Oxybutynin and cognitive dysfunction

Risks of Dementia After Treatment with an Anticholinergic, Beta-3 Agonist, or Combination of Both for an Overactive Bladder: A Korean National Cohort Study

BACKGROUND AND OBJECTIVE

An overactive bladder (OAB) is primarily managed with behavioural therapy and using anticholinergics and beta-3 agonists. Reports have shown that the use of anticholinergics by OAB patients was associated with an increased risk of new-onset dementia compared with those using beta-3 agonists. This study compares the risks of dementia among patients with an OAB starting on a beta-3 agonist alone, an anticholinergic alone, or a combination treatment.

METHODS

Using data from the Korean National Health Insurance Service database, we studied a nationwide population cohort comprising patients newly diagnosed with an OAB who initiated their OAB medications between 2015 and 2020. The treatment types were categorised as anticholinergics (oxybutynin, solifenacin, tolterodine, trospium, fesoterodine, flavoxate, and propiverine) alone, a beta-3 agonist (mirabegron) alone, and combination therapy (an anticholinergic plus the beta-3 agonist). To evaluate the impact of cumulative drug exposure, we quantified the cumulative exposure to solifenacin and mirabegron as cumulative defined daily doses (cDDDs) using proportional hazards regression analyses, adjusted for factors known to be associated with dementia.

KEY FINDINGS AND LIMITATIONS

Among the study's 3 452 705 patients, 671 974 were new users of a beta-3 agonist alone (19.5%), 1 943 414 new users of anticholinergics alone (56.3%), and 837 317 receiving combination therapy (24.3%). The most common anticholinergic used both alone and as part of a combination treatment was solifenacin (42.9% and 56.3%, respectively). There was an increased risk of dementia between the users of an anticholinergic alone (adjusted hazard ratio [aHR] = 1.213; 95% confidence interval [CI], 1.195-1.232) and those taking a combination treatment (aHR = 1.345; 95% CI, 1.323-1.366) compared with the users of beta-3 agonists alone after the adjustment of covariates. However, the incidence of dementia was also significantly higher, with an increase in the cumulative dose of mirabegron (aHR = 1.062 [1.021-1.106] for 28-120 cDDDs and aHR = 1.044 [1.004-1.084)] for patients who received >121 cDDDs compared with those who received <27 cDDDs). A marked increased risk of dementia was associated with the use of solifenacin, tolterodine, fesoterodine, and propiverine, both separately and in combination with mirabegron.

CONCLUSIONS AND CLINICAL IMPLICATIONS

In this large Korean cohort, the use of anticholinergics with or without a beta-3 agonist increased the risk of new-onset dementia compared with the use of a beta-3 agonist alone. Given that the risk of dementia was most significantly elevated with combination treatments, care should be taken when considering combination treatment for OAB patients with risk factors for dementia. Furthermore, there could be a possible association between beta-3 agonists and dementia, although future studies are needed.

PATIENT SUMMARY

This study investigated the risk of dementia induced by overactive bladder (OAB) treatment in a large Korean cohort. Two representative OAB treatment drugs, anticholinergics and beta-3 agonists, both increased the risk of new-onset dementia. Clinicians should be cautious in using OAB treatment drugs since no drugs could be concluded as safe.

The Twilight Zone: Oxybutynin Overuse Exacerbating Delirium

Anticholinergic medications, such as oxybutynin, are first-line pharmacologic therapies in overactive bladder. However, the cognitive adverse effect profiles of frequently used anticholinergic medications are extensive and limit their use in older patients. Additionally, many older patients continue on anticholinergic therapy if adverse effects are not self-reported by the patient or detected by the provider.Here, we present a case of a 73-year-old male with a history of major neurocognitive disorder, in which unreported oxybutynin overuse led to repeated delirious states, erratic driving, and subsequent psychiatric hospitalizations. During his hospitalizations, he displayed progressively more linear thought processes and improved insight without clear etiology. After a more thorough history of his medication use was obtained, he disclosed that he would often take additional doses of oxybutynin to prevent incontinence during car rides and had done so prior to recent hospitalizations.Our example highlights the importance of thorough history taking, medication review, reducing polypharmacy, careful patient education about medications with psychiatric adverse effects, and, importantly, the avoidance of anticholinergic medication prescription in older patients.

Management of Urologic and Sexual Dysfunction in Parkinson Disease

Parkinson disease (PD) is a complex of motor and nonmotor symptoms. Among the nonmotor symptoms, urinary and sexual dysfunctions are common and negatively affect the quality of life. More than 50% of patients with PD complain of urinary dysfunction and 20% have sexual dysfunction. Understanding the anatomy and physiology of the urogenital system informs the rationale for the mechanism of action of drug therapies. The management of urinary and sexual dysfunction in PD, including behavioral, medical, and procedural interventions, is reviewed in this article.

Anticholinergics for Overactive Bladder in Frail and Medically Complex Older People: The Case For

Overactive bladder (OAB) is a common, troublesome condition affecting the lives of many older people. When pharmacotherapy is considered, antimuscarinics remain the mainstay for treatment. Bladder antimuscarinics are effective in the relief of symptoms for OAB and treatment leads to significant improvements in quality of life for those with the condition. However, many older people (> 65 years) with OAB are in later life (> 75 years) and a proportion of these will either be medically complex, with multiple comorbid conditions, or frail. This article discusses the evidence for OAB treatment in the frail or medically complex elderly, outlines where caution should be exercised, giving examples from the recent literature, and advocates for an active approach for this group, who are often left without any treatment.

The effects of the selective muscarinic M3 receptor antagonist darifenacin, and of hyoscine (scopolamine), on motion sickness, skin conductance & cognitive function

AIMS

The aim of this study was to compare the effects of the selective M3 muscarinic acetylcholine receptor antagonist darifenacin, oral hyoscine hydrobromide and placebo on motion sickness induced by cross-coupled stimulation.

METHODS

The effects of darifenacin 10 mg or 20 mg, hyoscine hydrobromide 0.6 mg and placebo were assessed in a randomized, double-blind, four-way cross over trial of 16 healthy subjects. Motion sickness, skin conductance (a measure of sweating) and psychomotor cognitive function tests were investigated.

RESULTS

Hyoscine hydrobromide produced significantly increased tolerance to motion versus placebo (P < 0.05 to P < 0.01). The motion protection effect of darifenacin (10 or 20 mg) was approximately one third that of hyoscine hydrobromide but was not significant versus placebo. Darifenacin and hyoscine hydrobromide both significantly reduced skin conductance versus placebo. Darifenacin produced either no effect or an enhanced effect on cognitive function in contrast to hyoscine hydrobromide, where there was significant impairment of psychomotor performance.

CONCLUSION

The results suggest that selective antagonism of the M3 receptor may not be important in the prevention of motion sickness. However, selective M3 antagonism does not impair cognitive function. These observations may be important given that long-term treatment with non-selective anti-muscarinic agents such as oxybutynin may lead to an increased incidence of dementia.

Urological dysfunction in synucleinopathies: epidemiology, pathophysiology and management

OBJECTIVE

Parkinson's disease (PD) and multiple system atrophy (MSA) are major neurogenerative diseases characterized pathologically by abnormal alpha-synuclein aggregation. PD and MSA are clinically characterized by motor disorder and bladder dysfunction (mainly urinary urgency and frequency, also called overactive bladder). However, few literatures are available concerning bladder dysfunction in PD or MSA.

METHOD

A systematic review.

RESULTS

The bladder dysfunction in MSA is more severe than that in PD for large post-void residual or urinary retention. These bladder dysfunctions presumably reflect the different nervous system pathologies. Overactive bladder in PD reflects lesions in the brain, e.g., in the prefrontal-nigrostriatal D1 dopaminergic bladder-inhibitory pathway. Overactive bladder in MSA reflects lesions similar to PD and the cerebellum (bladder-inhibitory), and the urinary retention in MSA presumably reflects lesions in the pontine micturition center and the sacral intermediolateral nucleus of the spinal cord (bladder-facilitatory). Bladder dysfunction not only impairs an individual's quality of life, it can also cause emergency hospitalizations due to acute retention and early institutionalization. Anticholinergics are the first-line treatment for bladder dysfunction in PD and MSA patients, but care should be taken for the management of bladder dysfunction-particularly in MSA patients due to the high prevalence of difficult emptying, which needs clean, intermittent catheterization.

CONCLUSIONS

This review summarizes the epidemiology, pathophysiology, and management of bladder dysfunction in individuals with PD or MSA.

The management of paediatric neurogenic bladder: an approach in a resource-poor setting

BACKGROUND

If untreated, paediatric neurogenic bladder can cause renal failure and urinary incontinence. It is usually caused by neural tube defects such as myelomeningocele. Children with a neurogenic bladder should be monitored from birth and management should aim to preserve renal function and achieve social continence. This article outlines the management options appropriate for these children in resource-poor settings.

ASSESSMENT

In most low- and middle-income countries, a general lack of awareness of the neurological effects on the urinary tract results in late presentation, usually with urological complications even when spina bifida is diagnosed early. Physical examination must include neurological examination for spinal deformities and intact sacral reflexes. About 90% of children with occult spinal dysraphisms will have cutaneous sacral lesions. The work-up includes urinalysis, serial ultrasound of the urinary tracts and urodynamics. Urodynamic assessment is essential for the diagnosis and prognosis of the paediatric neurogenic bladder. In poorly resourced settings, simple eyeball urodynamics can be performed in the absence of a conventional urodynamic set-up.

TREATMENT

Clean intermittent catheterisation (CIC), the mainstay of treatment, is most suitable for resource-poor settings because it is effective and inexpensive. Antimuscarinic drugs such as oxybutynin complement CIC by reducing detrusor overactivity. Intravesical injection of Botox and bladder augmentation surgery is required by a small subset of patients who fail to respond to combined CIC and oxybutynin therapy.

CONCLUSION

Children with neurogenic bladder in resource-poor settings should have early bladder management to preserve renal function and provide social continence.

Delirium following fesoterodine treatment for urgency incontinence in an 89-year old man

We describe the case of an 89-year-old man who developed delirium following the introduction of fesoterodine to treat his urgency incontinence. The patient started experiencing visual hallucinations approximately five days after starting fesoterodine 4 mg once daily. Delirium resolved after fesoterodine was stopped. Despite the apparent safe cognitive profile due to its pharmacodynamic properties, fesoterodine should be used with caution in the elderly, frail population.

Oral pharmacotherapy for overactive bladder in older patients: mirabegron as a potential alternative to antimuscarinics

OBJECTIVE

Overactive bladder (OAB) is a particular challenge to treat in older adults with co-morbid conditions taking multiple medications. Antimuscarinics (e.g., solifenacin, fesoterodine) and β3-adrenergic receptor agonists (mirabegron) are similarly efficacious; however, antimuscarinics may be associated with side effects that result in poor persistence and contribute to anticholinergic burden, particularly in those taking other medications with anticholinergic properties. With a mechanism of action distinct from antimuscarinics, mirabegron has a different tolerability profile and does not contribute to anticholinergic burden. The objective of this review was to compare and contrast the tolerability profiles of antimuscarinics and mirabegron in older patients to inform practice.

METHODS

Prospective trials or retrospective subgroup analyses of antimuscarinics for the treatment of OAB in older patients were identified through a search of PubMed. Tolerability data and results of subgroup analyses of mirabegron in patients aged ≥65 and ≥75 years from a pooled analysis of three trials each of 12 weeks and a 1 year trial are described.

RESULTS

Anticholinergic adverse events (AEs) including dry mouth and constipation were more frequent with antimuscarinics versus mirabegron. In patients aged ≥65 years, dry mouth occurred with a six-fold higher incidence with tolterodine extended-release (ER) 4 mg than with mirabegron 25 mg or 50 mg over 12 weeks, and a three-fold higher incidence with tolterodine ER than mirabegron 50 mg over 1 year. Mirabegron had a low incidence of central nervous system effects. A systematic review of the cardiovascular safety profile of mirabegron has not identified any clinically significant effects on blood pressure or pulse rate at therapeutic doses amongst patients aged ≥65 years.

CONCLUSIONS

Mirabegron has a more favorable tolerability profile than antimuscarinics amongst older patients and may provide an improved benefit-to-risk ratio and therefore be considered as an alternative to antimuscarinics for older patients.

A guideline for the management of bladder dysfunction in Parkinson's disease and other gait disorders

Parkinson's disease (PD) is a common neurodegenerative disorder, and lower urinary tract (LUT) dysfunction is one of the most common autonomic disorders with an estimated incidence rate of 27-80%. Studies have shown that bladder dysfunction significantly influences quality-of-life (QOL) measures, early institutionalisation, and health economics. We review the pathophysiology of bladder dysfunction in PD, lower urinary tract symptoms (LUTS), objective assessment, and treatment options. In patients with PD, disruption of the dopamine D1-GABAergic direct pathway may lead to LUTS. Overactive bladder (OAB) is the most common LUT symptom in PD patients, and an objective assessment using urodynamics commonly shows detrusor overactivity (DO) in these patients. The post-void residual (PVR) volume is minimal in PD, which differs significantly from multiple system atrophy (MSA) patients who have a more progressive disease that leads to urinary retention. However, subclinical detrusor weakness during voiding may also occur in PD. Regarding bladder management, there are no large, double-blind, prospective studies in this area. It is well recognised that dopaminergic drugs can improve or worsen LUTS in PD patients. Therefore, an add-on therapy with anticholinergics is required. Beta-3 adrenergic agonists are a potential treatment option because there are little to no central cognitive events. Newer interventions, such as deep brain stimulation (DBS), are expected to improve bladder dysfunction in PD. Botulinum toxin injections can be used to treat intractable urinary incontinence in PD. Transurethral resection of the prostate gland (TURP) for comorbid BPH in PD is now recognised to be not contraindicated if MSA is excluded. Collaboration of urologists with neurologists is highly recommended to maximise a patients' bladder-associated QOL. Neurourol. Urodynam. 35:551-563, 2016. © 2015 Wiley Periodicals, Inc.

Lower urinary tract dysfunction in patients with brain lesions

Stroke and brain tumor are well-known brain diseases. The incidence of lower urinary tract dysfunction (LUTD) in these patients ranges from 14% to 53%, mostly overactive bladder (OAB), and is higher when the frontal cortex is involved. This presumably reflects damage at the prefrontal cortex, cingulate cortex, and other areas that regulate (mainly inhibit) the micturition reflex. White-matter disease (WMD) is a chronic, bilateral form of cerebrovascular disease, leading to a high prevalence of OAB (up to 90%). Since WMD is particularly common in the elderly, WMD may be one of the anatomic substrates for elderly OAB. Traumatic brain injury and normal-pressure hydrocephalus are rather diffuse brain diseases, which cause OAB with a prevalence rate of 60-95%. Recent neuroimaging studies have shown a relationship between LUTD and the frontal cortex in these diseases. Data on other brain diseases, particularly affecting deep brain structures, are limited. Small infarctions, tumors, or inflammatory diseases affecting the basal ganglia, hypothalamus, and cerebellum lead to mainly OAB. In contrast, similar diseases affecting the brainstem lead to either OAB or urinary retention. The latter reflects damage at the periaqueductal gray and the pontine micturition center that directly relay and modulate the micturition reflex. Urinary incontinence (UI) in brain disease can be divided into two types: neurogenic UI (due to OAB) and functional UI (immobility and loss of initiative/cognition). These two types of UI may occur together, but management differs significantly. Management of neurogenic UI includes anticholinergic drugs that do not penetrate the blood-brain barrier easily. Management of functional UI includes behavioral therapy (timed/prompted voiding with physical assistance and bladder/pelvic floor training) and drugs to treat gait as well as cognition that facilitate continence. These treatments will maximize the quality of life in patients with brain diseases.

Lower urinary tract function in dementia with Lewy bodies (DLB)

OBJECTIVES

Dementia with Lewy bodies (DLB) is the second most common degenerative cause of dementia, whereas lower urinary tract (LUT) function in DLB patients has not been fully delineated. We investigated LUT function in DLB by clinical-urodynamic observations.

METHODS

We examined 32 patients with DLB (23 men, 9 women; aged 59-86 [mean, 75.9] years; disease duration, 0.2-17 [3.3] years). All patients underwent an electromyography-cystometry, and 21 patients underwent the sphincter motor unit potential analysis.

RESULTS

Ninety-one percent of patients had LUT symptoms: nighttime frequency (>8 times), 84%, and urinary incontinence (>1 per week), 50%. Detrusor overactivity was revealed in 87.1%, whereas postvoid residual was minimal. Neurogenic changes were shown in 50%.

CONCLUSION

LUT dysfunction is a common feature in DLB, attributable not only to dementia and immobility, but also to central and peripheral types of somato-autonomic dysfunction.

Antimuscarinic treatment in overactive bladder: special considerations in elderly patients

Overactive bladder is a common condition that increases in prevalence in association with age. Antimuscarinic therapy remains the mainstay of pharmacological treatment for the condition, and there is an increasing body of evidence that supports the use of these drugs. Despite this, and because of concerns about associated adverse effects, older people are less likely to receive active treatment for their condition. This review considers some of the factors that need to be taken into account when using these medications.

[Cognitive adverse effects of anticholinergic medication for overactive bladder in PD/DLB]

Overactive bladder (OAB) is a common autonomic disorder due mostly to lesions in the micturition-inhibiting area (D1 dopaminergic pathway in the basal ganglia) in Parkinson's disease (PD) and dementia with Lewy bodies (DLB). anticholinergic drugs are the mainstay in the treatment of OAB. However, since 1997, anticholinergic adverse events on the cognitive function have been recognized. Drugs with less lipophilic, less permeable through the blood-brain barrier are the choice in the treatment of OAB in elderly neurologic patients.

Darifenacin for the treatment of overactive bladder

Overactive bladder is a debilitating disorder affecting 16.5% of adults and increasing in prevalence with age. Symptoms, including urgency, urge incontinence and frequency can result from detrusor overactivity with contraction of the bladder mediated primarily by activation of muscarinic M(3) receptors. Antimuscarinic agents are therefore an important approach to treating overactive bladder, but a lack of M(3) receptor subtype selectivity with these agents can generate a range of side effects that limits their effectiveness. This review describes an alternative approach to treating overactive bladder using the selective muscarinic M(3) receptor antagonist darifenacin. The M(3) receptor selectivity of darifenacin improves the symptoms of overactive bladder while reducing the potential for deleterious effects of non-M(3) muscarinic receptor antagonism in the brain or heart. The pharmacology and pharmacokinetics of darifenacin are summarized, and the its clinical efficacy and demonstrated safety profile are described.

Randomised, double-blind study of the effects of oxybutynin, tolterodine, trospium chloride and placebo on sleep in healthy young volunteers

OBJECTIVE

Central nervous effects of oral anticholinergics may limit the success of incontinence therapy and patient compliance. Only a few studies investigating this topic are available. This study was conducted to determine whether oral anticholinergics alter sleep and psychometric test parameters.

DESIGN

Randomised, double-blind, crossover, placebo-controlled study.

STUDY PARTICIPANTS

24 healthy volunteers (age 22-36 years) without sleeprelated problems.

INTERVENTIONS

Polysomnographic recordings, sleep questionnaires and psychometric tests (the number combination test [Zahlen-Verbindungs Test; ZVT] and the d2 attention test) were performed following single doses of oxybutynin 15mg, tolterodine 4mg, trospium chloride 45mg or placebo, each separated by an 8-day washout period.

RESULTS

Rapid eye movement (REM) sleep (relative to total sleep time) was the primary parameter of polysomnography. The REM sleep for oxybutynin was significantly lower than that for trospium chloride (18.4% vs 20.2%; p < 0.05) and lower than that for placebo (20.1%; ns). The number combination test (ZVT), the primary parameter of cognitive function, and the d2 test did not reveal any differences in reaction time. With regard to the other sleep parameters, the REM latency for oxybutynin was clearly higher than that for placebo, trospium chloride and tolterodine. Effects on non-REM sleep were observed only after administration of oxybutynin compared with placebo.

CONCLUSIONS

Oxybutynin influenced sleep structure, as was reflected by REM suppression and mild sedation, while subjective parameters and psychometric tests remained unaffected. The sleep and psychometric test values for tolterodine and trospium chloride were comparable to those of placebo. The clinical relevance of these effects is small in healthy young volunteers, but these results cannot be extended to the elderly.

Antimuscarinic treatment in overactive bladder: special considerations in elderly patients

Overactive bladder is a common condition that increases in prevalence in association with age. Antimuscarinic therapy remains the mainstay of pharmacological treatment for the condition, and there is an increasing body of evidence that supports the use of these drugs. Despite this, and because of concerns about associated adverse effects, older people are less likely to receive active treatment for their condition. This review considers some of the factors that need to be taken into account when using these medications.

Pathophysiology of bladder dysfunction in Parkinson's disease

Bladder dysfunction (urinary urgency/frequency) is a common non-motor disorder in Parkinson's disease (PD). In contrast to motor disorders, bladder dysfunction is sometimes non-responsive to levodopa treatment. The brain pathology causing the bladder dysfunction (appearance of overactivity) involves an altered dopamine basal ganglia-frontal circuit, which normally suppresses the micturition reflex. The pathophysiology of the bladder dysfunction in PD differs from that in multiple system atrophy; therefore, it might aid in differential diagnosis. Anticholinergic agents are used to treat bladder dysfunction in PD, although these drugs should be used with caution particularly in elderly patients who have cognitive decline. These treatments might be beneficial in maximizing the patients' quality of life.

Anticholinergics for overactive bladder therapy: central nervous system effects

The mainstay of pharmacological treatment of overactive bladder (OAB) is anticholinergic therapy using muscarinic receptor antagonists (tertiary or quaternary amines). Muscarinic receptors in the brain play an important role in cognitive function, and there is growing awareness that antimuscarinic OAB drugs may have adverse central nervous system (CNS) effects, ranging from headache to cognitive impairment and episodes of psychosis. This review discusses the physicochemical and pharmacokinetic properties of OAB antimuscarinics that affect their propensity to cause adverse CNS effects, as observed in phase III clinical trials and in specific investigations on cognitive function and sleep architecture. PubMed/MEDLINE was searched for "OAB" plus "muscarinic antagonists" or "anticholinergic drug." Additional relevant literature was identified by examining the reference lists of papers identified through the search. Preclinical and clinical trials in adults were assessed, focusing on the OAB antimuscarinics approved in the United States. The blood-brain barrier (BBB) plays a key role in protecting the CNS, but it is penetrable. The lipophilic tertiary amines, particularly oxybutynin, are more likely to cross the BBB than the hydrophilic quaternary amine trospium chloride, for which there are very few reports of adverse CNS effects. In fact, in 2008 the US product labels for oral oxybutynin were modified to include the potential for anticholinergic CNS events and a warning to monitor patients for adverse CNS effects. Even modest cognitive impairment in the elderly may negatively affect independence; therefore, selection of an antimuscarinic OAB drug with reduced potential for CNS effects is advisable.

Tolerability of solifenacin and oxybutynin immediate release in older (> 65 years) and younger (≤ 65 years) patients with overactive bladder: sub-analysis from a Canadian, randomized, double-blind study

OBJECTIVE

Overactive bladder (OAB) is a common condition whose prevalence increases with age. Antimuscarinic agents are the pharmacologic treatment of choice, but adverse events such as dry mouth may lead to early discontinuation. The purpose of this analysis was to compare the incidence and severity of dry mouth and other adverse events with solifenacin 5 mg/day and oxybutynin immediate release (IR) 15 mg/day in patients ≤ 65 years and >65 years in the Canadian VECTOR study (VEsicare in Comparison To Oxybutynin for oveRactive bladder patients).

RESEARCH DESIGN AND METHODS

VECTOR was a randomized, multicentre, prospective, double-blind, double-dummy study in 132 subjects with ≥ 1 urgency episode per 24 h, with or without urgency incontinence, and ≥ 8 micturitions per 24 h for ≥ 3 months. After a 2-week washout, patients received solifenacin 5 mg once daily or oxybutynin IR 5 mg tid for 8 weeks. For the current post-hoc analysis, adverse events were evaluated in subgroups of patients ≤ 65 years and >65 years, using a full logistic regression model, multinomial logit regression model and reduced model.

CLINICAL TRIAL REGISTRATION

NCT00431041.

RESULTS

The incidence and severity of dry mouth and other adverse events with solifenacin were similar between younger and older patients. In both age subgroups, solifenacin 5 mg/day was associated with fewer episodes and lower severity of dry mouth, and a lower discontinuation rate, compared with oxybutynin IR 15 mg/day.

CONCLUSIONS

Solifenacin 5 mg/day was better tolerated than oxybutynin IR 15 mg/day in younger (≤ 65 years) and older (> 65 years) subgroups. Solifenacin was equally well tolerated in both age subgroups. Limitations of the analysis were that the study was not preplanned to perform post-hoc subgroup analysis, patients knew that dry mouth was a primary outcome, and the study used fixed doses of each drug.

Trospium chloride has no effect on memory testing and is assay undetectable in the central nervous system of older patients with overactive bladder

BACKGROUND

Muscarinic receptors in the brain play an important role in cognitive function, especially memory, and there is growing awareness that specific antimuscarinic drugs for overactive bladder (OAB) may have adverse central nervous system (CNS) effects. Selection of an antimuscarinic OAB drug with reduced potential for CNS effects could be especially beneficial in the elderly people, in whom even the modest cognitive impairment may negatively affect independence.

PURPOSE

The purpose of the study is to determine if trospium chloride is assay detectable in the CNS of older adults with OAB and to assess whether deterioration of memory occurs in these individuals.

METHODS

Twelve cognitively intact older adults (>or=65-75 years old) with OAB were given extended-release trospium chloride 60 mg once daily over a 10-day period to achieve plasma steady-state levels. Standardised memory testing (Hopkins Verbal Learning Test-Revised and Brief Visuospatial Memory Test-Revised) was performed predose and postdose. Cerebrospinal spinal fluid (CSF) and plasma samples were drawn on day 10 and assayed for trospium chloride. Predose (day 0) and postdose (day 10) results on the memory tests were compared using a reliable change index to assess a meaningful change in learning or memory.

RESULTS

Trospium chloride levels in all the CSF samples (n = 72) of all participants were assay undetectable (<40 pg/ml) on day 10 at steady-state peak plasma concentration concurrent with measureable peak plasma values (C(max) = 925 pg/ml). Repeat memory testing revealed no significant net drug effect on learning or recall.

CONCLUSIONS

This is the first study to investigate for the presence of an OAB antimuscarinic in the human brain, performed by assaying for concentrations of trospium chloride and correlating with simultaneous clinical cognitive safety measures. The results of both pharmacological and neuropsychological testing support the hypothesis of a lack of detectable CNS penetration for the quaternary amine trospium chloride.

Review of cognitive impairment with antimuscarinic agents in elderly patients with overactive bladder

Overactive bladder (OAB) will become an increasingly prevalent problem as the proportion of older people in the population increases over the next 20 years. In addition to the urological symptoms (urinary urgency, with or without urgency incontinence, usually with increased daytime frequency and nocturia), OAB is associated with other problems in older patients, especially an increased risk of falls and fractures. The bother caused by OAB needs not be an inevitable consequence of ageing, because the symptoms can usually be alleviated, even in frail older people. Pharmacological treatment for OAB involves the use of antimuscarinic agents, whose efficacy and safety profiles depend on their interactions with muscarinic receptors that are widely distributed throughout the body. Interactions between antimuscarinics and M(1) receptors in the central nervous system may have the potential to cause cognitive impairment in older people, depending on muscarinic receptor binding profiles, lipophilicity and the ability to cross the blood brain barrier. Concerns over the possibility of cognitive impairment have contributed to an under-utilisation of antimuscarinics in the geriatric population, despite the high prevalence and severity of OAB in older subjects. Antimuscarinic agents should be actively considered for elderly patients with OAB, but it is desirable to establish the cognitive risk for every type of antimuscarinic, using robust cognition assessment methods.

Exploratory pilot study assessing the risk of cognitive impairment or sedation in the elderly following single doses of solifenacin 10 mg

OBJECTIVES

To assess the cognitive effects of single doses of solifenacin 10 mg compared with placebo (primary objective) and oxybutynin immediate release (IR) 10 mg (secondary objective) in elderly subjects.

METHODS

Single-centre, randomised, double-blind, placebo-controlled study in 12 healthy elderly volunteers, with three crossover periods separated by two 14-day washout periods. Each sequence consisted of a single dose of solifenacin 10 mg in one period, oxybutynin IR 10 mg in another and placebo in another. Aspects of attention, information processing, working memory, episodic memory and self-rated mood and alertness were tested using the validated Cognitive Drug Research computerised assessment system.

RESULTS

There was no evidence from absolute mean values or changes from baseline to suggest that solifenacin 10 mg impaired cognition or self-ratings of mood and alertness versus placebo. Post-hoc ANCOVA showed no statistically significant cognitive deterioration with solifenacin versus placebo, when measured at a time point closest to the probable C(max) of solifenacin. Oxybutynin was associated with statistically significant impairments in several measures of cognitive function at a time point corresponding with its probable C(max).

CONCLUSION

In this pilot study, single 10 mg doses of solifenacin did not show any clear propensity to impair cognitive function in a healthy elderly population.

Intravesical oxybutynin in the pediatric neurogenic bladder

Pediatric neuropathic bladder dysfunction can cause irreversible renal damage and urinary incontinence. Etiologically, it is usually the consequence of a congenital neural tube defect. The majority of affected children can be successfully managed with the standard medical treatment of clean intermittent catheterization and anticholinergic (typically oxybutynin) medication. A subset of patients experience severe side effects or insufficient suppression of detrusor overactivity on oral oxybutynin. Intravesical instillations offer an effective alternative; this Review considers their indications, administration, safety and efficacy.

Tolterodine extended release is well tolerated in older subjects

OBJECTIVES

To investigate the tolerability of tolterodine extended release (ER) in older subjects with overactive bladder (OAB).

METHODS

This was a retrospective analysis of pooled data from five large, randomised, double-blind, placebo-controlled trials. Subjects with OAB symptoms, including urinary frequency and urgency (and nocturia in two studies) with or without urgency urinary incontinence, received qd treatment with tolterodine ER (4 mg) or placebo for 8-12 weeks. Data were stratified post hoc by age group: < 65 (n = 2531), 65-74 (n = 1059) and > or = 75 years (n = 573). Tolerability was assessed by evaluating the occurrence of adverse events (AEs). AE occurrences from each study were mapped to the MedDRA coding dictionary of preferred terms.

RESULTS

Discontinuation rates were slightly higher among subjects > or = 75 years of age vs. those < 65 years of age; however, this was observed in subjects treated with placebo as well as tolterodine ER. Overall, there were no significant differences in the occurrence of dry mouth, headache, constipation, nausea, urinary tract infection, blurred vision, dry eye, dizziness and micturition disorder in older (65-74 or > or = 75 years) vs. younger (< 65 years) subjects treated with tolterodine ER relative to placebo (treatment x age; all p > 0.1). Dry mouth was the only AE consistently associated with tolterodine ER treatment (< 65 years, 17%; 65-74 years, 16%; > or = 75 years, 15%). The occurrence of all other AEs was < or = 5% in most age and treatment cohorts. Most AEs were mild or moderate in all age and treatment cohorts.

CONCLUSION

The nature and frequency of AEs associated with tolterodine ER treatment were similar across age groups in subjects with OAB, suggesting that tolterodine ER was not associated with an increased risk of AEs in older vs. younger subjects and, thus, is a suitable first-line pharmacotherapy treatment for OAB in this population.

Recognizing and treating common psychiatric disorders in multiple sclerosis

BACKGROUND

The rate of depression and other psychiatric disorders is greater in multiple sclerosis (MS) than in other chronic conditions or neurologic diseases. This means that clinical neurologists seeing MS patients will frequently be engaged in the diagnosis and treatment of psychiatric distress.

REVIEW SUMMARY

This review provides a summary of what is known about psychiatric dysfunction in MS. It offers information about the current views on the link between various psychiatric disorders and MS. More important, it offers suggestions on how the knowledge from existing research can be integrated into real-world practice.

CONCLUSION

Clinicians need to understand the factors that influence the development of psychiatric disorders in MS, the relationship between disease-modifying therapies and psychiatric distress, and the issues surrounding the treatment of psychiatric conditions in MS. Thorough knowledge of psychiatric dysfunction and MS will allow the clinician to design an effective treatment regimen that helps patients cope with their disease.

Cognitive dysfunction with tolterodine use

This is the first case of a 65 year old healthy woman developing de novo mental confusion during treatment with 2 mg tolterodine twice daily. It is a rare complication of therapy for overactive bladder and resolved when dosage was reduced to 1 mg, although overactive bladder symptoms were still controlled.

Cognitive impairment in multiple sclerosis: evidence-based analysis and recommendations

Cognitive impairment is common in multiple sclerosis (MS), occurring at all stages of the disease, and can be a major source of vocational disability, social impairment, and impoverished quality of life. Dysfunction in free recall from long-term memory, speed of information processing, working memory, and abstract reasoning are frequently observed in MS. Despite weak correlation with disease duration and physical disability status, the degree of cognitive impairment in MS has been related to the extent of topographically specific neuronal tissue damage and loss. Additional clinical factors including disease course, fatigue, affective disturbance, and medication can impact on the degree of MS-related cognitive impairment. We suggest that the symbol digits modalities test, paced auditory serial addition task, the clock drawing test and the MS neuropsychological screening questionnaire be considered as valid and relevant screening tests for cognitive impairment in MS.

Overactive bladder syndrome in older people

The overactive bladder symptom complex (OAB) is the commonest cause of urinary incontinence in older people, and is usually due to underlying detrusor overactivity, and as such is a treatable condition. Older people are a heterogeneous group, which includes fit community-dwelling individuals and those with significant medical comorbidity; thus the requirements of care for this group are many and varied. The International Continence Society definition of the frail elderly, those aged >65 years with continence problems, who by virtue of comorbidity are house-bound or living in an institution, is clearly not applicable to all. However, many conditions begin to appear in later life and practitioners need to be aware of the need to manage these, and their treatment, when dealing with older people. Studies of medication for OAB have included the elderly and there is evidence of an equivalent benefit in younger people. The impact of treatment on the cognitively impaired and those receiving acetylcholinesterase inhibitors is discussed.