes be combined with treatments aimed at suppressing any neurogenic detrusor overactivity (NDO) or compliance alteration (anticholinergics, intra-detrusor botulinum toxin). Resort to surgery is sometimes necessary either after failure of non-invasive treatments (e.g. bladder augmentation in case of NDO resistant to pharmacological treatment), or as a first line treatment in the absence of other non-invasive alternatives (e.g. aponeurotic suburethral tape or artificial urinary sphincter for sphincter insufficiency; urinary diversion by ileal conduit if self-catheterisation is impossible).

CONCLUSION

Spinal dysraphism is a complex pathology with multiple neurological, orthopedic, gastrointestinal and urological involvement. The management of bladder and bowel dysfunctions must continue throughout the life of these patients and must be integrated into a multidisciplinary context.

Safety and tolerability of solifenacin in children and adolescents with overactive bladder- a systematic review

BACKGROUND

Solifenacin is an anticholinergic that is used to treat overactive bladder syndrome (OAB) in children. It is important to ascertain the safety and tolerability of solifenacin in the paediatric population as solifenacin offers an alternative, is more bladder specific, and should have less anticholinergic side effects than other therapies.

OBJECTIVE

The aim of this study is to systematically evaluate the safety and tolerability of solifenacin in children and adolescents with OAB.

STUDY DESIGN

We included studies that reported the safety and tolerability of solifenacin in children and adolescents. All study types were included. Electronic searches were conducted in Ovid MEDLINE, Ovid Embase, TRIP, CINAHL and ICTRP on the 18th of January 2022. Risk of bias was assessed with the Cochrane Risk of Bias tool 2.0 (ROB-2) for randomised controlled trials (RCTs) and the Newcastle-Ottowa scale for cohort studies.

RESULTS

A total of twelve studies including two RCTs were included in this review. Results from the meta-analysis of RCTs showed the commonest side effects were constipation (RR 3.5, 95%CI 0.9-13.7) and dry mouth (RR 3.1 95%CI 0.2-53). In terms of tolerability, the effect estimate of ceasing solifenacin due to an adverse effect was 2.7 (95%CI 0.8-9.1). Within the cohort studies, out of the 779 patients 21.7% experienced side effects. The most common side effects were constipation (6.8%) and dry mouth/lips (6.0%) and 3.5% of patients ceased solifenacin due to adverse effects. Overall, the certainty of the evidence for side effects and tolerability were very low.

DISCUSSION

The reported incidence of side effects is low, and less than reported with oxybutynin use. However, the very low certainty of the evidence means the findings should be interpreted with caution. There is limited reporting of a prolonged QTc interval on ECG. Studies that described this only had an increase of QTc from baseline and not a clinically significant prolonged QTc that resulted in arrhythmias.

CONCLUSION

Solifenacin is an alternative anticholinergic for the treatment of OAB in children. However, given the paucity of good quality data on safety and tolerability it should be used cautiously in children with close monitoring for potential side effects.

Associations between the use of β-adrenoceptor acting drugs and the risk of dementia in older population

Objective

Age-related decline within the noradrenergic system is associated with reduced cognition. The β-adrenoceptors are widely expressed in the brain as well as in the peripheral. Medications targeting β-adrenoceptor activity have been widely used in older adults. The aim of this study was to explore the associations between β-adrenoceptor acting drugs and the risk of dementia in the older population.

Methods

The subjects' information was collected from the electronic medical record (EMR) database. A propensity score matching strategy was conducted to select control participants for users of β2-agonists or β-antagonists. Logistic regression analysis was performed to estimate the risk of dementia with the use of β2-agonists or β-antagonists.

Results

A total of 1,429 participants in the EMR database were included in the study. The use of β2-agonists was strongly associated with a decreased risk of dementia [OR = 0.324, 95% confidence interval (CI): 0.149-0.707, P = 0.005]. This decreased risk showed a statistically significant inverse time-dependent pattern (P _trend = 0.014). However, the use of non-selective β-antagonists significantly correlated with an increased dementia risk (OR = 1.961, 95% CI: 1.144-3.359, P = 0.014), although no time-dependent manner was found (P _trend = 0.220). There was no association between selective β1-antagonists usage and dementia risk (OR = 1.114, P = 0.625).

Conclusion

The use of β-adrenoceptor acting drugs seems to be associated with the risk of dementia. Pharmacological interventions modulating β2-adrenoceptor activity might be a potential target in therapeutics for dementia.

SUFU white paper on overactive bladder anticholinergic medications and dementia risk

AIMS

Anticholinergic medications are widely used in the treatment of overactive bladder (OAB), as well as for short-term treatment of bladder symptoms following a variety of urologic surgeries. Mounting evidence points to an association between anticholinergic medications and the increased risk of incident dementia. The Society for Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) thus convened a committee of subject experts to contextualize the current understanding of the cognitive risks of anticholinergic medications in the urologic patient population and to provide practical clinical guidance on this subject.

METHODS

Statements are based on an expert literature review and the committee's opinion. The document has been reviewed and approved by the SUFU board.

RESULTS

Chronic use (>3 months) of OAB anticholinergic medications is likely associated with an increased risk of new-onset dementia. Short-term (<4 weeks) use of most OAB anticholinergic medications is likely safe in most individuals. Clinicians should consider potential cognitive risks in all patient populations when prescribing OAB anticholinergics for chronic use. Consideration should be given to progressing to advanced therapy (botulinum toxin or neuromodulation) earlier in the OAB treatment paradigm CONCLUSIONS: The current body of literature supports a likely small but significant increased risk of dementia with chronic exposure to OAB anticholinergic medications. Potential harms should be balanced against potential quality of life improvement with treatment.

Multimorbidity Clusters in the Oldest Old: Results from the EpiChron Cohort

Multimorbidity is challenging for both patients and healthcare systems due to its increasing prevalence and high impact on people's health and well-being. The risk of multimorbidity increases with age, but there is still more to discover regarding the clinical profile of the oldest old. In this study, we used information from the EpiChron Cohort Study to identify multimorbidity patterns in individuals who died during the period 2010-2019 at the ages of 80-89, 90-99, and ≥100. This cohort links the demographic, clinical, and drug dispensation information of public health system users in Aragón, Spain. We saw a significantly lower number of chronic diseases and drugs and a lower prevalence of polypharmacy in centenarians compared to those aged 80-99. K-means clustering revealed different multimorbidity clusters by sex and age group. We observed clusters of cardiovascular and metabolic diseases, obstructive pulmonary conditions, and neoplasms, amongst other profiles. One in three octogenarian women had a metabolic pattern (diabetes, dyslipidaemia, and other endocrine-metabolic disorders) with the highest number of diseases (up to seven) and prevalence of polypharmacy (64%). We observed clusters of dementia and genitourinary disorders in individuals on medication with anticholinergic activity. Our study offers an opportunity to better understand the urgency of adequately addressing multimorbidity in our older adults.

Impaired sweating in patients with cholinergic urticaria is linked to low expression of acetylcholine receptor CHRM3 and acetylcholine esterase in sweat glands

Background

Cholinergic urticaria (CholU), a frequent form of chronic inducible urticaria, is characterized by itchy wheals and angioedema in response to sweating. As of now, the rate and pathophysiological relevance of impaired sweating in patients with CholU are ill-defined.

Aim

To assess in CholU patients the rate and extent of impaired sweating and its links to clinical and pathophysiological features of CholU.

Patients and methods

We assessed sweating in patients with CholU (n = 13) subjected to pulse-controlled ergometry (PCE) provocation testing. Pre- and post-PCE biopsies of lesional (L) and non-lesional (NL) skin were analyzed for the expression of acetylcholine receptor M3 (CHRM3) and acetylcholine esterase (ACh-E) by quantitative histomorphometry and compared to those of healthy control subjects (HCs). CholU patients were assessed for disease duration and severity as well as other clinical features.

Results

Of the 13 patients with CholU, 10 showed reduced sweating in response to PCE provocation, and 3 had severely reduced sweating. Reduced sweating was linked to long disease duration and high disease severity. CholU patients with impaired sweating responses showed reduced sweat gland epithelial expression of CHRM3 and ACh-E.

Conclusion

Reduced sweating is common in CholU patients, especially in those with long-standing and severe disease, and it can be severe. Reduced expression of CHRM3 and ACh-E may be the cause or consequence of CholU in patients with impaired sweating, and this should be explored by further studies.

A Prescribing Cascade of Proton Pump Inhibitors Following Anticholinergic Medications in Older Adults With Dementia

Introduction: Prescribing cascade refers to use of a medication to treat a drug-related adverse event. Prescribing cascades increase medication use, cost, and risk of adverse events.

Objective: Our objective was to use administrative health data to identify whether use of medications from the anticholinergic cognitive burden scale was associated with proton pump inhibitor (PPI) prescribing consistent with a prescribing cascade in older adults with dementia.

Method: The cohort was comprised of Nova Scotia Seniors’ Pharmacare beneficiaries identified to have dementia and medication dispensation data recorded between 1 April 2010, or cohort entry and 31 March 2015. Anticholinergic medications from the anticholinergic cognitive burden scale (ACB) were abstracted. A look back period of 365 days identified if a PPI had been dispensed preceding anticholinergic dispensation. PPI initiation within 30, 60, 90, or 180 days of the anticholinergic medication was assessed. Demographic description of those dispensed anticholinergic medications or PPIs were reported. Risk factors for the prescribing cascade were investigated with logistic regression and Cox proportional hazards modelling including a sex-stratified analysis.

Results: We identified 28,952 Nova Scotia Seniors’ Pharmacare beneficiaries with dementia and prescription dispensation data. Anticholinergic medications were frequently dispensed with 63.4% of the cohort dispensed at least one prescription for an anticholinergic medication. The prescribing cascade defined as up to 180-days between anticholinergic medication inititation and PPI dispensation, occurred in 1,845 Nova Scotia Seniors’ Pharmacare beneficiaries with dementia (incidence 6.4%). Multivariate regression showed those experiencing the prescribing cascade after initiating any anticholinergic were younger (OR 0.98, 95%CI [0.97–0.98]), less likely to live in an urban location (OR 0.82, 95%CI [0.74–0.91]), or to be men (OR 0.74, 95%CI [0.67–0.82]). Cox regression demonstrated an increased risk of starting a PPI within 180 days when initiating any medication from the ACB (HR 1.38, 95%CI [1.29–1.58]).

Discussion: Regression modelling suggested that anticholinergic medications increased the risk of PPI dispensation consistent with a prescribing cascade in the cohort. The identification of the prescribing cascade in this population of older Nova Scotia Seniors’ Pharmacare Program beneficiaries with dementia using administrative health data highlights how routinely collected health data can be used to identify prescribing cascades.

A systematic review of interventions to reduce anticholinergic burden in older people with dementia in primary care

OBJECTIVE

This systematic review aimed to assess the types and effectiveness of interventions that sought to reduce anticholinergic burden (ACB) in people with dementia (PwD) in primary care.

METHODS

One trial registry and eight electronic databases were systematically searched to identify eligible English language studies from inception until December 2021. To be eligible for inclusion, studies had to be randomised controlled trials (RCTs) or non-randomised studies (NRS), including controlled before-and-after studies and interrupted time-series studies, of interventions to reduce ACB in PwD aged ≥65 years (either community-dwelling or care home residents). All outcomes were to be considered. Quality was to be assessed using the Cochrane Risk of Bias tool for RCTs and ROBINS-I tool for NRS. If data could not be pooled for meta-analysis, a narrative synthesis was to be conducted.

RESULTS

In total, 1880 records were found, with 1594 records remaining after removal of duplicates. Following title/abstract screening, 13 full-text articles were assessed for eligibility. None of these studies met the inclusion criteria for this review. Reasons for exclusion were incorrect study design, ineligible study population, lack of focus on reducing ACB, and studies conducted outside the primary care setting.

CONCLUSIONS

This 'empty' systematic review highlights the lack of interventions to reduce ACB in PwD within primary care, despite this being highlighted as a priority area for research in recent clinical guidance. Future research should focus on development and testing of interventions to reduce ACB in this patient population through high-quality clinical trials.

The role of plant-based products in the prevention of neurological complications

BACKGROUND

Neurological complications are most likely to be fatal and cause loss of ability to function or care for self. These include Alzheimer's disease and cognitive impairment. The main aim of the review is to determine the effects of various drugs and their cognitive risk with the need to opt for herbal therapy as an adjuvant in treating neurological conditions like Alzheimer's disease with lesser-known side effects. The Methodology: Involved a detailed literature survey which was performed through an online database, such as Science Direct, Google Scholar, Scopus, Cochrane, and PubMed. The study included randomized trials and original research conducted by herbal supplements on animal models to assess expression of upregulation of signalling pathways. Various studies involved in treating dementia, neurological disorders, Alzheimer disease, cognitive dysfunction were included.

RESULTS

Found that various studies involved plant-based products were showing improvement in prevention of disease and signalling pathways with lesser-known side effects.

CONCLUSION

It was observed that plant-based products play a major role in the prevention of neurological complications. Herbal medicines could most suitably prevent Alzheimer's risk with less known side effects in contrast with the existing treatment patterns. However, to improve the utility of herbal medicines, more evidences from in vitro, in vivo, and clinical trials need to be addressed.

Association between anticholinergic burden and dementia in UK Biobank

Background

Previous studies on the relationship between anticholinergic drugs and dementia have reported heterogeneous results. This variability could be due to different anticholinergic scales and differential effects of distinct classes of drugs.

Methods

Using Cox proportional hazards models, we computed the association between annual anticholinergic burden (AChB) and the risk of dementia in UK Biobank with linked general practitioner prescription records between the years 2000 and 2015 (n = 171,775).

Results

AChB according to most anticholinergic scales (standardized odds ratio range: 1.027-1.125) and the slope of the AChB trajectory (hazard ratio = 1.094; 95% confidence interval: 1.068-1.119) were predictive of dementia. However, the association between AChB and dementia held only for some classes of drugs, especially antidepressants, antiepileptics, and antidiuretics.

Discussion

The heterogeneity in previous findings may partially be due to different effects for different classes of drugs. Future studies should establish differences in more detail and further examine the practicality of a general measure of AChB relating to the risk of dementia.

The Usage of Histamine Type 1 Receptor Antagonist and Risk of Dementia in the Elderly: A Nationwide Cohort Study

Background

The histamine type 1 receptor antagonist (H1RA) has been commonly used. This study aimed to examine the association between the usage of H1RA and the risk of dementia.

Methods

A total of 8,986 H1RA users aged ≥50 and 26,958 controls matched a ratio of 1:3 for age, sex, and comorbidity, were selected between January 1, and December 31, 2000, from Taiwan’s National Health Insurance Research Database. Fine and Gray’s survival analysis (competing with mortality) was used to compare the risk of developing dementia during a 15-year follow-up period (2000–2015).

Results

In general, the H1RA usage was not significantly associated with dementia (adjusted subdistribution hazard ratio [SHR] = 1.025, 95% confidence interval [CI] = 0.883–1.297, p = 0.274) for the H1RA cohort. However, a differential risk was found among the groups at risk. The patients with the usage of H1RA aged ≥65 years (adjusted SHR: 1.782, 95% CI = 1.368–2.168, p &lt; 0.001) were associated with a higher risk of dementia, in comparison to the control groups. Furthermore, the patients with the usage of H1RA that were male, or had more comorbidities, were also associated with an increased risk of dementia.

Conclusion

The usage of H1RA was associated with the risk of developing dementia in the patients aged ≥ 65 years.

Aquagenic Keratoma: Treatment Update

{0>La Queratodermia Acuagénica (QA) es una afectación dermatológica adquirida poco frecuente que se caracteriza por la aparición de edema y pápulas blanquecinas-translúcidas desencadenado por la inmersión o contacto con agua.<}100{>Aquagenic keratoderma is an uncommon acquired dermatosis characterized by edema and whitish-translucent papules triggered by immersion or contact with water.<0} {0>Se han descrito casos asociados a fármacos, hiperhidrosis y a fibrosis quística.<}100{>Cases have been described in association with certain medications, hyperhidrosis, and cystic fibrosis.<0} {0>Los objetivos del estudio son evaluar la efectividad de los distintos tratamientos existentes para la QA.<}0{>The aim of this review is to evaluate the effectiveness of different treatments for aquagenic keratoderma.<0} {0>Realizamos una revisión de la literatura existente al respecto hasta el momento, incluyendo series de casos y reportes de caso.<}94{>We reviewed the literature and analyzed treatments for aquagenic keratoderma described in case series and reports.<0} {0>El tratamiento de la QA es efectivo en las formas asociadas a hiperhidrosis.<}100{>Aquagenic keratoderma associated with hyperhidrosis can be treated effectively.<0} {0>La iontoforesis de agua del grifo, la simpatectomía torácica endoscópica, las inyecciones de toxina botulínica y la oxibutinina son efectivas en las formas refractarias.<}100{>Tap water iontophoresis, endoscopic thoracic sympathectomy, botulinum toxin injections, and oxybutynin are effective against refractory forms.<0} {0>La aplicación tópica de ácido salicílico o sales de aluminio es efectiva pero resulta poco eficaz como tratamiento de mantenimiento.<}0{>Topical salicylic acid and aluminum salts are effective, but of little value as maintenance therapy.<0} {0>Probablemente la mejor alternativa para el tratamiento de la QA sea la Oxibutinina 5mg/día v.o.<}100{>Oral oxybutynin 5 mg/d is probably the best option for treating aquagenic keratoderma.<0} {0>Se ha observado que los efectos fisiopatológicos de los antiinflamatorios no esteroideos en la QA podrían justificar el uso de las prostaglandinas como un tratamiento dirigido de la enfermedad.<}100{>The reported pathophysiological effects of nonsteroidal anti-inflammatory drugs in this setting suggest that the use of prostaglandins might be justified.<0} {0>Se necesitan estudios adicionales para fortalecer estas deducciones y abordar las incertidumbres restantes.<}100{>Additional studies are needed to investigate these hypotheses and resolve other questions.<0}.