Analysis of anticholinergic and sedative medicine effects on physical function, cognitive function, appetite and frailty: a cross-sectional study in Australia

Comparison of appetite assessment methods in older adults from the APPETITE study

Poor appetite is an important health concern in older adults. Numerous methods exist for appetite assessment, without a consensual gold standard. This study aims to compare Simplified Nutritional Appetite Questionnaire (SNAQ) and two single-item appetite questions with appetite ratings from visual analogue scales (VAS) and energy intake (EI). In 126 community-dwelling adults aged ≥65 years from the APPETITE trial, appetite was assessed using SNAQ, SNAQ 1st item, Center for Epidemiologic Studies-Depression scale (CES-D) 2nd item and using VAS appetite ratings (fasting, 0, 30, 60, 120, 180 min post-breakfast, post-lunch) and EI (ad libitum lunch) in a test meal setting. Spearman correlations were calculated between SNAQ, single-items, VAS-fasting, and EI. Differences in VAS-fasting and EI between normal and poor appetite groups (based on SNAQ, single-items) were examined using Mann-Whitney-U-test. Repeated measures Generalized Linear Models were used to compare all VAS ratings across the test morning and post-breakfast response ratings with VAS-fasting as a covariate between appetite groups. SNAQ score was correlated with VAS-fasting (r = 0.26, p < 0.001) and EI (r = 0.22, p < 0.05). VAS-fasting was lower in the SNAQ-based poor appetite group (p = 0.01). Time/group interaction effects (SNAQ, ηp2 = 0.02; CES-D-item, ηp2 = 0.02) for all VAS ratings, and group (SNAQ-item, ηp2 = 0.04) and interaction effects (CES-D-item, ηp2 = 0.03) for post-breakfast ratings were observed (p < 0.05, respectively). SNAQ identified differences in VAS-fasting, possibly reflecting processes related to the drive to eat, while the two single-items identified appetite differences in response to a standardised breakfast. Different methods appear to capture different aspects of appetite, which should be considered when choosing an assessment method.

Symptoms of Orthostatic Hypotension and Drugs Affecting Autonomic Function are Associated with the Onset of Frailty in Community-Dwelling Persons Aged 80 Years and Above: A Prospective Observational Study

BACKGROUND

Both autonomic dysfunction and frailty are common and complex geriatric syndromes with similar negative health outcomes. Both conditions are characterized by a loss of homeostasis that makes individuals more vulnerable to stressors.

AIM

The primary aim of this study is to examine the association between drugs that affect autonomic function and frailty onset in community-dwelling octogenarians. The secondary aim is to investigate the relationship between autonomic dysfunction and frailty onset in this population.

METHODS

In total, 372 nonfrail adults aged 80 years and above (mean age 83 ± 3 years) from the BUTTERFLY project were prospectively followed for 2 years (mean follow-up of 22 ± 6 months). The association between autonomic dysfunction (defined as neurogenic orthostatic hypotension and symptoms of orthostatic hypotension), the use of medications affecting autonomic function, and frailty status were examined using binary logistic regression analysis.

RESULTS

The completely adjusted binary logistic regression model showed that the use of drugs affecting autonomic function was associated with frailty {adjusted odds ratio (aOR) = 1.78 [95% confidence interval (CI) 1.06-3.00], p = 0.030}. Furthermore, symptoms of orthostatic hypotension were related to frailty (aOR = 2.98 [95% CI 1.13-7.88], p = 0.027).

CONCLUSIONS

Our results show that symptoms of orthostatic hypotension and the use of drugs that affect autonomic function are accompanied with respectively 3-fold and 1.8-fold higher odds of frailty onset in persons aged 80 years and over. Therefore, pharmacological treatment that affects autonomic function should be started with caution and timely discontinued in older persons.

Polypharmacy and anticholinergic burden scales in older adults: a cross-sectional study among psychiatric outpatients in a tertiary care hospital

INTRODUCTION

Mental disorders are prevalent among older adults, often leading to the use of multiple medications, many with anticholinergic properties. Polypharmacy, common in this population, is a major contributor to anticholinergic burden, which is linked to cognitive and physical decline. This study investigates the relationship between polypharmacy and anticholinergic burden across seven anticholinergic burden scales in elderly patients attending the psychiatric outpatient.

METHODS

Study was conducted at a psychiatry outpatient clinic at All India Institute of Medical Sciences, Rishikesh, India, from December 2021 to March 2023. Elderly patients (aged ≥ 60 years) who were on at least one psychotropic medication and had a primary working diagnosis of psychiatric illness were included. All psychotropic medications, including antidepressants, antipsychotics, mood stabilizers, and hypnotics, were evaluated. Anticholinergic burden scales were calculated by the respective tools. Univariate analysis was adopted to determine the factors that may affect polypharmacy.

RESULTS

Study included 1165 elderly patients aged ≥ 60 years. The prevalence of polypharmacy was 20.43% (n = 238). Clonazepam (n = 364, 17.28%), escitalopram (n = 197, 9.35%), metformin (n = 165, 7.83%), sertraline (n = 141, 6.69%), mirtazapine (n = 129, 6.12%), and lorazepam (n = 110, 5.22%) were among the most frequently prescribed anticholinergic drugs. Univariate analysis demonstrated that all anticholinergic risk assessment scales were closely correlated with polypharmacy, with the strongest association observed for the Anticholinergic Load Scale (ALS) (Odds Ratio = 4.3; p < 0.001). Polypharmacy was also positively associated with adverse drug reactions (Odds Ratio = 1.81; 95% Confidence Interval = 1.27-2.56).

CONCLUSION

The anticholinergic burden in this cohort of elderly psychiatry patients was high, with 95.1% (n = 1108) experiencing a significant burden. Adverse drug events and anticholinergic burden scales were positively associated with polypharmacy, with a stronger correlation between polypharmacy and ALS scores than with other anticholinergic burden scales in older adults.

Effect of Increasing or Decreasing Use of Polypharmacy on Recovery of Activities of Daily Living in Patients With Stroke in the Recovery-Phase Rehabilitation Ward: A Retrospective Cohort Study Using Propensity Score Matching

Background: Polypharmacy is a predictor of adverse outcomes, making its management crucial for improving patient health and recovery. Managing polypharmacy is particularly challenging in patients with stroke with many comorbidities and sequelae. Although reducing inappropriate prescribing is necessary, the number of medications may increase to effectively implement secondary prevention, potentially offsetting any changes in medication count. For patients with stroke undergoing recovery-phase rehabilitation, balancing secondary prevention and optimizing drug use early without hindering recovery of activities of daily living are crucial. This study is aimed at examining the effect of increasing or decreasing the use of polypharmacy on recovery of motor and cognitive function during recovery-phase rehabilitation in patients with stroke. Methods: The study was conducted from July 2010 to June 2019 among patients with stroke discharged from the convalescent rehabilitation ward during the study period. Patients who were using more than five drugs on admission and had either an increase or decrease in the number of drugs used on discharge were compared. Propensity score matching (PSM) was used to control for background variables such as patient demographics, laboratory values, and functional independence measure (FIM) scores at baseline. The primary outcomes were motor, cognition, and total FIM gain. Results: Of the 226 patients initially enrolled, 156 were matched on propensity score. The total motor FIM gain, total cognitive FIM gain, and total FIM gain were significantly higher in the decreased group than in the increased group (p = 0.0139, p = 0.0377, and p = 0.0077, respectively). Conclusion: In patients with stroke, reducing rather than increasing the number of drugs administered during recovery-phase rehabilitation could improve rehabilitation outcomes. Therefore, it is important to consider whether the drugs are essential for the patient and proactively revise the drug regimen to ensure rapid rehabilitation of patients with stroke.

Clozapine and Pneumonia: Synthesizing the Link by Reviewing Existing Reports-A Systematic Review and Meta-Analysis

Background and Objectives: Clozapine is a highly effective antipsychotic used for treating treatment-refractory psychotic and mood disorders. However, clozapine also has a serious risk of side effects leading to mortality, particularly its potentiated risk of leading to pneumonia. This review aims to overview the demographic and health-related risk factors leading to pneumonia to better inform risk assessment for clozapine users and to summarise current theories on the mechanisms for clozapine-associated pneumonia. This paper will highlight the need to prioritise pneumococcal vaccination in this population group. Materials and Method: We conducted a literary search of five online databases conforming to PRISMA. Our review includes all peer-reviewed papers with original data that discuss clozapine and pneumonia and excludes case reports. Baseline information of participants, pneumonia-related information and information regarding risk factors and mechanisms causing pneumonia were also extracted. Results: Clozapine was found to have an increased risk of pneumonia compared to other antipsychotic medications. Factors included comorbidities, higher clozapine dosages, and concurrent use of other antipsychotic medications. Key mechanisms for clozapine-associated pneumonia include clozapine-induced hyper sedation, sialorrhea and neutropoenia. Conclusions: While clozapine improves overall mortality for patients, our review confirms clozapine has the highest risk of pneumonia of all antipsychotics. The review also highlights the prevalent underuse of pneumococcal vaccines among clozapine users and the urgent need to increase uptake.

Association between Drug Therapy and Risk of Incident Frailty: A Systematic Review

Medication is a potential factor influencing frailty. However, the relationship between pharmaceutical treatments and frailty remains unclear. Therefore, we conducted the present systematic review to summarize the association between drug therapy and the risk of incident frailty in older adults. We systematically searched the MEDLINE electronic database for articles indexed between January 1, 2000, and December 31, 2021, for randomized controlled trials (RCTs) and cohort studies reporting frailty changes associated with drug therapy. A total of six RCTs and 13 cohort studies involving 211,948 participants were identified, and their treatments were categorized into six medication classes: analgesics, cardiometabolic medication, chemotherapy, central nervous system (CNS)-active medication, hormonal therapy, and nutritional supplements. While the analysis revealed that only CNS-active medications were associated with an elevated risk of frailty, other medication classes also affected frailty; however, this is not conclusively attributable to a class-wide effect.

The association between anticholinergic/sedative burden and physical frailty in people aging with HIV

OBJECTIVE

This study aimed to estimate the strength of the association between anticholinergic/sedative burden and concurrent physical frailty in people aging with HIV.

DESIGN

This cross-sectional analysis examined baseline data from 824 adults with a mean age of 53 enrolled in the Positive Brain Health Now study.

METHODS

Anticholinergic medications were identified using four methods: Anticholinergic Cognitive Burden (ACB) Scale, Anticholinergic Risk Scale (ARS), Anticholinergic Drug Scale (ADS), and the anticholinergic list of the Anticholinergic and Sedative Burden Catalog (ACSBC). Sedatives were identified using the Sedative Load Model (SLM) and the sedative list of the ACSBC. Physical frailty was assessed using a modified Fried Frailty Phenotype (FFP) based on self-report items. Multivariable logistic regression models, adjusted for sociodemographic factors, lifestyle considerations, HIV-related variables, comorbidities, and co-medication use, were used to estimate odds ratios (ORs).

RESULTS

Anticholinergic burden demonstrated associations with frailty across various methods: total anticholinergic burden (OR range: 1.22-1.32; 95% confidence interval (CI) range: 1.03-1.66), sedative burden (OR range: 1.18-1.24; 95% CI range: 1.02-1.45), high anticholinergic burden (OR range: 2.12-2.74; 95% CI range: 1.03-6.19), and high sedative burden (OR range: 1.94-2.18; 95% CI: 1.01-4.34).

CONCLUSION

The anticholinergic and sedative burdens may represent modifiable risk factors for frailty in people aging with HIV. Future studies should evaluate the effects of reducing anticholinergic and sedative burdens on frailty outcomes and explore the prognostic value of diverse scoring methods.

Association of drug burden index with delirium in community-dwelling older adults with dementia: a longitudinal observational study

BACKGROUND

The Drug Burden Index (DBI) is a validated tool for assessing the dose-dependent cumulative exposure to sedative and anticholinergic medications. However, the increased risk of delirium superimposed dementia (DSD) with high DBI levels has not yet been investigated.

AIM

This study aimed to examine the potential association between DBI scores and delirium in community-dwelling older adults with dementia.

METHOD

A total of 1105 participants with cognitive impairment underwent a comprehensive geriatric assessment. Experienced geriatricians made the final diagnosis of delirium based on DSM-IV-TR and DSM-V. We calculated the DBI as the sum of all sedatives and anticholinergics taken continuously for at least four weeks before admission. Polypharmacy was defined as regular use of five or more medications. We classified the participants as having no exposure (DBI = 0), low exposure (0 < DBI < 1), and high exposure (DBI ≥ 1).

RESULTS

Of the 721 patients with dementia, the mean age was 78.3 ± 6.7 years, and the majority were female (64.4%). In the whole sample, low and high exposures to anticholinergic and sedative medications at admission were 34.1% (n = 246) and 38.1% (n = 275), respectively. Patients in the high-exposure group had higher physical impairment (p = 0.01), higher polypharmacy (p = 0.01), and higher DBI scores (p = 0.01). In the multivariate Cox regression analysis, high exposure to anticholinergic and sedative medications increased the risk of delirium 4.09-fold compared to the no exposure group (HR = 4.09, CI: 1.63-10.27, p = 0.01).

CONCLUSION

High exposure to drugs with sedative and anticholinergic properties was common in community-dwelling older adults. A high DBI was associated with DSD, highlighting the need for an optimal prescription in this vulnerable population.

TRIAL REGISTRATION

The trial was retrospectively registered at ClinicalTrials.gov. Identifier: NCT04973709 Registered on 22 July 2021.

Using wrist-worn accelerometers to identify the impact of medicines with anticholinergic or sedative properties on sedentary time: A 12-month prospective analysis

INTRODUCTION

Studies have shown that use of medicines with sedative or anticholinergic properties is associated with a decline in physical function; however, the effects have not been quantified, and it is not known how and which specific physical movements are affected. This prospective study quantified the impact of a change in sedative or anticholinergic load over time on 24-hour activity composition.

METHODS

This study used data collected from a randomised trial assessing an ongoing pharmacist service in residential aged care. The 24-hour activity composition of sleep, sedentary behaviour, light-intensity physical activity, and moderate to vigorous physical activity was derived from 24-hour accelerometry bands. Mixed effect linear models were used to regress the multivariate outcome of 24-hour activity composition on medication load at baseline and at 12 months. A fixed effect interaction between trial stage and medication load was included to test for differing sedative or anticholinergic load effects at the two trial stages.

RESULTS

Data for 183 and 85 participants were available at baseline and 12 months respectively. There was a statistically significant interaction between medication load and time point on the multivariate outcome of 24-hour activity composition (sedative F = 7.2, p < 0.001 and anticholinergic F = 3.2, p = 0.02). A sedative load increase from 2 to 4 over the 12-month period was associated with an average increase in daily sedentary behaviour by an estimated 24 min.

CONCLUSION

As sedative or anticholinergic load increased, there was an increase in sedentary time. Our findings suggest wearable accelerometry bands are a possible tool for monitoring the effects on physical function of sedative and anticholinergic medicines.

TRIAL REGISTRATION

The ReMInDAR trial was registered on the Australian and New Zealand Trials Registry ACTRN12618000766213.

Associations of poor sleep quality, chronic pain and depressive symptoms with frailty in older patients: is there a sex difference?

Background

Sleep disturbance, chronic pain and depressive symptoms later in life are modifiable risk factors and may contribute to frailty. However, much less is known about sex differences in the association between these concurrent symptoms and frailty in older patients. Therefore, we conducted this study to explore the associations of poor sleep quality, chronic pain, and depressive symptoms with frailty in older patients, and the sex-specific associations.

Methods

In an observational population-based study, 540 older hospitalized patients from Zhejiang Hospital in China were enrolled. We collected data on poor sleep quality, pain, depressive symptoms and frailty using the Pittsburgh Sleep Quality Index, the Numerical Rating Scale, the 15-item Geriatric Depression Scale, and the Clinical Frailty Scale. Multivariate logistic regression models were used to explore the total sample and sex-specific associations among symptom burdens, symptom combination patterns and symptom counts, and frailty.

Results

After adjusting for the potential covariates, concurrent poor sleep quality and depressive symptoms (OR = 4.02, 95% CI 1.57–10.26), concurrent poor sleep quality and chronic pain (OR = 2.05, 95% CI 1.04–4.05), and having three symptoms (OR = 3.52, 95% CI 1.19–10.44) were associated with a higher likelihood of frailty in older inpatients. In addition, older patients with 2 or 3 symptoms (2 and 3 vs. 0 symptoms) had a higher risk of frailty, and the odds ratios were 2.40 and 3.51, respectively. Interaction analysis and sex-stratified associations exhibited conflicting results. The nonsignificant effect of the interaction of sex and symptoms on frailty, but not the sex-stratified associations, showed that individual symptoms, symptom combination patterns, and symptom counts were associated with elevated risks of frailty in older male patients, but not in older female patients.

Conclusions

Increased symptom burdens were associated with a higher risk of frailty in older inpatients, especially in those with poor sleep quality concurrent with at least one of the other two symptoms. Thus, a multidisciplinary program addressing these common symptoms is required to reduce adverse outcomes.

Medicine-related problems: A recurrent issue among residents living in nursing homes

Aim: To examine the incidence and nature of medicine-related problems over time experienced by nursing home residents. Method: We analyzed records collected in the Reducing Medicine-Induced Deterioration and Adverse Events (ReMInDAR) trial. The trial pharmacists provided services to reduce medicine-induced deterioration and adverse reactions for residents every 8-weeks over a year. The problems identified by the pharmacists were documented in reports and subsequently classified independently by research pharmacists using the D.O.C.U.M.E.N.T system. The number and type of problems at each service and time to develop a new problem post first session were assessed. All analyses were performed using R software (Version 4.1.1). Results: The cohort was 115 nursing home residents who received 575 services. In the 12-months, a total of 673 medicine-related problems or symptom reports were identified in 112 residents. Most residents (75%) experienced a new medicine-related problem by the fourth month post the first assessment. After the first session, the proportion of residents with a new medicine-related problem or symptom report declined at each repeated pharmacy session (59% at visit 2 vs. 28% at visit 6, p < 0.01). Conclusion: Residents living in nursing homes frequently experience medicine-related problems. Our results suggest clinical pharmacist services performed every 4-months may have the potential to reduce the medicine-related problems in nursing homes.

Fall risk-increasing drugs and gait performance in community-dwelling older adults: A systematic review

PURPOSE

Medication use, and gait impairment are two major risk factors for falls in older adults. There are several mechanisms linking fall risk-increasing drugs (FRIDs) and increased fall risk. One pathway involves gait performance as an intermediate variable. It is plausible that FRIDs indirectly increase fall risk by causing gait impairment. The purpose of this review was to systematically review the existing evidence on the association between FRIDs and gait performance in community-dwelling older adults without neurological movement disorders.

METHODS

Two searches were performed using MeSH terms and keywords in the electronic databases MEDLINE, EMBASE, PsycINFO, CINAHL and grey literature. We included clinical trials and observational studies that assessed the association between a FRID class and any quantitative measure of gait performance. Quality assessment was performed using the Newcastle-Ottawa scale for observational studies and the Cochrane risk-of-bias tool for clinical trials. Study characteristics and findings were summarized in a descriptive approach for each drug class.

RESULTS

A total of 11,197 studies were retrieved from both searches at the first step and a total of 23 studies met the final inclusion criteria. Fourteen studies assessed the association between psychotropic FRIDs and gait performance and nine assessed cardiovascular FRIDs. Four out of five studies found that drugs with sedative properties are associated with reduced gait speed in older adults. Three out of four studies found no association between statin use and gait speed. There is insufficient evidence on the association between FRIDs and other gait performance measures.

CONCLUSION

Caution should be taken when prescribing drugs with sedative properties to older adults at risk of falls. Further research is required to assess the impact of the use FRIDs on gait performance measures other than gait speed.

Effect of an ongoing pharmacist service to reduce medicine-induced deterioration and adverse reactions in aged-care facilities (nursing homes): a multicentre, randomised controlled trial (the ReMInDAR trial)

Objective

To assess the effectiveness of a pharmacist-led intervention using validated tools to reduce medicine-induced deterioration and adverse reactions.

Design and setting

Multicenter, open-label parallel randomised controlled trial involving 39 Australian aged-care facilities.

Participants

Residents on ≥4 medicines or ≥1 anticholinergic or sedative medicine.

Intervention

Pharmacist-led intervention using validated tools to detect signs and symptoms of medicine-induced deterioration which occurred every 8 weeks over 12 months.

Comparator

Usual care (Residential Medication Management Review) provided by accredited pharmacists.

Outcomes

Primary outcome was change in Frailty Index at 12 months. Secondary outcomes included changes in cognition, 24-hour movement behaviour by accelerometry, grip strength, weight, adverse events and quality of life.

Results

248 persons (median age 87 years) completed the study; 120 in the interventionand, 128 in control arms. In total 575 pharmacist, sessions were undertaken in the intervention arm. There was no statistically significant difference for change in frailty between groups (mean difference: 0.009, 95% CI: −0.028, 0.009, P = 0.320). A significant difference for cognition was observed, with a mean difference of 1.36 point change at 12 months (95% CI: 0.01, 2.72, P = 0.048). Changes in 24-hour movement behaviour, grip strength, adverse events and quality of life were not significantly different between groups. Point estimates favoured the intervention arm at 12 months for frailty, 24-hour movement behaviour and grip strength.

Conclusions

The use of validated tools by pharmacists to detect signs of medicine-induced deterioration is a model of practice that requires further research, with promising results from this trial, particularly with regards to improved cognition.

DOTA: Deep Learning Optimal Transport Approach to Advance Drug Repositioning for Alzheimer's Disease

Alzheimer's disease (AD) is the leading cause of age-related dementia, affecting over 5 million people in the United States and incurring a substantial global healthcare cost. Unfortunately, current treatments are only palliative and do not cure AD. There is an urgent need to develop novel anti-AD therapies; however, drug discovery is a time-consuming, expensive, and high-risk process. Drug repositioning, on the other hand, is an attractive approach to identify drugs for AD treatment. Thus, we developed a novel deep learning method called DOTA (Drug repositioning approach using Optimal Transport for Alzheimer's disease) to repurpose effective FDA-approved drugs for AD. Specifically, DOTA consists of two major autoencoders: (1) a multi-modal autoencoder to integrate heterogeneous drug information and (2) a Wasserstein variational autoencoder to identify effective AD drugs. Using our approach, we predict that antipsychotic drugs with circadian effects, such as quetiapine, aripiprazole, risperidone, suvorexant, brexpiprazole, olanzapine, and trazadone, will have efficacious effects in AD patients. These drugs target important brain receptors involved in memory, learning, and cognition, including serotonin 5-HT2A, dopamine D2, and orexin receptors. In summary, DOTA repositions promising drugs that target important biological pathways and are predicted to improve patient cognition, circadian rhythms, and AD pathogenesis.

Preclinical frailty assessments: Phenotype and frailty index identify frailty in different mice and are variably affected by chronic medications

Use of different objective frailty assessment tools may improve understanding of the biology of frailty and allow evaluation of effects of interventions on frailty. Polypharmacy is associated with increased risk of frailty in epidemiologic studies, regardless of frailty definition, but the pathophysiology of the association is not well understood. This study aims to (1) assess and compare the prevalence of frailty from middle to old age following control, chronic polypharmacy or monotherapy treatment, when measured using the clinical frailty index assessment and the mouse frailty phenotype tools; and (2) to evaluate and compare the effects of chronic polypharmacy regimens with zero, low and high Drug Burden Index (DBI) and monotherapies from middle to old age on the rate of deficit accumulation on the frailty index, mean number of phenotype criteria, odds of being frail assessed by the frailty index or phenotype, and the time to onset of frailty assessed by the frailty index or phenotype. In a longitudinal study, middle-aged (12 months) male C57BL/6J(B6) mice were administered non medicated control feed and water, or therapeutic doses of different polypharmacy combinations or monotherapies in feed and/or water. Frailty assessments were performed at 12, 15, 18, 21 and 24 months. There was limited overlap between animals identified as frail using different frailty assessments. Polypharmacy has measurable and different effects on each frailty assessment. Long-term chronic administration of some polypharmacy and monotherapy therapeutic drug regimens increased the number of frailty deficits (clinical frailty index: low DBI polypharmacy (15 and 21 months), high DBI polypharmacy (15-21 months), oxycodone (15-18 months), oxybutynin (15-18 months), citalopram (15-21 months) and metoprolol monotherapy (15 months) and modified frailty phenotype assessment (over the whole duration of treatment, low DBI polypharmacy (adjusted Risk Ratio(aRR) = 1.97, 95% confidence interval (CI) 1.43-2.72), high DBI polypharmacy (aRR = 1.88; 95% CI 1.36-2.60), oxybutynin (aRR = 1.48; 95% CI 1.01-2.16) and citalopram monotherapy (aRR = 1.96; 95% CI 1.41-2.74), p < 0.05) . The odds of developing frailty measured with the clinical frailty index increased with high DBI polypharmacy (adjusted odds ratio (aOR) = 3.13; 95% CI 1.01-9.66) and when measured with the frailty phenotype assessment increased with low DBI polypharmacy (aOR = 4.38, 95% CI 1.40-13.74), high DBI polypharmacy (aOR = 3.43; 95% CI 1.12-10.50) and citalopram monotherapy (aOR = 4.63; 95% CI 1.39-15.54)). No treatment affected time to frailty using either frailty assessment. Analysis of the number of deficits on the frailty index or number of positive criteria on the frailty phenotype allows analysis of rate of change and provides greater sensitivity, while the odds of being frail analysis provided a clinically relevant indicator of whether mice had greater chance of reaching a cut-off for becoming frail with medication exposure than without. Our results are consistent with clinical studies, demonstrating that certain polypharmacy regimens induce frailty, with different relationships observed when using different frailty assessments and analyses.

Association of anticholinergic burden with undernutrition in older adults: A cross-sectional study

BACKGROUND

Limited data are available concerning the contribution of drugs with anticholinergic properties (DAPs) to undernutrition among older adults. This study aimed to determine the potential association of anticholinergic burden (ACB) to nutrition status in older people.

METHODS

We prospectively enrolled participants aged over 65 who underwent a comprehensive geriatric assessment between January 2017 and June 2020. Nutrition status was assessed by the Mini Nutritional Assessment-Short Form (MNA-SF). The ACB was assessed using the ACB scale.

RESULTS

A total of 615 participants were included in the analysis (mean age ± SD, 78.5 ± 6.6 years; male, 55.3%). The prevalence of undernutrition (MNA-SF score <12) was 22.6% (n = 139). Participants with undernutrition were predominantly older (P < 0.001), had lower mean body mass index scores (undernutrition, 27.3 ± 5.4 vs healthy, 29.5 ± 8.0; P = 0.007), had a lower educational level (P = 0.016), had higher cardiovascular disease morbidity (P < 0.001), and had a higher ACB (P < 0.001) when compared with those with normal nutrition status. In adjusted analysis, the odds of having undernutrition were higher among participants with an ACB score >1 (odds ratio, 1.20; 95% CI, 1.01-1.43; P = 0.044). The weighted multivariate linear regression analysis showed a significant inverse association between the total ACB score and MNA-SF score controlling for multiple confounders.

CONCLUSION

ACB appears to be inversely correlated with nutrition status among older adults. Undernutrition may be considered an additional reason to consider deprescribing DAPs in this population.

Quantifying Anticholinergic Burden and Sedative Load in Older Adults with Polypharmacy: A Systematic Review of Risk Scales and Models

BACKGROUND

Patients taking medication with high anticholinergic and sedative properties are at increased risk of experiencing poor cognitive and physical outcomes. Therefore, precise quantification of the cumulative burden of their drug regimen is advisable. There is no agreement regarding which scale to use to simultaneously quantify the burden associated with medications.

OBJECTIVES

The objective of this review was to assess the strengths and limitations of available tools to quantify medication-related anticholinergic burden and sedative load in older adults. We discuss specific limitations and agreements between currently available scales and models and propose a comprehensive table combining drugs categorized as high, moderate, low, or no anticholinergic or sedative activity as excerpted from the selected studies.

METHODS

A targeted search was carried out using the National Library of Medicine through PubMed using medical subject heading terms and text words around the following search terms: (anticholinergic OR sedative) AND (load OR burden OR scale) for studies published between 1 January 1945 and 5 June 2021. In addition, the following databases were searched using the same terms: MEDLINE-EBSCO, APA PsycInfo, CINAHL Plus, Cochrane Library, Scopus, OAIster, OVID-MEDLINE, Web of Science, and Google Scholar. Screening by titles was followed by an abstract and full-text review. After blind evaluation, agreement between reviewers was reached to establish drug characteristics and categories.

RESULTS

After 3163 articles were identified, 13 were included: 11 assigned risk scores to anticholinergic drugs and two to sedative drugs. Considerable variability between anticholinergic scales was observed; scales included between 27 and 548 drugs. We generated a comprehensive table combining the anticholinergic and sedative activities of drugs evaluated and proposed a categorization of these drugs based on available scientific and clinical evidence. Our table combines information about 642 drugs and categorizes 44, 25, 99, and 474 drugs as high, moderate, low, or no anticholinergic and sedative activity, respectively.

CONCLUSIONS

Variability and inconsistency exists among scales used to categorize drugs with anticholinergic or sedative burden. In this review, we provide a comprehensive table that proposes a new categorization of these drugs. A longitudinal study will be required to validate the new proposed anticholinergic and sedative burden catalog in an evidence-based manner.

Polypharmacy Results in Functional Impairment in Mice: Novel Insights Into Age and Sex Interactions

Males and females may respond differently to medications, yet knowledge about sexual dimorphisms in the effects of polypharmacy remains limited, particularly in aging. This study aimed to assess the effect of high Drug Burden Index (DBI) polypharmacy treatment compared to control on physical function and behavior in young and old, male and female mice. We studied whether age and sex play a role in physical function and behavior following polypharmacy treatment and whether they are paralleled by differences in serum drug levels. Young (2.5 months) and old (21.5 months), C57BL/6 mice were randomized to control or high DBI polypharmacy treatment (simvastatin, metoprolol, oxybutynin, oxycodone, and citalopram; n = 6-8/group) for 4-6 weeks. Compared to control, polypharmacy reduced physical function (grip strength, rotarod latency, gait speed, and total distance), middle zone distance (increased anxiety), and nesting score (reduced activities of daily living) in mice of both ages and sexes (p < .001). Old animals had a greater decline in nesting score (p < .05) and midzone distance (p < .001) than young animals. Grip strength declined more in males than females (p < .05). Drug levels at steady state were not significantly different between polypharmacy-treated animals of both ages and sexes. We observed polypharmacy-induced functional impairment in both age and sex groups, with age and sex interactions in the degree of impairment, which were not explained by serum drug levels. Studies of the pathogenesis of functional impairment from polypharmacy may improve management strategies in both sexes.

The cognitive effects of anticholinergic drugs on apolipoprotein ε4 carriers and noncarriers in the Wisconsin Registry for Alzheimer's Prevention study

OBJECTIVES

The purpose of the study was to test the hypothesis that anticholinergic drug exposure is associated with cognitive decline in the Wisconsin Registry for Alzheimer's Prevention (WRAP) study. Secondary aims were to assess if the effects of anticholinergic drugs on different domains of cognitive functioning varied for the entire sample and by apolipoprotein ε4 status.

METHODS

The WRAP study includes a sample of 1,573 subjects who self-reported medication use and were administered several cognitive tests four times over a decade. Partial correlations assessed relationships between reported days of definite anticholinergic drug exposure with changes in cognitive performance. Linear mixed models were conducted testing main effects for anticholinergic drug use and interaction effects between anticholinergic drug use, apolipoprotein ε4 status, and time on neuropsychological assessment performance.

RESULTS

Partial correlations indicated that days of anticholinergic drug exposure was associated with a decline in mental status for the entire sample (r = -.043, p = .011), and immediate verbal memory (r = -.066, p = .043), delayed verbal memory (r = -.077, p = .018), psychomotor speed (r = -.066, p = .043), and cognitive flexibility (r = -.067, p = .040) of apolipoprotein ε4 carriers only. The linear mixed-model results suggested that anticholinergic drug users had a greater decline than nonusers in delayed memory, psychomotor speed, and cognitive flexibility. Apolipoprotein ε4 carrier, anticholinergic drug users performed worse in delayed memory than nonusers and noncarrier, anticholinergic drug users.

CONCLUSIONS

Anticholinergic drug use may have deleterious effects on the cognitive functioning of subjects in populations at risk for dementia, especially among apolipoprotein ε4 carriers. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Associations Between Anticholinergic Medication Exposure and Adverse Health Outcomes in Older People with Frailty: A Systematic Review and Meta-analysis

Introduction

There are robust associations between use of anticholinergic medicines and adverse effects in older people. However, the nature of these associations for older people living with frailty is yet to be established.

Objectives

The aims were to identify and investigate associations between anticholinergics and adverse outcomes in older people living with frailty and to investigate whether exposure is associated with greater risks according to frailty status.

Methods

MEDLINE, CINAHL, EMBASE, Cochrane Database of Systematic Reviews, Web of Science and PsycINFO were searched to 1 August 2019. Observational studies reporting associations between anticholinergics and outcomes in older adults (average age ≥ 65 years) that reported frailty using validated measures were included. Primary outcomes were physical impairment, cognitive dysfunction, and change in frailty status. Risk of bias was evaluated using the Cochrane Risk of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool. Meta-analysis was undertaken where appropriate.

Results

Thirteen studies (21,516 participants) were included (ten community, one residential aged-care facility and two hospital studies). Observed associations included reduced ability for chair standing, slower gait speeds, poorer physical performance, increased risk of falls and mortality. Conflicting results were reported for grip strength, timed up and go test, cognition and activities of daily living. No associations were observed for transitions between frailty states, psychological wellbeing or benzodiazepine-related adverse reactions. There was no clear evidence of differences in risks according to frailty status.

Conclusions

Anticholinergics are associated with adverse outcomes in older people living with frailty; however, the literature has significant methodological limitations. There is insufficient evidence to suggest greater risks based on frailty, and there is an urgent need to evaluate this further in well-designed studies stratifying by frailty.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40801-021-00256-5.

Gait Speed is independently associated with Depression Symptoms in Mild Cognitive Impairment

Depression symptoms are known to influence gait speed in cognitively healthy adults. In this study, we aimed to examine the relationship between gait speed and depression symptoms in older patients with mild cognitive impairment. The participants were classified as slow and normal gait speed based on the Fried criteria. A total of 152 subjects with mild cognitive impairment were included. Of these, 39.5% (n=60) had slow gait speed. Compared to normal speed group (n=92), patients with slow speed had more clinically significant depression (geriatric depression scale score ≥ 6) (p=0.004), cardiovascular disease (p=0.007), recent falls (p<0.001), and anticholinergic burden (p=0.005). Multivariable logistic regression analysis yielded statistically significant associations between slow gait speed and depression in age and gender adjusted [OR:3.30 (1.46-7.46), p=0.004] and fully adjusted [OR: 2.80 (1.10-7.08), p=0.030] models. This study showed an independent association between slow gait speed and depression symptoms in older people with mild cognitive impairment.

Prevalence and predictors of mortality for older adults referred to hospital avoidance program

AIM

Following discharge from a hospital avoidance program, to examine the prevalence of patient mortality, demographic characteristics associated with risk of mortality up to 33 months, patient demographic and health characteristics associated with mortality within 1 year.

METHODS

A retrospective data linkage study of older adults with mean age of 80.5 years discharged from a hospital avoidance program between January 2017 and January 2018. The prevalence of death at 3, 6, 12, 18 and 33 months was calculated. Patient demographic and health characteristics associated with participant mortality within 12 (n = 195) and 33 (n = 185) months of discharge was examined using Cox multivariable regression for patients with complete health characteristic data.

RESULTS

The mortality prevalence was 17% at 6 months and cumulative prevalence at 1 year, 18 months and 33 months post-discharge were 24%, 29% and 36% respectively. Characteristics associated with mortality within 12 months of discharge were lower cognition, increased burden of comorbidity, decreased physical function, weight <55 kg and male sex. The same variables were associated with death up to 33 months as well as age, interaction between household arrangement and time, and albumin.

CONCLUSIONS

The establishment of potential risk indicators allows greater specificity for identifying older people at risk of dying in the next 12 months and an opportunity to discuss their advanced care planning. Geriatr Gerontol Int 2021; ••: ••-••.

Frailty status and increased risk for falls: The role of anticholinergic burden

PURPOSE OF THE STUDY

Frailty leads to serious adverse outcomes including falls. The relationship between frailty and falls has not been evaluated in the context of the side effects of drugs with anticholinergic properties. The aim of this study was to examine the potential association of anticholinergic burden (ACB) with the risk of falls among frail older adults.

DESIGN AND METHODS

Community-dwelling older adults were consecutively selected from the geriatrics outpatient clinic. Based on a fall history in the last 12 months, the participants were grouped as fallers and non-fallers. Frailty status was assessed by Fried's phenotype method. Exposure to anticholinergic medications was estimated using the ACB scale, and the participants were classified into ACB_0 (none), ACB_1 (possible) and ACB_2+ (definite).

RESULTS

The study included 520 older adults (mean age 77.7 years, 62.7 % female), with a fall prevalence of 25.8 % 12 months past. The proportions of frailty and pre-frailty were 33.1 % and 57.4 %, respectively. After adjustment for study confounders, receiving at least 1 drug with either possible or definite anticholinergic properties was independently associated to falls in frail [OR = 3.84 (1.48-9.93), p = 0.006] and pre-frail participants [OR = 2.71 (1.25-5.89); p = 0.012], but not in robust subjects. Moreover, ACB was significantly associated with the frailty components on adjusted analysis (p's<0.05).

IMPLICATIONS

Current study showed that the use of any drugs with possible or definite anticholinergic properties was associated with an increased risk of falls in frail older adults. The results emphasize the importance of medication management with respect to fall prevention in these patients.

Reducing medicine-induced deterioration and adverse reactions (ReMInDAR) trial: study protocol for a randomised controlled trial in residential aged-care facilities assessing frailty as the primary outcome

INTRODUCTION

Many medicines have adverse effects which are difficult to detect and frequently go unrecognised. Pharmacist monitoring of changes in signs and symptoms of these adverse effects, which we describe as medicine-induced deterioration, may reduce the risk of developing frailty. The aim of this trial is to determine the effectiveness of a 12-month pharmacist service compared with usual care in reducing medicine-induced deterioration, frailty and adverse reactions in older people living in aged-care facilities in Australia.

METHODS AND ANALYSIS

The reducing medicine-induced deterioration and adverse reactions trial is a multicentre, open-label randomised controlled trial. Participants will be recruited from 39 facilities in South Australia and Tasmania. Residents will be included if they are using four or more medicines at the time of recruitment, or taking more than one medicine with anticholinergic or sedative properties. The intervention group will receive a pharmacist assessment which occurs every 8 weeks. The pharmacists will liaise with the participants' general practitioners when medicine-induced deterioration is evident or adverse events are considered serious. The primary outcome is a reduction in medicine-induced deterioration from baseline to 6 and 12 months, as measured by change in frailty index. The secondary outcomes are changes in cognition scores, 24-hour movement behaviour, grip strength, weight, percentage robust, pre-frail and frail classification, rate of adverse medicine events, health-related quality of life and health resource use. The statistical analysis will use mixed-models adjusted for baseline to account for repeated outcome measures. A health economic evaluation will be conducted following trial completion using data collected during the trial.

ETHICS AND DISSEMINATION

Ethics approvals have been obtained from the Human Research Ethics Committee of University of South Australia (ID:0000036440) and University of Tasmania (ID:H0017022). A copy of the final report will be provided to the Australian Government Department of Health.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Trials Registry ACTRN12618000766213.