Exposure to anticholinergic and sedative drugs, risk of falls, and mortality: an elderly inpatient, multicenter cohort

Preadmission medications and recent falls in older inpatients: an observational study

BACKGROUND

Falls in older adults might increase due to polypharmacy.

AIM

This study aimed to explore the association between preadmission medications and history of falls in older inpatients.

METHOD

This observational study of inpatients aged ≥ 65 years was conducted over 4 years at Ballina Hospital, Australia. The Medication Regimen Complexity Index (MRCI), Drug Burden Index (DBI), and Anticholinergic Effect on Cognition (AEC) scores were calculated for preadmission medications. Polypharmacy and falls questionnaires were administered to identify falls in the past 6 months and aptitude toward medication use.

RESULTS

Overall, 194 participants with a mean age of 80.2 (SD 8.0) years were included. The mean daily number of regular medications was 7.8 (SD 3.9) and the mean MRCI score was 22 (SD 12.6). Among the participants, 107 (55%) reported falls in the past 6 months and 47 (24%) reported ≥ 2 falls. Age and hearing impairment were positively associated with falls (p = 0.007 and p = 0.003, respectively). History of falls was positively associated with a MRCI score of ≥ 20 (p = 0.018), an AEC score of ≥ 2 (p = 0.010) and a DBI score of ≥ 1 after adjustment for age (p = 0.041). Forgetting medications was associated with falls (p = 0.043). Antihypertensive use did not increase falls risk.

CONCLUSION

Implementing a decisive approach to simplify complex medication regimens, along with patient-focused medication management strategies, may help reduce the risk of falls in older adults. Sedatives and anticholinergic medications increase the risk of falls and should be avoided whenever possible.

A parallel-group randomized controlled trial of blue light versus red light for improving sleep, fatigue, and cognition following stroke: Pilot results and recommendations for further study

BACKGROUND

Disordered sleep and fatigue are common in the acute phase of stroke and can impede recovery.

OBJECTIVE

A randomized parallel group placebo-controlled pilot study compared daily morning exposure to blue light or red light (placebo) for improving daytime sleepiness, fatigue, nocturnal sleep, and cognition in patients receiving inpatient rehabilitation for acute stroke.

METHODS

43 patients with disordered sleep secondary to first episode stroke (n = 34 ischemic, n = 9 hemorrhagic; aged 66.2 ± 14.1 years) were randomized to receive 25 min of blue or red light for 5 or more days depending on inpatient rehabilitation length of stay (blue-light n = 21, red-light n = 22). At baseline and study discharge, daytime sleepiness was measured with the Karolinska Sleepiness Scale and Wits Pictorial Sleepiness Scale, fatigue with a visual analogue scale, and cognitive function with the Rey Auditory Verbal Learning Test and Trail Making Test (TMT). Wrist actigraphs measured nocturnal sleep parameters. Effect sizes were used to estimate sample sizes for larger studies.

RESULTS

Blue light exposure led to significant improvements in daytime sleepiness, fatigue, auditory verbal learning, and time to sleep onset (all p < .05) relative to red light exposure (effect size range 0.75 to 1.83). Change in TMT, minutes of nocturnal sleep, and number of awakenings after sleep onset were not statistically significant (effect sizes range 0.38 to 0.57).

CONCLUSION

Morning blue light exposure for 5 or more days after acute stroke led to greater improvements than red light exposure. Effect sizes suggest a larger study is warranted to confirm generalizability of pilot findings.

TRIAL REGISTRATION

ClinicalTrials.govNCT03125967 (Registered 01/01/2017).

Assessing the feasibility of anticholinergic burden scales and measures in administrative data: A systematic review

AIM

This systematic review aimed to identify and evaluate the quality and adaptability of existing anticholinergic burden scales and measures by using administrative dispensing data.

METHOD

A comprehensive literature search was conducted using the Medline, Embase, CINAHL, and Google Scholar databases from 2001 to 2022. Studies that introduced, updated, or modified anticholinergic burden scales and measures were included in this review. Quality assessment considered various aspects, including scoring systems, tool development criteria, and specific requirements tailored for administrative data.

RESULTS

Twenty-eight anticholinergic burden scales and measures were identified in 14 countries. The Modified Anticholinergic Risk Scale excelled in the scoring system, while the German Anticholinergic Burden Scale stood out in the scale development process. However, significant variability was observed in methodologies, medication listings, and adaptability to administrative data. Quality assessment considers aspects such as potency, dose, exposure duration, longitudinal measurement, clinical interpretation, and compatibility with administrative data variables. The evaluation also considered tool development criteria including evidence for medication selection, panel expertise, relevance, updating methods, international applicability, validation, and clinical guidance.

CONCLUSION

This review emphasizes the importance of adaptable and robust tools that can work well with administrative data to ensure patient safety and better health outcomes, given the ongoing evolution of anticholinergic medications. The findings of this systematic review provide valuable insights for clinicians and researchers in selecting the most appropriate anticholinergic burden scale or measure according to their specific needs and data sources. This systematic review was registered with PROSPERO (registration ID CRD42023423959).

Falls in hospitalized older adults and the use of fall risk-increasing drugs and anticholinergic medications in Colombia: a case‒control study

Introduction

In-hospital falls are multicausal in older hospitalized patients. Drugs with anticholinergic load and psychotropic effects can increase the risk of falling.

Objective

This study aimed to determine the associations between fall risk-increasing drugs (FRIDs) and the anticholinergic risk score (ARS) with falls in hospitalized older hospitalized patients.

Methods

This was a case‒control study of patients ≥65 years of age of either sex treated in four clinics in Colombia between 2018 and 2020. Each patient who suffered a fall during hospitalization was matched with four hospitalized patients who did not. Sociodemographic, clinical, and pharmacologic variables and the use of the ARS and FRIDs were evaluated. The risk associated with FRIDs was estimated using conditional logistic regression.

Results

There were 250 patients and 1,000 controls (ratio of 1:4), with a mean age of 77.4 ± 7.4 years and a predominance of men (n = 800, 64.0%). The majority of falls occurred during hospitalization (n = 192 patients, 76.8%). Polypharmacy, calcium channel blockers, antiepileptics, antipsychotics, sodium-glucose cotransporter type 2 inhibitors, and nonsteroidal anti-inflammatory drugs were associated with falls during hospitalization. With an ARS score of 3, the probability of falling during the hospital stay increased (aOR: 2.34; 95% CI: 1.64-3.32).

Conclusion

There is an association between suffering a fall and the use of drugs with anticholinergic load or FRIDs in hospitalized adults more than 65 years of age in Colombia.

Association of the Drug Burden Index (DBI) exposure with outcomes: A systematic review

BACKGROUND

The Drug Burden Index (DBI) measures an individual's total exposure to anticholinergic and sedative medications. This systematic review aimed to investigate the association of the DBI with clinical and prescribing outcomes in observational pharmaco-epidemiological studies, and the effect of DBI exposure on functional outcomes in pre-clinical models.

METHODS

A systematic search of nine electronic databases, citation indexes and gray literature was performed (April 1, 2007-December 31, 2022). Studies that reported primary data on the association of the DBI with clinical or prescribing outcomes conducted in any setting in humans aged ≥18 years or animals were included. Quality assessment was performed using the Joanna Briggs Institute critical appraisal tools and the Systematic Review Centre for Laboratory animal Experimentation risk of bias tool.

RESULTS

Of 2382 studies screened, 70 met the inclusion criteria (65 in humans, five in animals). In humans, outcomes reported included function (n = 56), cognition (n = 20), falls (n = 14), frailty (n = 7), mortality (n = 9), quality of life (n = 8), hospitalization (n = 7), length of stay (n = 5), readmission (n = 1), other clinical outcomes (n = 15) and prescribing outcomes (n = 2). A higher DBI was significantly associated with increased falls (11/14, 71%), poorer function (31/56, 55%), and cognition (11/20, 55%) related outcomes. Narrative synthesis was used due to significant heterogeneity in the study population, setting, study type, definition of DBI, and outcome measures. Results could not be pooled due to heterogeneity. In animals, outcomes reported included function (n = 18), frailty (n = 2), and mortality (n = 1). In pre-clinical studies, a higher DBI caused poorer function and frailty.

CONCLUSIONS

A higher DBI may be associated with an increased risk of falls and decreased function and cognition. Higher DBI was inconsistently associated with increased mortality, length of stay, frailty, hospitalization or reduced quality of life. Human observational findings with respect to functional outcomes are supported by preclinical interventional studies. The DBI may be used as a tool to identify older adults at higher risk of harm.

The effect of the anticholinergic burden on mortality following elective cardiac surgery

OBJECTIVE

The cumulative effect of drugs with anticholinergic properties may pose a significant risk in the post-discharge period of patients who have undergone elective cardiac surgery. The aim of this study was to investigate the association between anticholinergic burden and 6-month postdischarge mortality in older cardiac surgery patients.

METHODS

This study performed a retrospective longitudinal analysis of patients undergoing elective cardiac surgery at a tertiary care centre from January 2021 to January 2022. The Deyo-Charlson comorbidity index (D-CCI) was used to estimate the burden of comorbidities. The anticholinergic burden was assessed using the Anticholinergic Cognitive Burden scale (ACB) and Drug Burden Index (DBI) scale. All-cause postdischarge mortality was determined from electronic medical records.

RESULTS

A total of 255 older adults who had undergone elective cardiac surgery and had been followed up for at least 6 months were included in this study. Approximately 12.5% (n = 32) of older patients died within 6 months of discharge. In multivariate Cox regression analysis, ACB (HR:1.31, 95%CI:1.10-1.56 p = 0.01) and DBI (HR:2.08, 95%CI:1.27-3.39 p = 0.01) showed significantly increased risk of 6-month postdischarge mortality after adjusting for several possible confounders (age, gender, D-CCl, and American Society of Anaesthesiologists (ASA) score). Overall event-free survival differed significantly between patients undergoing cardiac surgery based on anticholinergic burden according to the group-stratified ACB and DBI scales (χ2: 5.907, log-rank test, p = 0.015 and χ2: 15.389, log-rank test, p < 0.001 respectively).

CONCLUSION

The anticholinergic burden is associated with 6-month all-cause post-discharge mortality in older cardiac surgery patients. A deprescribing approach should be considered, especially for older adults in the perioperative period.

TRIAL REGISTRATION

The trial was retrospectively registered at ClinicalTrials.gov. Identifier: NCT05312684 Registered on 5 April 2022.

Drug Burden Index in Older Adults with Psychiatric Illnesses: A Cross-Sectional Study

BACKGROUND

Medications with anticholinergic and/or sedative properties are commonly used in the management of psychiatric illnesses. The burden of anticholinergic and sedative medication use has been measured by the Drug Burden Index (DBI) score tool. A higher DBI score has been associated with increased risk of falls, bone and hip fractures, and functional and cognitive impairment, among other serious health outcomes, especially in older adults.

OBJECTIVES

We aimed to describe the drug burden in older adults with psychiatric illnesses using DBI, determine the factors that are associated with the drug burden measured by DBI, and examine the association between DBI score and Katz for activities of daily living (ADL) index.

METHODS

A cross-sectional study was conducted in the psychogeriatric division of an aged-care home. The study sample comprised all inpatients, aged ≥ 65 years, diagnosed with psychiatric illness. The data obtained included demographic characteristics, duration of hospital stay, primary psychiatric diagnosis and comorbidities, functional status using the Katz ADL index, and cognitive status using the Mini-Mental State Examination (MMSE) score. DBI score was calculated for each anticholinergic and sedative medication used.

RESULTS

Of the 200 patients eligible for analysis, 106 (53.1%) were females and the mean age was 76 ± 9 years. The most commonly encountered chronic disorders were hypertension 102 (51%) and schizophrenia 94 (47%). The use of drugs with anticholinergic and/or sedative effects was seen in 163 (81.5%) patients; the mean DBI score was 1.25 ± 1. The results of the multinomial logistic regression showed that schizophrenia (odds ratio (OR) = 2.1 (95% confidence interval (CI) 1.57-4.45), p = 0.01), level of dependency (OR = 3.50 (95% CI 1.38-5.70), p = 0.001), and polypharmacy (OR = 2.99 (95% CI 2.15-4.29), p = 0.003) were significantly associated with DBI score ≥ 1 compared to DBI score 0.

CONCLUSIONS

The study showed that anticholinergic and sedative medication exposure measured by DBI was associated with higher levels of dependency on the Katz ADL index in a sample of older adults with psychiatric illnesses from an aged-care home.

External validation of the Johns Hopkins Fall Risk Assessment Tool in older Dutch hospitalized patients

PURPOSE

Fall prevention is a safety goal in many hospitals. The performance of the Johns Hopkins Fall Risk Assessment Tool (JHFRAT) in older inpatients is largely unknown. We aimed to assess the JHFRAT performance in a large sample of Dutch older inpatients, including its trend over time.

METHODS

We used an Electronic Health Records (EHR) dataset with hospitalized patients (≥ 70), admitted for ≥ 24 h between 2016 and 2021. Inpatient falls were extracted from structured and free-text data. We assessed the association between JHFRAT and falls using logistic regression. For test accuracy, we calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Discrimination was measured by the AUC. For calibration, we plotted the predicted fall probability with the actual probability of falls. For time-related effects, we calculated the AUC per 6 months (using data of patients admitted during the 6 months' time interval) and plotted these different AUC values over time. Furthermore, we compared the model (JHFRAT and falls) with and without adjusting for seasonal influenza, COVID-19, spring, summer, fall or winter periods.

RESULTS

Data included 17,263 admissions with at least 1 JHFRAT measurement, a median age of 76 and a percentage female of 47%. The in-hospital fall prevalence was 2.5%. JHFRAT [OR = 1.11 (1.03-1.20)] and its subcategories were significantly associated with falls. For medium/high risk of falls (JHFRAT > 5), sensitivity was 73%, specificity 51%, PPV 4% and NPV 99%. The overall AUC was 0.67, varying over time between 0.62 and 0.71 (for 6 months' time intervals). Seasonal influenza did affect the association between JHFRAT and falls. COVID-19, spring, summer, fall or winter did not affect the association.

CONCLUSIONS

Our results show an association between JHFRAT and falls, a low discrimination by JHFRAT for older inpatients and over-prediction in the calibration. Improvements in the fall-risk assessment are warranted to improve efficiency.

Anticholinergic Drug Use on Admission and the Risk of In-Hospital Falls in Older Hospitalized Patients

Purpose

In-hospital falls, especially among older patients, are a major and underestimated problem. Several studies have suggested a possible association between anticholinergic drug use and falls, but the results are inconclusive and studies focusing on in-hospital falls are scarce. The aim of the present study was to investigate whether anticholinergic drug exposure on admission is associated with in-hospital falls.

Patients and Methods

This retrospective chart review study was conducted in the Erasmus MC University Medical Center, Rotterdam, the Netherlands. Patients aged 65 years and older, who were acutely admitted to the geriatric ward between 2012 and 2015, were included. Anticholinergic drug exposure was determined with the Anticholinergic Risk Scale (ARS), the Anticholinergic Cognitive Burden scale (ACB) and the list of Chew. Logistic regression was used to investigate the possible association between anticholinergic drug exposure and in-hospital falls. Analyses were adjusted for age, sex, fall history, fall as reason for admission, number of drugs on admission, use of a mobility aid and delirium.

Results

A total of 905 patients were included, of which 94 patients experienced one or more in-hospital falls. Each additional anticholinergic drug in use, according to the ARS, was associated with an increased odd of experiencing a fall (OR = 1.49, 95% CI: 1.06–2.10). Other measures, ie anticholinergic drug use (yes/no) and different categories of anticholinergic drug burden, measured with the ARS, ACB and list of Chew, were all not associated with in-hospital falls.

Conclusion

Anticholinergic drug exposure on admission is possibly not a main risk factor for in-hospital falls among older patients.

Potentially inappropriate medications and their effect on falls during hospital admission

OBJECTIVE

to investigate the effect of potentially inappropriate medications (PIMs) on inpatient falls and to identify whether PIMs as defined by STOPPFall or the designated section K for falls of STOPP v2 have a stronger association with inpatient falls when compared to the general tool STOPP v2.

METHODS

a retrospective observational matching study using an electronic health records dataset of patients (≥70 years) admitted to an academic hospital (2015-19), including free text to identify inpatient falls. PIMs were identified using the STOPP v2, section K of STOPP v2 and STOPPFall. We first matched admissions with PIMs to those without PIMs on confounding factors. We then applied multinomial logistic regression analysis and Cox proportional hazards analysis on the matched datasets to identify effects of PIMs on inpatient falls.

RESULTS

the dataset included 16,678 hospital admissions, with a mean age of 77.2 years. Inpatient falls occurred during 446 (2.7%) admissions. Adjusted odds ratio (OR) (95% confidence interval (CI)) for the association between PIM exposure and falls were 7.9 (6.1-10.3) for STOPP section K, 2.2 (2.0-2.5) for STOPP and 1.4 (1.3-1.5) for STOPPFall. Adjusted hazard ratio (HR) (95% CI) for the effect on time to first fall were 2.8 (2.3-3.5) for STOPP section K, 1.5 (1.3-1.6) for STOPP and 1.3 (1.2-1.5) for STOPPFall.

CONCLUSIONS

we identified an independent association of PIMs on inpatient falls for all applied (de)prescribing tools. The strongest effect was identified for STOPP section K, which is restricted to high-risk medication for falls. Our results suggest that decreasing PIM exposure during hospital stay might benefit fall prevention, but intervention studies are warranted.

The effect of the anticholinergic burden on duration and severity of delirium in older hip-surgery patients with and without haloperidol prophylaxis: A post hoc analysis

BACKGROUND

Anticholinergic acting drugs have been associated with delirium in older patients.

OBJECTIVE

To examine the association between the anticholinergic burden (ACB) and the duration and severity of delirium in older hip-surgery patients with or without haloperidol prophylaxis.

METHODS

Older patients with a postoperative delirium following hip surgery from a randomized controlled trial investigating the effects of haloperidol prophylaxis on delirium incidence were included in this study. The ACB was quantified using two different tools, the Anticholinergic Drug Scale and an Expert Panel. Using linear regression, the association between the ACB and delirium was analyzed.

RESULTS

Overall delirium duration and severity were not significantly associated with the ACB. Also, no statistically significant differences were found in delirium duration or severity between the placebo and haloperidol treatment groups for the ACB groups. The protective effect of haloperidol on delirium duration and severity however tended to be present in patients with no or a low ACB but not or to a lesser extent in patients with an intermediate to high ACB.

CONCLUSIONS

The ACB was not significantly associated with delirium duration or severity. Haloperidol prophylaxis tended to shorten delirium duration and decrease delirium severity in patients with no or a low ACB. To further explore the influence of anticholinergic acting drugs on delirium duration and severity and the effect of concomitant haloperidol use, additional research with a higher haloperidol dose, a larger study population, and ACB quantification taking drug exposure into account is warranted.

Association between Anticholinergic Burden and Constipation: A Systematic Review

The association between anticholinergic burden and constipation is not well defined and documented; for this reason, a systematic review was carried out in five databases (Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and Scopus), including studies assessing the correlation between anticholinergic burden, and constipation between January 2006 and December 2020. Data extraction was conducted independently by two researchers. Abstracts and titles were reviewed to determine eligibility for review with eligible articles read in full. From 2507 identified articles, 11 were selected for this review: six cross-sectional studies, four retrospective cohort studies, and a post hoc analysis of a randomized clinical trial. Overall, nine studies reported at least one statistical association between anticholinergic burden and constipation, finding 13 positive results out of 24 association measurements. A total of 211,921 patients were studied. The association between constipation and anticholinergic burden could be demonstrated in studies including 207,795 patients. Most studies were not designed to find differences in constipation prevalence and did not adjust the results by confounding factors. Our findings suggest that a correlation between anticholinergic burden and constipation exists. Higher quality-evidence studies are needed, including analysis that considers confounding factors, such as other non-pharmacological causes of constipation.

Comparative risk of adverse outcomes associated with nonselective and selective antimuscarinic medications in older adults with dementia and overactive bladder

OBJECTIVE

The differential muscarinic receptor selectivity could cause selective antimuscarinics to offer advantages over nonselective agents with respect to adverse effects. The objective was to examine the comparative risk of falls/fractures and all-cause hospitalizations among older adults with dementia and overactive bladder (OAB) using nonselective and selective antimuscarinics METHODS/DESIGN: A retrospective cohort study design was conducted among older patients with dementia and OAB using incident antimuscarinics. The primary exposure was classified as nonselective (oxybutynin, tolterodine, trospium, and fesoterodine) and selective (solifenacin and darifenacin). Cox proportional-hazards regression using inverse probability of treatment weighting (IPTW) evaluated the risk of falls/fractures and all-cause hospitalizations within 6 months of nonselective and selective antimuscarinic use.

RESULTS

The study cohort consisted of 13,896 (76.9%) nonselective and 4,179 (23.1%) selective antimuscarinic incident users. The unadjusted falls/fractures rate was 27.14% (3,772) for nonselective and 24.55% (1,026) for selective users (p-value< 0.01). The unadjusted all-cause hospitalizations rate was 24.14% (3,354) for nonselective and 21.58% (902) for selective users (p-value <0.01). The IPTW models did not find a significant difference in the risk of falls/fractures (Hazard Ratio [HR] 1.03; 95% Confidence Interval [CI] 0.99-1.07) and risk of all-cause hospitalizations (HR 1.04; 95% CI 0.99-1.08) between nonselective and selective antimuscarinics. Several sensitivity analyses corroborated the main findings.

CONCLUSIONS

The study did not find a differential risk of falls/fractures and all-cause hospitalizations in older adults with dementia and OAB using nonselective and selective antimuscarinics. More research is needed to understand the role of pharmacodynamics and pharmacokinetics in the safety profile of antimuscarinics in dementia.

Exposure to Anticholinergic and Sedative Drugs and Healthcare Costs in Older Patients with Neurocognitive Disorders

BACKGROUND

Literature supports an increasing number of older patients living with neurocognitive disorders alongside with their annual worldwide costs. Therapeutic management of behavioral and psychological symptoms includes the use of anticholinergic and sedative drugs for which significant exposure is negatively associated with clinical outcomes.

OBJECTIVE

The aim of this study was to assess the healthcare costs differences related to an increase in the exposure to anticholinergic and sedative drugs in older patients with neurocognitive disorder.

METHODS

A longitudinal study was conducted during 3 years on 1,604 participants of the MEMORA cohort linked with both regional public health insurance and hospital discharge databases between 2012 and 2017. Direct medical and non-medical costs were included. Exposure to anticholinergic and sedative drugs was measured by the drug burden index (DBI).

RESULTS

Costs difference associated with a DBI≥0.5 were + 338€ (p < 0.001). After adjustment on comorbidities, NCD stage, cognitive impairment, functional limitation, polypharmacy, and sociodemographic characteristics, a DBI≥0.5 was found to be an independent predictor of an increase of total healthcare costs by 22%(p < 0.001).

CONCLUSION

Anticholinergic and sedative drugs have a substantial economic burden among older patients with neurocognitive disorder. More studies are required to assess the clinical and economic impact of an efficient strategy based on the reduction of the exposure to anticholinergic and sedative drugs and the promotion of non-pharmacological interventions.

Concomitant inpatient prescribing of strong opioids with sedatives: Associations with comorbid conditions

Co-prescribing of opioids and sedatives is a known risk factor for opioid-induced ventilatory impairment (OIVI). Prevalence data for sedative and opioid co-prescription in inpatients in Australia are unknown. Our objective was to determine the prevalence of inpatient sedative and opioid co-prescribing and to identify factors associated with co-prescription. We conducted a retrospective cross-sectional study from July 2017 to October 2017 across four South Australian hospitals utilizing a centralized electronic health record. Multivariate analysis was used to identify characteristics predictive of co-prescribing of a strong opioid (fentanyl, hydromorphone, morphine, and oxycodone) and sedative medications (benzodiazepines, antiepileptics, antipsychotics, and tricyclic antidepressants). Of the 6170 inpatients, 2795 (45.3%) were prescribed a strong opioid and of those, 1889 (30.6% of all inpatients) were co-prescribed a sedative. Of those prescribed a strong opioid, five (0.18%) developed OIVI. Patients prescribed a strong opioid had a 27-77% increased likelihood of being prescribed a sedative. Factors predictive of sedative co-prescribing included the presence of disease of the central nervous system adjusted OR (aOR) 8.66 [95% CI 5.83-12.9] and respiratory disease aOR 1.42 [95% CI 1.17-1.72]. Nearly, one third of all hospital inpatients were co-prescribed a strong opioid and a sedative medication. Patients with comorbidities resulting in increased risk of respiratory depression/OIVI were more likely to have sedative co-prescription. Clinicians should be aware of the effects of high-risk medications and ensure that systems and monitoring are in place that help mitigate adverse outcomes.

Are Anticholinergic Symptoms a Risk Factor for Falls in Older General Practice Patients With Polypharmacy? Study Protocol for the Development and Validation of a Prognostic Model

Background: Cumulative anticholinergic exposure, also known as anticholinergic burden, is associated with a variety of adverse outcomes. However, studies show that anticholinergic effects tend to be underestimated by prescribers, and anticholinergics are the most frequently prescribed potentially inappropriate medication in older patients. The grading systems and drugs included in existing scales to quantify anticholinergic burden differ considerably and do not adequately account for patients’ susceptibility to medications. Furthermore, their ability to link anticholinergic burden with adverse outcomes such as falls is unclear. This study aims to develop a prognostic model that predicts falls in older general practice patients, to assess the performance of several anticholinergic burden scales, and to quantify the added predictive value of anticholinergic symptoms in this context.

Methods: Data from two cluster-randomized controlled trials investigating medication optimization in older general practice patients in Germany will be used. One trial (RIME, n = 1,197) will be used for the model development and the other trial (PRIMUM, n = 502) will be used to externally validate the model. A priori, candidate predictors will be selected based on a literature search, predictor availability, and clinical reasoning. Candidate predictors will include socio-demographics (e.g. age, sex), morbidity (e.g. single conditions), medication (e.g. polypharmacy, anticholinergic burden as defined by scales), and well-being (e.g. quality of life, physical function). A prognostic model including sociodemographic and lifestyle-related factors, as well as variables on morbidity, medication, health status, and well-being, will be developed, whereby the prognostic value of extending the model to include additional patient-reported symptoms will be also assessed. Logistic regression will be used for the binary outcome, which will be defined as “no falls” vs. “≥1 fall” within six months of baseline, as reported in patient interviews.

Discussion: As the ability of different anticholinergic burden scales to predict falls in older patients is unclear, this study may provide insights into their relative importance as well as into the overall contribution of anticholinergic symptoms and other patient characteristics. The results may support general practitioners in their clinical decision-making and in prescribing fewer medications with anticholinergic properties.

Potentially Inappropriate Medications, Drug-Drug Interactions, and Anticholinergic Burden in Elderly Hospitalized Patients: Does an Association Exist with Post-Discharge Health Outcomes?

BACKGROUND

Polypharmacy is very common in elderly patients and is associated with detrimental outcomes.

OBJECTIVE

Our objective was to evaluate the associations between a large panel of therapy quality indicators, including explicit lists of potentially inappropriate medications (PIMs; Beers criteria and Screening Tool of Older Persons' potentially inappropriate Prescriptions [STOPP] criteria), the Anticholinergic Cognitive Burden (ACB) score, and the number of drug-drug interactions (DDIs), with respect to mortality, rehospitalization, and physical function decline within 3 months from hospital discharge in a cohort of hospitalized elderly patients.

METHODS

We studied 2631 individuals aged ≥ 65 years (median age 79.6; males 48.6%) enrolled in the REPOSI registry. The relationships with mortality and rehospitalization were evaluated using Cox regressions, and relationships with functional status change (as percentage variation of Barthel Index [BI]) were evaluated using mixed linear models.

RESULTS

None of the studied indicators was associated with mortality and rehospitalization. Conversely, only ACB was associated with physical function decline, even after correction for confounders (adjusted mean BI variation of - 7.55%; 95% confidence interval [CI] - 12.37 to - 2.47). The number of medications at discharge, particularly polypharmacy (more than five drugs daily), were the only therapy-related factors associated with mortality (adjusted hazard ratio [aHR] 1.05 [95% CI 1.01-1.10] and 1.70 [95% CI 1.12-2.58], respectively) and rehospitalization (aHR 1.05 [95% CI 1.01-1.08] and 1.31 [95% CI 1.01-1.71], respectively).

CONCLUSION

Polypharmacy, a very simple measure, outperformed sophisticated PIM and DDI indicators of quality of therapy as a correlate of primary clinical outcomes, whereas ACB was associated with physical function decline. Thus, innovative approaches to the definition and research of PIMs and DDIs are eagerly awaited from the perspective of averaging the quantitative burden and qualitative interaction of drugs.

Association between anticholinergic burden and anticholinergic adverse outcomes in the elderly: Pharmacological basis of their predictive value for adverse outcomes

The use of anticholinergic drugs and other drugs with anticholinergic activity is highly prevalent in older people. Cumulative anticholinergic effects, known as anticholinergic burden, are associated with important peripheral and central adverse effects and outcomes. Several methods have been developed to quantify anticholinergic burden and to estimate the risk of adverse anticholinergic effects. Serum anticholinergic activity (SAA) and anticholinergic burden scoring systems are the most commonly used methods to predict the occurrence of important negative outcomes. These tools could guide clinicians in making more rational prescriptions to enhance patient safety, especially in older people. However, the literature has reported conflicting results about the predictive ability of these tools. The majority of these instruments ignore relevant pharmacologic aspects such as the doses used, differential muscarinic receptor subtype affinities, and blood-brain barrier permeability. To increase the clinical relevance of these tools, mechanistic and clinical pharmacology should collaborate. This narrative review describes the rational and pharmacological basis of anticholinergic burden tools and provides insight about their predictive value for adverse outcomes.

Quantifying cumulative anticholinergic and sedative drug load among US Medicare Beneficiaries

PURPOSE

Medications with anticholinergic and sedative properties are widely used among older adults despite strong evidence of harm. The drug burden index (DBI), a pharmacological screening tool, measures these properties across drug classes, and higher DBI drug exposure (DBI > 1) has been associated with certain physical function-related adverse events. Our aim was to quantify mean daily DBI drug exposure among older adults in the United States (US).

METHODS

We screened medications for DBI properties and operationalized the DBI for US Medicare claims. We then conducted a retrospective cohort study of a 20% random, nationwide sample of 4 137 384 fee-for-service Medicare beneficiaries aged 66+ years (134 757 039 person-months) from January 2013 to December 2016. We measured the monthly distribution based on mean daily DBI, categorized as (a) >0 vs 0 (any use) and (b) 0, 0 < DBI ≤ 1, 1 < DBI ≤ 2, and DBI > 2, and examined temporal trends. We described patient-level factors (eg, demographics, healthcare use) associated with high (>2) vs low (0 < DBI≤1) DBI drug exposure.

RESULTS

The distribution of the mean daily DBI, aggregated at the month-level, was: 58.1% DBI = 0, 29.0% 0 < DBI≤1, 9.3% 1 < DBI≤2, and 3.7% DBI > 2. Predictors of high monthly DBI drug exposure (DBI > 2) included certain indicators of increased healthcare use (eg, high number of drug claims), white race, younger age, frailty, and a psychosis diagnosis code.

CONCLUSIONS

The predictors of high DBI drug exposure can inform discussions between patients and providers about medication appropriateness and potential de-prescribing. Future Medicare-based studies should assess the association between the DBI and adverse events.

Risk of Mortality Associated with Non-selective Antimuscarinic medications in Older Adults with Dementia: a Retrospective Study

BACKGROUND

Selective antimuscarinics may offer a favorable safety profile over non-selective antimuscarinics for the management of overactive bladder (OAB) in patients with dementia.

OBJECTIVE

To test the hypothesis that non-selective antimuscarinics are associated with increased risk of mortality compared to selective antimuscarinics in older adults with dementia and OAB.

DESIGN

Propensity score-matched retrospective new-user cohort design among Medicare beneficiaries in community settings.

PATIENTS

Older adults with dementia and OAB with incident antimuscarinic use.

MAIN MEASURES

The primary exposure was antimuscarinic medications classified as non-selective (oxybutynin, tolterodine, trospium, fesoterodine) and selective (solifenacin, darifenacin) agents. All-cause mortality within 180 days of incident antimuscarinic use formed the outcome measure. New users of non-selective and selective antimuscarinics were matched on propensity scores using the Greedy 5 → 1 matching technique. Cox proportional-hazards model stratified on matched pairs was used to evaluate the risk of mortality associated with the use of non-selective versus selective antimuscarinics in the sample.

KEY RESULTS

The study identified 16,955 (77.6%) non-selective antimuscarinic users and 4893 (22.4%) selective antimuscarinic users. Propensity score matching yielded 4862 patients in each group. The unadjusted mortality rate at 180 days was 2.6% (126) for non-selective and 1.6% (78) for selective antimuscarinic users in the matched cohort (p value < 0.01). The Cox model stratified on matched pairs found 50% higher risk of 180-day mortality with non-selective antimuscarinics as compared to selective ones (hazard ratio (HR) 1.50; 95% confidence interval (CI) 1.04-2.16). The study findings remained consistent across multiple sensitivity analyses.

CONCLUSIONS

Use of non-selective antimuscarinics was associated with a 50% increase in mortality risk among older adults with dementia and OAB. Given the safety concerns regarding non-selective antimuscarinic agents, there is a significant need to optimize their use in the management of OAB for older patients with dementia.

Anticholinergic burden in middle-aged women and recurrent falls in later life: findings from the Aberdeen prospective osteoporosis screening study (APOSS)

Background:

Anticholinergic burden (ACB) is a recognised risk factor for falls in older people; however, whether ACB in middle age predicts falls in later life is unknown.

Methods:

We examined this association in the middle-aged women of the Aberdeen Prospective Osteoporosis Screening Study (APOSS). ACB was calculated at the second health visit (1997–1999, study baseline) using the Anticholinergic Cognitive Burden Scale. Outcomes were incidence of 1 fall and recurrent falls (⩾2 falls) during the 12 months prior to follow up 2007–2011. Multinomial logistic regression analyses adjusted for potential confounders including demographics, comorbidities and falls history.

Results:

A total of 2125 women {mean age (standard deviation [SD]): 54.7 (2.2) years at baseline and 66.0 (2.2) years at follow up} were included. Prevalence of baseline ACB score of 0, 1 and ⩾2 was 87.1%, 7.3% and 5.6%, respectively. Compared with no ACB, ACB ⩾2 was associated with recurrent falls in the previous 12 months [adjusted odds ratio (OR): 2.34, 95% confidence interval (CI): 1.31, 4.19] at an average of 11 years after initial exposure. No such association was found for an ACB score of 1.

Conclusions:

These findings highlight the potential negative effects of anticholinergic medications in middle age. While cautious use of anticholinergic medications is advisable, further longitudinal research should be conducted to confirm these findings before any specific clinical recommendations can be made.

Prevalence of Alternative Diagnoses and Implications for Management in Idiopathic Normal Pressure Hydrocephalus Patients

BACKGROUND

Following Bayes theorem, ventriculomegaly and ataxia confer only a 30% chance of idiopathic Normal Pressure Hydrocephalus (NPH). When coupled with positive responses to best diagnostic testing (extended lumbar drainage), 70% of patients recommended for shunting will not actually have NPH. This is inadequate clinical care.

OBJECTIVE

To determine the proportion of alternative and treatable diagnoses in patients referred to a multidisciplinary NPH clinic.

METHODS

Patients without previously diagnosed NPH were queried from prospectively collected data. At least 1 neurosurgeon, cognitive neurologist, and neuropsychologist jointly formulated best treatment plans.

RESULTS

Of 328 total patients, 45% had an alternative diagnosis; 11% of all patients improved with treatment of an alternative diagnosis. Of 87 patients with treatable conditions, the highest frequency of pathologies included sleep disorders, and cervical stenosis, followed by Parkinson disease. Anti-cholinergic burden was a contributor for multiple patients. Of 142 patients undergoing lumbar puncture, 71% had positive responses and referred to surgery. Compared to NPH patients, mimickers were statistically significantly older with lower Montreal Cognitive Assessment (MoCA) score and worse gait parameters. Overall, 26% of the original patients underwent shunting. Pre-post testing revealed a statistically significant improved MoCA score and gait parameters in those patients who underwent surgery with follow-up.

CONCLUSION

Because the Multidisciplinary NPH Clinic selected only 26% for surgery (corroborating 30% in Bayes theorem), an overwhelming majority of patients with suspected NPH will harbor alternative diagnoses. Identification of contributing/confounding conditions will support the meticulous work-up necessary to appropriately manage patients without NPH while optimizing clinical responses to shunting in correctly diagnosed patients.

Use of Medications with Anticholinergic Properties and the Long-Term Risk of Hospitalization for Falls and Fractures in the EPIC-Norfolk Longitudinal Cohort Study

The consumption of medications with anticholinergic activity has been suggested to result in the adverse effects of mental confusion, visual disturbance, and muscle weakness, which may lead to falls. Existing published evidence linking anticholinergic drugs with falls, however, remains weak. This study was conducted to evaluate the relationship between anticholinergic cognitive burden (ACB) and the long-term risk of hospitalization with falls and fractures in a large population study. The dataset comprised information from 25,639 men and women (aged 40-79 years) recruited from 1993 to 1997 from Norfolk, United Kingdom into the European Prospective Investigation into Cancer (EPIC)-Norfolk study. The time to first hospital admission with a fall with or without fracture was obtained from the National Health Service hospital information system. Cox-proportional hazards analyses were conducted to adjust for confounders and competing risks. The fall hospitalization rate was 5.8% over a median follow-up of ~ 19.4 years. The unadjusted incidence rate ratio for the use of any drugs with anticholinergic properties was 1.79 (95% CI 1.66-1.93). The hazard ratios (95% CI) for ACB scores of 1, 2-3, and ≥ 4 compared with ACB = 0 for fall hospitalization were 1.20 (1.09-1.33), 1.42 (1.25-1.60), and 1.39 (1.21-1.60) after adjustment for age, gender, medical conditions, physical activity, and blood pressure. Medications with anticholinergic activity are associated with an increased risk of subsequent hospitalization with a fall over a 19-year follow-up period. The biological mechanisms underlying the long-term risk of hospitalization with a fall or fracture following baseline ACB exposure remains unclear and requires further evaluation.

Greater Changes in Drug Burden Index (DBI) during Hospitalization and Increased 30-Day Readmission Rates among Older In-Hospital Fallers

A higher drug burden index (DBI) is known to be associated with pre-admission falls leading to hospitalization. We investigated whether a mean difference in DBI (ΔDBI) between the events of in-hospital falls and hospital admission was associated with 30-day readmission in 113 patients ≥50 years who fell during their hospital stays between 2007 and 2014. A greater ΔDBI (≥0.09) was positively associated with higher 30-day readmission rates (incident rate ratio: 2.02; 95% confidence interval: 1.49-2.74). An effort to keep DBI low may thus decrease 30-day readmissions for older in-hospital fallers.

Anticholinergic Cognitive Burden as a Predictive Factor for In-hospital Mortality in Older Patients in Korea

BACKGROUND

With the increasing prevalence of chronic disease due to aging, many older adults experience multimorbidity and polypharmacy. Medications with anticholinergic properties are particularly associated with adverse cognitive outcomes, including functional decline and mortality. We assessed the clinical impact of anticholinergic cognitive burden (ACB) on clinical outcomes of older patients acutely admitted to a single, hospitalist-operated medical unit of a tertiary hospital in Korea.

METHODS

This retrospective study reviewed electronic medical records of 318 patients aged 65 years or older admitted to the hospitalist-operated medical unit through the emergency department of Seoul National University Hospital. The analyzed clinical outcomes were the length of hospital stay, in-hospital mortality, unplanned intensive care unit admission, and unexpected readmission within 30 days.

RESULTS

The clinical outcomes did not differ between patients who took five or more drugs and those who did not. Patients with an ACB score of 3 or higher had a higher in-hospital mortality rate and longer hospital stay than those who did not. After adjusting for confounding factors, an ACB score of 3 or higher was an independent predictive factor for in-hospital mortality (odds ratio=3.09; 95% confidence interval, 1.18-8.06).

CONCLUSION

ACB rather than the number of medications was associated with in-hospital mortality in acutely ill older patients. Further analytic and interventional studies are required to assess potentially inappropriate medication use and ACB in older inpatients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Falls during inpatient rehabilitation in spinal cord injury, acquired brain injury, and neurologmusculoskeletal disease programs

STUDY DESIGN

Retrospective chart review.

OBJECTIVES

To compare the proportion of fallers and the patient level and fall characteristics among inpatients who had experienced at least one fall in a spinal cord injury (SCI), an acquired brain injury (ABI), and a neuromusculoskeletal disease (NMS) rehabilitation program.

SETTING

Tertiary rehabilitation hospital.

SUBJECTS

Inpatients who had experienced at least one fall during rehabilitation.

METHODS

Patient and fall level variables were extracted from electronic medical records over a 5-year period (January 1, 2011 to January 1, 2016): hospital program, age, sex, Functional Independence Measure (FIM) scores, length of stay, number of medications, as well as fall date, time, location, cause, harm, fall risk assessment data, and whether the fall was witnessed. The impact of hospital program on fall was examined using bivariate and multivariable analysis.

RESULTS

Two hundred and thirty-seven (16%) inpatients experienced at least one fall during the study period. Inpatients with SCI had the highest proportion of fallers (20%) and fell later after admission than inpatients in the other programs. Patients with ABI were more likely to sustain moderate-to-severe physical harm from falls. Taking >5 medications at time of fall and being earlier in one's rehabilitation course were associated with increased fall rate among fallers.

CONCLUSIONS

Although the type of program was not a significant predictor of fall rate in the multivariable analysis, there were some important differences among the rehabilitation programs on patient and fall level characteristics. These results may be useful when developing and timing fall prevention interventions for inpatient rehabilitation.

Association of Drug Burden Index with grip strength, timed up and go and Barthel index activities of daily living in older adults with intellectual disabilities: an observational cross-sectional study

BACKGROUND

Drug Burden Index (DBI), a measure of exposure to medications with anticholinergic and sedative activity, has been associated with poorer physical function in older adults in the general population. While extensive study has been conducted on associations between DBI and physical function in older adults in the general population, little is known about associations in older adults with intellectual disabilities (ID). This is the first study which aims to examine the association between DBI score and its two sub-scores, anticholinergic and sedative burden, with two objective measures of physical performance, grip strength and timed up and go, and a measure of dependency, Barthel Index activities of daily living, in older adults with ID.

METHODS

Data from Wave 2 (2013/2014) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA) was analysed. Analysis of Covariance (ANCOVA) was used to detect associations and produce adjusted means for the physical function and dependency measures with respect to categorical DBI scores and the anticholinergic and sedative sub-scores (DBA and DBS).

RESULTS

After adjusting for confounders (age, level of ID, history of falls, comorbidities and number of non-DBI medications, Down syndrome (grip strength only) and gender (timed up and go and Barthel Index)), neither grip strength nor timed up and go were significantly associated with DBI, DBA or DBS score > 0 (p > 0.05). Higher dependency in Barthel Index was associated with DBS exposure (p < 0.001).

CONCLUSIONS

DBI, DBA or DBS scores were not significantly associated with grip strength or timed up and go. This could be as a result of established limitations in physical function in this cohort, long-term exposure to these types of medications or lifelong sedentary lifestyles. Higher dependency in Barthel Index activities of daily living was associated with sedative drug burden, which is an area which can be examined further for review.

Drugs Contributing to Anticholinergic Burden and Risk of Fall or Fall-Related Injury among Older Adults with Mild Cognitive Impairment, Dementia and Multiple Chronic Conditions: A Retrospective Cohort Study

BACKGROUND

It is not known whether drugs with different anticholinergic ratings contribute proportionately to overall anticholinergic score.

OBJECTIVES

Our objective was to assess the risk of falls or fall-related injuries as a function of the overall anticholinergic score resulting from drugs with different anticholinergic ratings among people with impaired cognition.

METHODS

This was a retrospective cohort study of adults aged  ≥ 65 years with mild cognitive impairment (MCI) or dementia and two or more additional chronic conditions (N = 10,698) in an integrated delivery system. Electronic health record data, including pharmacy fills and diagnosis claims, were used to assess anticholinergic medication use, quantified using the anticholinergic cognitive burden (ACB) scale, falls and fall-related injuries.

RESULTS

During a median follow-up of 366 days, 63% of the cohort used one or more ACB drug; 2015 (18.8%) people experienced a fall or fall-related injury. Among patients with a daily ACB score of 5, the greatest increase in risk of falls or fall-related injuries was seen when level 2 and level 3 drugs were used in combination [hazard ratio (HR) 2.06; 95% confidence interval (CI) 1.51-2.83]. Multiple ACB level 1 drugs taken together also increased the hazard of a fall or fall-related injury (HR 1.16; 95% CI 1.03-1.32). The risk of fall or fall-related injury as a function of exposure to ACB level 2 drugs (HR 1.56; 95% CI 1.16-2.10) was higher than that for ACB level 1 or 3 drugs.

CONCLUSIONS

The same daily ACB score was associated with a different degree of risk, depending on the ACB ratings of the individual drugs comprising the score. Combinations of level 2 and level 3 drugs had the greatest risk of fall or fall-related injury relative to other individuals with the same daily ACB score. Low-potency anticholinergic drugs taken together modestly increased the hazard of a fall or fall-related injury.

A patient-centered deprescribing intervention for hospitalized older patients with polypharmacy: rationale and design of the Shed-MEDS randomized controlled trial

BACKGROUND

Polypharmacy is prevalent among hospitalized older adults, particularly those being discharged to a post-care care facility (PAC). The aim of this randomized controlled trial is to determine if a patient-centered deprescribing intervention initiated in the hospital and continued in the PAC setting reduces the total number of medications among older patients.

METHODS

The Shed-MEDS study is a 5-year, randomized controlled clinical intervention trial comparing a patient-centered describing intervention with usual care among older (≥50 years) hospitalized patients discharged to PAC, either a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IPR). Patient measurements occur at hospital enrollment, hospital discharge, within 7 days of PAC discharge, and at 60 and 90 days following PAC discharge. Patients are randomized in a permuted block fashion, with block sizes of two to four. The overall effectiveness of the intervention will be evaluated using total medication count as the primary outcome measure. We estimate that 576 patients will enroll in the study. Following attrition due to death or loss to follow-up, 420 patients will contribute measurements at 90 days, which provides 90% power to detect a 30% versus 25% reduction in total medications with an alpha error of 0.05. Secondary outcomes include the number of medications associated with geriatric syndromes, drug burden index, medication adherence, the prevalence and severity of geriatric syndromes and functional health status.

DISCUSSION

The Shed-MEDS trial aims to test the hypothesis that a patient-centered deprescribing intervention initiated in the hospital and continuing through the PAC stay will reduce the total number of medications 90 days following PAC discharge and result in improvements in geriatric syndromes and functional health status. The results of this trial will quantify the health outcomes associated with reducing medications for hospitalized older adults with polypharmacy who are discharged to post-acute care facilities.

TRIAL REGISTRATION

This trial was prospectively registered at clinicaltrials.gov ( NCT02979353 ). The trial was first registered on 12/1/2016, with an update on 09/28/17 and 10/12/2018.

The excess mortality risk associated with anticholinergic burden among older patients discharged from acute care hospital with depressive symptoms

BACKGROUND

The relationship between anticholinergic burden and mortality is controversial, and the impact of anticholinergic burden on prognosis may vary in presence of other conditions common in old age. We aimed at investigating the role of depressive symptoms as potential effect modifiers in the association between anticholinergic burden and 1-year mortality in older patients discharged from hospital.

METHODS

Our series consisted of 576 older patients consecutively admitted to seven geriatric and internal medicine acute care wards in the context of a prospective multicenter observational study. Overall anticholinergic burden was assessed by Anticholinergic Cognitive Burden (ACB) score. Depressive symptoms were assessed by 15-item Geriatric Depression Scale (GDS). The study outcome was all-cause mortality during 12-months follow-up. Statistical analysis was carried out by Cox regression analysis.

RESULTS

After adjusting for potential confounders, discharge ACB score = 2 or more was significantly associated with the outcome among patients with GDS > 5 (HR = 3.70; 95%CI = 1.18-11.6), but not among those with GDS ≤ 5 (HR = 2.32; 95%CI = 0.90-6.24). The association was confirmed among depressed patients after adjusting for ACB score at 3-month follow-up (HR = 3.58; 95%CI = 1.21-10.7), as well as when considering ACB score as a continuous variable (HR = 1.42; 95%CI = 1.10-1.91). The interaction between ACB score at discharge and BADL dependency was statistically significant (p < .005).

CONCLUSIONS

ACB score at discharge may predict mortality among older patients discharged from acute care hospital carrying high GDS score e. Hospital physician should be aware that prescribing anticholinergic medications in such a vulnerable population may have negative prognostic implications.

Trends of atropinic (anticholinergic) exposure in the elderly: a 10-year analysis in the French EGB database

Atropinic drugs are known to potentially induce physical and/or mental impairments in the elderly. The aim of this study was to investigate trends of atropinic exposure in patients ≥65 years in France between 2006 and 2015. A repeated cross-sectional study was performed quarterly from January 1, 2006 to December 31, 2015, in the 'Echantillon Généraliste des Bénéficiaires (EGB)', a representative sample of the French population. Exposed patients were identified using the Anticholinergic Durán's list. Outcomes were rate of patients exposed to at least one atropinic drug (atropinic prevalence rate) and atropinic burden per patient (sum of atropinic burden scores). Interrupted time series were used to analyze the impact of market withdrawal of some drugs with atropinic properties during the period of the study. The number of patients ≥65 years registered in the EGB ranged from 75 611 in 2006 to 95 389 in 2015. Atropinic prevalence rate decreased significantly from 45.6% in 2006 to 33.2% in 2015 (-12.4%, slope significance P < 0.05). Subjects aged ≥85 years were the most exposed. Total atropinic burden decreased significantly between 2006 and 2015 (2.2 ± 1.7 in 2006; 2.0 ± 1.5 in 2015; slope significance P < 0.05), especially in patients ≥85 years. Market withdrawals for safety reasons of some atropinic drugs were significantly associated with a decrease in the atropinic prevalence rate (P < 0.05) and atropinic burden per patient (P < 0.05). In conclusion, atropinic drug exposure in the elderly significantly decreased in France between 2006 and 2015. This decrease can be partly explained by regulatory measures against some atropinic drugs.

An anticholinergic burden score for German prescribers: score development

Background

Anticholinergic drugs put elderly patients at a higher risk for falls, cognitive decline, and delirium as well as peripheral adverse reactions like dry mouth or constipation. Prescribers are often unaware of the drug-based anticholinergic burden (ACB) of their patients. This study aimed to develop an anticholinergic burden score for drugs licensed in Germany to be used by clinicians at prescribing level.

Methods

A systematic literature search in pubmed assessed previously published ACB tools. Quantitative grading scores were extracted, reduced to drugs available in Germany, and reevaluated by expert discussion. Drugs were scored as having no, weak, moderate, or strong anticholinergic effects. Further drugs were identified in clinical routine and included as well.

Results

The literature search identified 692 different drugs, with 548 drugs available in Germany. After exclusion of drugs due to no systemic effect or scoring of drug combinations (n = 67) and evaluation of 26 additional identified drugs in clinical routine, 504 drugs were scored. Of those, 356 drugs were categorised as having no, 104 drugs were scored as weak, 18 as moderate and 29 as having strong anticholinergic effects.

Conclusions

The newly created ACB score for drugs authorized in Germany can be used in daily clinical practice to reduce potentially inappropriate medications for elderly patients. Further clinical studies investigating its effect on reducing anticholinergic side effects are necessary for validation.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0929-6) contains supplementary material, which is available to authorized users.

Tools for Assessment of the Appropriateness of Prescribing and Association with Patient-Related Outcomes: A Systematic Review

BACKGROUND

There are tools and criteria in the literature aimed at distinguishing between appropriate and inappropriate medicines use. However, many have not been externally validated with regard to patient-related outcomes, potentially limiting their use in clinical practice.

OBJECTIVES

The aim of the study was to conduct a systematic review to summarise (1) available prescribing appropriateness assessment tools and criteria, and (2) their associations with patient-related outcomes (external validity).

METHODS

A systematic review was conducted using MEDLINE, EMBASE and Informit (Health Collection) databases to screen for articles in English that examined (1) tools to assess the appropriateness of prescribing and (2) associations of tools with patient-related outcomes, published between 2000 and 2016, without any limits placed on the study design, participant age or setting.

RESULTS

After screening 1710 articles, removing duplicates and shortlisting relevant articles, 42 prescribing assessment tools were identified. Out of the 42 tools, 78.6% (n = 33) provided guidance around stopping inappropriate medications, 28.6% (n = 12) around starting appropriate medications, 61.9% (n = 26) were explicit (criteria based) and 31.0% (n = 13) had been externally validated, with hospitalisation being the most commonly used patient-related outcome (n = 9, 21.4%).

CONCLUSION

The results of this systematic review highlight the need for evidence-based and externally validated tools, which combine the different aspects of medication management to optimise patient-related outcomes. PROSPERO registration number: CRD42017067233.

Anticholinergic Burden is Associated With Increased Mortality in Older Patients With Dependency Discharged From Hospital

OBJECTIVES

To determine whether anticholinergic burden may predict differently 1-year mortality in older patients discharged from acute care hospitals with or without dependency in basic activities of daily living (BADL).

DESIGN

Prospective observational study.

SETTING AND PARTICIPANTS

Our series consisted of 807 patients aged 65 years or older consecutively discharged from 7 acute care geriatric wards throughout Italy between June 2010 and May 2011.

MEASURES

Overall anticholinergic burden was assessed by the anticholinergic cognitive burden (ACB) score. Dependency was rated by BADL, and dependency in at least 1 BADL was considered as a potential mediator in the analysis. The study outcome was all-cause mortality during 12-months of follow-up.

RESULTS

Patients included in the study were aged 81.0 ± 7.4 years, and 438 (54.3%) were female. During the follow-up period, 177 out of 807 participants (21.9%) died. After adjusting for potential confounders, discharge ACB score = 2 or more was significantly associated with the outcome among patients with dependency in at least 1 BADL [hazard ratio (HR) 2.25 95% confidence (CI) 1.22‒4.14], but not among independent ones (HR 1.06 95% CI 0.50‒2.34). The association was confirmed among dependent patients after adjusting for the number of lost BADL at discharge (HR 2.20 95% CI 1.18‒4.04) or ACB score at 3-month follow-up (HR 2.18 95% CI 1.20‒3.98), as well as when considering ACB score as a continuous variable (HR 1.28 95% CI 1.11‒1.49). The interaction between ACB score at discharge and BADL dependency was highly significant (P < .001).

CONCLUSIONS/IMPLICATIONS

ACB score at discharge may predict mortality among older patients discharged from an acute care hospital carrying at least 1 BADL dependency. Hospital physicians should be aware that prescribing anticholinergic medications in this population may have negative prognostic implications and they should try to reduce anticholinergic burden at discharge whenever possible.

[Atropinic burden and anticholinergic drugs: Interest and application in clinical practice in the elderly]

Anticholinergic drugs (also called antimuscarinics or atropinics) increase the risk of falls, cognitive impairment and/or mortality in older patients. These drugs belong to the lists of potentially inappropriate medications in the elderly. The aim of this review was to present and discuss the different tools available to measure the atropinic risk in drug exposure of older patients. Several scales, developed from biological and/or clinical criteria, allow to classify anticholinergic drugs according to their atropinic potency and to assign to them an atropinic burden. Total atropinic burden of patient drug exposure can be calculated as the sum of atropinic score of each drug. Other tools include drug daily doses to better estimate the atropinic risk. These different methods are a precious help to decrease atropinic exposure in the elderly. Nevertheless, they have to be considered as upgradable and it is necessary to adapt them regularly according to the introduction of new drugs in clinical practice.

Safety of brotizolam in hospitalized patients

PURPOSE

The objective of this study was to evaluate the safety of brotizolam in hospitalized patients.

METHODS

A single-center, comparative retrospective cohort analysis of patients hospitalized in internal medicine wards. Patients treated with brotizolam were compared to patients not treated with any benzodiazepines during hospitalization. Primary outcome was any of the following safety events: mechanical ventilation, delirium, and falls.

RESULTS

Six hundred patients were included after exclusion in the final analysis; 300 treated with brotizolam (treatment) and 300 not treated with any benzodiazepines (comparator). The brotizolam-treated patients were older with more comorbidities and psychotropic medications. After adjustment using multivariate logistic regression analysis with propensity score, the primary outcomes occurred at significantly higher rates in treated patients than in untreated patients (17 vs. 2 events; OR = 7.33). Any psychotropic medication administered during hospitalization was found by logistic regression to be the main independent risk factor for the studied safety outcomes while age, comorbidities, and the cause of hospitalization were not.

CONCLUSIONS

Treatment with brotizolam during hospitalization in internal medicine wards is linked to a higher risk of respiratory deterioration, delirium, and falls. Use of psychotropic medications during hospitalization is the main independent risk factor of safety outcomes. Further research is needed to fully evaluate the risks and benefits of sleep induction medications in hospitals.

Anticholinergic burden and 1-year mortality among older patients discharged from acute care hospital

AIM

The association between anticholinergic burden and mortality is controversial. We aimed to investigate whether the anticholinergic cognitive burden (ACB) score predicts 1-year mortality in older patients discharged from acute care hospitals.

METHODS

Our series consisted of 807 hospitalized patients aged ≥65 years. Patients were followed up for 12 months after discharge. All-cause mortality was the outcome of the study. The ACB score at discharge (0, 1, ≥2) and increasing ACB score from admission to discharge (no increase, +1, +2 or more) were calculated and used as exposure variables. Cox proportional hazards models adjusted for potential confounders were used for the analysis. Interactions between the ACB score and cognitive impairment or history of falls were also investigated.

RESULTS

During the follow-up period, 177 out of 807 participants (21.9%) died. After adjusting for potential confounders, a discharge ACB score of ≥2 (HR 1.69, 95% CI 1.09-2.65) was significantly associated with the outcome, whereas the association between increasing ACB score of +2 or more and mortality was weaker (HR 1.30, 95% CI 0.95-1.92). The interaction between the ACB score at discharge or increasing ACB score and cognitive impairment was statistically significant (P = 0.003 and P = 0.004, respectively), whereas that between the ACB score and falls was not.

CONCLUSIONS

The ACB score at discharge and, to a lesser extent, an increasing ACB score during hospital stay are associated with an increased risk of 1-year mortality in older patients discharged from hospital. Such an association is stronger among patients with cognitive impairment. Geriatr Gerontol Int 2018; 18: 705-713.

Comparative Associations Between Measures of Anti-cholinergic Burden and Adverse Clinical Outcomes

PURPOSE

No consensus has been reached regarding which anticholinergic scoring system works most effectively in clinical settings. The aim of this population-based cohort study was to examine the association between anticholinergic medication burden, as defined by different scales, and adverse clinical outcomes among older adults.

METHODS

From Taiwan's Longitudinal Health Insurance Database, we retrieved data on monthly anticholinergic drug use measured by the Anticholinergic Risk Scale (ARS), the Anticholinergic Cognitive Burden Scale (ACB), and the Drug Burden Index - Anticholinergic component (DBI-Ach) for 116,043 people aged 65 years and older during a 10-year follow-up. For all 3 scales, a higher score indicates greater anticholinergic burden. We used generalized estimating equations to examine the association between anticholinergic burden (ARS and ACB: grouped from 0 to ≥4; DBI-Ach: grouped as 0, 0-0.5, and 0.5-1) and adverse outcomes, and stratified individuals by age-group (aged 65-74, 75-84, and ≥85 years).

RESULTS

Compared with the ARS and DBI-Ach, the ACB showed the strongest, most consistent dose-response relationships with risks of all 4 adverse outcomes, particularly in people aged 65 to 84 years. For example, among those 65 to 74 years old, going from an ACB score of 1 to a score of 4 or greater, individuals' adjusted odds ratio increased from 1.41 to 2.25 for emergency department visits; from 1.32 to 1.92 for all-cause hospitalizations; from 1.10 to 1.71 for fracture-specific hospitalizations; and from 3.13 to 10.01 for incident dementia.

CONCLUSIONS

Compared with the 2 other scales studied, the ACB shows good dose-response relationships between anticholinergic burden and a variety of adverse outcomes in older adults. For primary care and geriatrics clinicians, the ACB may be a helpful tool for identifying high-risk populations for interventions.

A multi-center, randomized, controlled trial to assess the efficacy of optimization of drug prescribing in an elderly population, at 18 months of follow-up, in the evolution of functional autonomy: the OPTIM study protocol

BACKGROUND

Pharmacotherapy is necessary for the management of many diseases which number increased with aging. However, potentially inappropriate prescriptions and polymedication increases iatrogenic risks and can lead to adverse events. To limit the consequences of potentially harmful prescriptions, optimization of drug prescribing is a major stake of improving quality and safety of care in the elderly. The purpose of the OPTIM study is to study the impact of the optimization of drug prescribing on the evolution of functional autonomy at 18 months of follow-up.

METHODS

A multicenter, open-label, Randomized Controlled Trial was designed to assess the impact of an optimization program of drug prescribing consisting in a clinical medication review by a pharmacist, in collaboration with specialist physician of the geriatric/memory center and the referent physician, on the evolution of functional autonomy level, measured during 18 months of follow-up. The study will include 302 elderly outpatients visiting geriatric and memory centers, randomly distributed in one of the two parallel groups. One group will benefit of the intervention, while the other will be considered as control group. The effect of the intervention on evolution of the level of autonomy function, defined with repeated measures, will be estimated in a generalized linear mixed model. The intervention will be considered significant if the interaction between time and the study group is significant. Secondary analysis will be conducted to assess the impact of the intervention on secondary clinical outcomes.

DISCUSSION

The "OPTIM" program should enable optimization of drug prescribing in elderly patients and therefore slow or prevent progression to loss of functional autonomy. It should also help to strengthen collaboration between the hospital team of geriatric/neurologist, the pharmacist and the private practice who are all involved in caring for the patient's health. The benefits for the patient are thus optimizing its medical management by linking health professionals met during his care pathway. In addition, pharmaceutical recommendations sent to referent physicians should help raise awareness of the prescription of drugs in these patients.

TRIAL REGISTRATION NUMBER CLINICALTRIALS

NCT02740764.

Anticholinergic drugs and functional, cognitive impairment and behavioral disturbances in patients from a memory clinic with subjective cognitive decline or neurocognitive disorders

Background

Drugs with anticholinergic properties may be associated with various adverse clinical effects. The relationship between the anticholinergic (AC) burden and functional, global cognitive performance and behavior disturbances was assessed among elderly patients.

Methods

A cross-sectional study was conducted between January 2012 and June 2014 in a memory clinic among outpatients living at home and with subjective cognitive decline (SCD) or neurocognitive disorders (NCD). The AC burden was measured using the Anticholinergic Drug Scale (ADS), the Anticholinergic Risk Scale (ARS), the Anticholinergic Cognitive Burden (ACB), Chew’s score, Han’s score, and the number of drugs with AC activity. Functional, cognitive performance and behavior disturbances were assessed using the Instrumental Activities of Daily Living (IADL) scale (IADL), the Mini Mental State Examination (MMSE), and the Neuropsychiatric Inventory (NPI).

Results

Among 473 included patients, 46.3% were at major NCD. Patients took on average 5.3 ± 2.6 drugs. MMSE was lower when Han’s score (p = 0.04) and number of AC drugs were higher (p < 0.001). IADL was lower when AC burden was higher, whatever the AC measurement. NPI was higher when ACB, Han’s score, and number of AC drugs were higher. After adjustment, all AC scores remained associated with IADL, while Han’s score and number of drugs with AC remained associated with the MMSE.

Conclusions

In patients with SCD or NCD, AC burden is associated with lower functional score, whereas the cross-sectional association between AC burden and cognitive performance or behavioral disturbance varies according to AC scores. Particular attention should be paid when prescribing drugs with AC properties, especially among patients with memory complaints.