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Azmi H, Walter BL, Brooks A, Richard IH, Amodeo K, Okun MS. Editorial: Hospitalization and Parkinson's disease: safety, quality and outcomes. Front Aging Neurosci 2024; 16:1398947. [PMID: 38638192 PMCID: PMC11024459 DOI: 10.3389/fnagi.2024.1398947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 03/14/2024] [Indexed: 04/20/2024] Open
Affiliation(s)
- Hooman Azmi
- Department of Neurosurgery, Hackensack University Medical Center, Hackensack, NJ, United States
- Hackensack Meridian School of Medicine, Nutley, NJ, United States
| | | | - Annie Brooks
- Parkinson's Foundation, New York, NY, United States
| | - Irene Hegeman Richard
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
| | - Katherine Amodeo
- Westchester Medical Center Health Network, Valhalla, NY, United States
| | - Michael S. Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
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Jiao J, Brumbach BH, Hantke N, Wilhelmi M, Bonilla C, Safarpour D. Changes in Anticholinergic Burden in Parkinson's Disease After Deep Brain Stimulation. Neuromodulation 2024; 27:538-543. [PMID: 38085189 DOI: 10.1016/j.neurom.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/30/2023] [Accepted: 11/02/2023] [Indexed: 04/05/2024]
Abstract
OBJECTIVE This study aimed to evaluate the effect of deep brain stimulation (DBS) on anticholinergic burden in Parkinson's disease (PD) and the association of anticholinergic burden with cognition. MATERIALS AND METHODS A retrospective chart review in patients with PD who underwent bilateral subthalamic nucleus (STN) or globus pallidus internus (GPi) DBS from 2010 to 2020 reviewed medications with anticholinergic burden at baseline, six months, and one year (N = 216) after surgery. The cumulative anticholinergic burden at each visit was calculated using the Anticholinergic Risk Scale (ARS). RESULTS ARS scores were significantly lower for patients six months and one year after surgery than at baseline (z = 6.58, p < 0.0001; z = 6.99, p < 0.0001). Change in ARS scores at both six months and one year were driven by down-titration of PD medications (z = 9.35, p < 0.0001; z = 8.61, p < 0.0001), rather than changes in pain, psychiatric, or urinary medications with anticholinergic effects. There was no significant difference in change in ARS scores at one year between targets (t = 0.41, p = 0.68). In addition, there was no significant association between anticholinergic burden and cognitive performance. CONCLUSION GPi and STN DBS are associated with decreased anticholinergic burden due to PD medications in the first year after surgery.
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Affiliation(s)
- Jocelyn Jiao
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA.
| | - Barbara H Brumbach
- Oregon Health and Science University-Portland State University School of Public Health, Biostatistics and Design Program, Oregon Health and Science University, Portland, OR, USA
| | - Nathan Hantke
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA; Mental Health and Clinical Neuroscience Division, Veterans Affairs Portland Health Care System, Portland, OR, USA
| | - Morgan Wilhelmi
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Christian Bonilla
- School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Delaram Safarpour
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA
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Carroll C, Clarke CE, Grosset D, Rather A, Mohamed B, Parry M, Reddy P, Fackrell R, Chaudhuri KR. Addressing Comorbidities in People with Parkinson's Disease: Considerations From An Expert Panel. J Parkinsons Dis 2024; 14:53-63. [PMID: 38217610 PMCID: PMC10836549 DOI: 10.3233/jpd-230168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2024]
Abstract
In the UK, guidance exists to aid clinicians and patients deciding when treatment for Parkinson's disease (PD) should be initiated and which therapies to consider. National Institute for Health and Care Excellence (NICE) guidance recommends that before starting PD treatment clinicians should discuss the following: the patient's individual clinical circumstances; lifestyle; preferences; needs and goals; as well as the potential benefits and harms of the different drug classes. Individualization of medicines and management in PD significantly improves patients' outcomes and quality of life. This article aims to provide simple and practical guidance to help clinicians address common, but often overlooked, co-morbidities. A multi-disciplinary group of PD experts discussed areas where clinical care can be improved by addressing commonly found co-morbidities in people with Parkinson's (PwP) based on clinical experience and existing literature, in a roundtable meeting organized and funded by Bial Pharma UK Ltd. The experts identified four core areas (bone health, cardiovascular risk, anticholinergic burden, and sleep quality) that, if further standardized may improve treatment outcomes for PwP patients. Focusing on anticholinergic burden, cardiac risk, sleep, and bone health could offer a significant contribution to personalizing regimes for PwP and improving overall patient outcomes. Within this opinion-based paper, the experts offer a list of guiding factors to help practitioners in the management of PwP.
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Affiliation(s)
- Camille Carroll
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
- University of Plymouth and University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Carl E Clarke
- University of Birmingham and City Hospital, Birmingham, UK
| | | | | | - Biju Mohamed
- Cardiff and Vale University Health Board, Cardiff, UK
| | - Miriam Parry
- Parkinson Foundation Centre of Excellence, King's College Hospital NHS Foundation Trust, London, UK
| | | | | | - Kallol Ray Chaudhuri
- Parkinson Foundation Centre of Excellence, King's College Hospital NHS Foundation Trust, London, UK
- King's College London, London, UK
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Azmi H, Cocoziello L, Ruzicka F, Clar E, Pederson JM, Jacob B, Thomas J, Rocco A, Bobek M, Pereira-Argenziano L, Roth P, Thomas FP. Custom order entry for Parkinson's medications in the hospital improves timely administration: an analysis of over 31,000 medication doses. Front Aging Neurosci 2023; 15:1267067. [PMID: 38187358 PMCID: PMC10768191 DOI: 10.3389/fnagi.2023.1267067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 11/28/2023] [Indexed: 01/09/2024] Open
Abstract
Background Patients with Parkinson's disease (PD) are at increased risk for hospital acquired complications. Deviations from home medication schedules and delays in administration are major contributing factors. We had previously developed a protocol to ensure adherence to home medication schedules using "custom" ordering. In this study we are assessing the impact this order type may have on reducing delays in PD medication administration in the hospital. Material and methods We reviewed 31,404 orders placed for PD medications from January 2, 2016 to April 30 2021. We evaluated the orders to determine if they were placed in a Custom format or using a default non-custom order entry. We further evaluated all orders to determine if there was a relationship with the order type and timely administration of medications. We compared medications that were administered within 1 min, 15 min, 30 min and 60 min of due times across custom orders vs. non-custom default orders. We also evaluated the relationship between ordering providers and type of orders placed as well as hospital unit and type of orders placed. Results 14,204 (45.23%) orders were placed using a custom schedule and 17,200 (54.77%) orders were placed using non-custom defaults. The custom group showed a significantly lower median delay of 3.06 minutes compared to the non-custom group (p<.001). Custom orders had a significantly more recent median date than non-custom default orders (2019-10-07 vs. 2018-01-06, p<0.001). In additional analyses, medication administration delays were significantly improved for custom orders compared to non-custom orders, with likelihoods 1.64 times higher within 1 minute, 1.40 times higher within 15 minutes, and 1.33 times higher within 30 minutes of the due time (p<0.001 for all comparisons). Conclusion This is the largest study to date examining the effects of order entry type on timely administration of PD medications in the hospital. Orders placed using a custom schedule may help reduce delays in administration of PD medications.
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Affiliation(s)
- Hooman Azmi
- Department of Neurosurgery, Hackensack University Medical Center, Hackensack, NJ, United States
- New Jersey Brain and Spine Center, Hackensack, NJ, United States
- Hackensack Meridian School of Medicine, Nutley, NJ, United States
| | - Lisa Cocoziello
- Department of Neurosurgery, Hackensack University Medical Center, Hackensack, NJ, United States
| | - Francis Ruzicka
- Hackensack Meridian School of Medicine, Nutley, NJ, United States
| | - Elana Clar
- New Jersey Brain and Spine Center, Hackensack, NJ, United States
- Hackensack Meridian School of Medicine, Nutley, NJ, United States
- Department of Neurology, Hackensack University Medical Center, Hackensack, NJ, United States
| | | | - Blessy Jacob
- Department of Pharmacy, Hackensack University Medical Center, Hackensack, NJ, United States
| | - Jewell Thomas
- Department of Pharmacy, Hackensack University Medical Center, Hackensack, NJ, United States
| | - Anthony Rocco
- Department of Patient Safety and Quality, Hackensack University Medical Center, Hackensack, NJ, United States
| | - Mary Bobek
- Department of Nursing Clinical Education, Hackensack University Medical Center, Hackensack, NJ, United States
| | - Lucy Pereira-Argenziano
- Department of Patient Safety and Quality, Hackensack University Medical Center, Hackensack, NJ, United States
| | - Patrick Roth
- Department of Neurosurgery, Hackensack University Medical Center, Hackensack, NJ, United States
- New Jersey Brain and Spine Center, Hackensack, NJ, United States
- Hackensack Meridian School of Medicine, Nutley, NJ, United States
| | - Florian P. Thomas
- Hackensack Meridian School of Medicine, Nutley, NJ, United States
- Department of Neurology, Hackensack University Medical Center, Hackensack, NJ, United States
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Venuto CS, Smith G, Herbst K, Zielinski R, Yung NC, Grosset DG, Dorsey ER, Kieburtz K. Predicting Ambulatory Capacity in Parkinson's Disease to Analyze Progression, Biomarkers, and Trial Design. Mov Disord 2023; 38:1774-1785. [PMID: 37363815 PMCID: PMC10615710 DOI: 10.1002/mds.29519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/10/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND In Parkinson's disease (PD), gait and balance is impaired, relatively resistant to available treatment and associated with falls and disability. Predictive models of ambulatory progression could enhance understanding of gait/balance disturbances and aid in trial design. OBJECTIVES To predict trajectories of ambulatory abilities from baseline clinical data in early PD, relate trajectories to clinical milestones, compare biomarkers, and evaluate trajectories for enrichment of clinical trials. METHODS Data from two multicenter, longitudinal, observational studies were used for model training (Tracking Parkinson's, n = 1598) and external testing (Parkinson's Progression Markers Initiative, n = 407). Models were trained and validated to predict individuals as having a "Progressive" or "Stable" trajectory based on changes of ambulatory capacity scores from the Movement Disorders Society Unified Parkinson's Disease Rating Scale parts II and III. Survival analyses compared time-to-clinical milestones and trial outcomes between predicted trajectories. RESULTS On external evaluation, a support vector machine model predicted Progressive trajectories using baseline clinical data with an accuracy, weighted-F1 (proportionally weighted harmonic mean of precision and sensitivity), and sensitivity/specificity of 0.735, 0.799, and 0.688/0.739, respectively. Over 4 years, the predicted Progressive trajectory was more likely to experience impaired balance, loss of independence, impaired function and cognition. Baseline dopamine transporter imaging and select biomarkers of neurodegeneration were significantly different between predicted trajectory groups. For an 18-month, randomized (1:1) clinical trial, sample size savings up to 30% were possible when enrollment was enriched for the Progressive trajectory versus no enrichment. CONCLUSIONS It is possible to predict ambulatory abilities from clinical data that are associated with meaningful outcomes in people with early PD. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Charles S. Venuto
- Center for Health + Technology, University of Rochester, Rochester, NY, USA
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Greta Smith
- Center for Health + Technology, University of Rochester, Rochester, NY, USA
| | - Konnor Herbst
- Center for Health + Technology, University of Rochester, Rochester, NY, USA
| | - Robert Zielinski
- Center for Health + Technology, University of Rochester, Rochester, NY, USA
- Department of Biostatistics, Brown University, Providence, RI, USA
| | - Norman C.W. Yung
- Center for Health + Technology, University of Rochester, Rochester, NY, USA
| | - Donald G. Grosset
- School of Neuroscience and Psychology, University of Glasgow, Glasgow, United Kingdom
| | - E. Ray Dorsey
- Center for Health + Technology, University of Rochester, Rochester, NY, USA
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | - Karl Kieburtz
- Center for Health + Technology, University of Rochester, Rochester, NY, USA
- Department of Neurology, University of Rochester, Rochester, NY, USA
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Abraham DS, Pham Nguyen TP, Newcomb CW, Gray SL, Hennessy S, Leonard CE, Liu Q, Weintraub D, Willis AW. Comparative safety of antimuscarinics versus mirabegron for overactive bladder in Parkinson disease. Parkinsonism Relat Disord 2023; 115:105822. [PMID: 37713748 PMCID: PMC10853986 DOI: 10.1016/j.parkreldis.2023.105822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/25/2023] [Accepted: 08/23/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Overactive bladder (OAB) is a common non-motor symptom of Parkinson disease (PD), often treated with antimuscarinics or beta-3 agonists. There is lack of evidence to guide OAB management in PD. OBJECTIVES To assess the comparative safety of antimuscarinics versus beta-3 agonists for OAB treatment in PD. METHODS We employed a new-user, active-comparator cohort study design. We included Medicare beneficiaries age ≥65 years with PD who were new users of either antimuscarinic or beta-3 agonist. The primary outcome was any acute care encounter (i.e., non-elective hospitalization or emergency department visit) within 90 days of OAB drug initiation. The main secondary outcome was a composite measure of acute care encounters for anticholinergic related adverse events (AEs). Matching on high-dimensional propensity score (hdPS) was used to address potential confounding. We used Cox proportional hazards models to examine the association between OAB drug category and outcomes. We repeated analyses for 30- and 180-day follow-up periods. RESULTS We identified 27,091 individuals meeting inclusion criteria (mean age: 77.8 years). After hdPS matching, antimuscarinic users had increased risks for any acute care encounter (hazard ratio [HR] 1.23, 95% confidence interval [CI] 1.12-1.37) and encounters for anticholinergic related AEs (HR 1.18, 95% CI 1.04-1.34) compared to beta-3 agonist users. Similar associations were observed for sensitivity analyses. CONCLUSIONS Among persons with PD, anticholinergic initiation was associated with a higher risk of acute care encounters compared with beta-3 agonist initiation. The long-term safety of anticholinergic vs. beta-3 agonist therapy in the PD population should be evaluated in a prospective study.
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Affiliation(s)
- Danielle S Abraham
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Neurology Translational Center for Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Real-world Effectiveness and Safety of Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Thanh Phuong Pham Nguyen
- Department of Neurology Translational Center for Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Real-world Effectiveness and Safety of Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Biostatistics, University of Pennsylvania Perelman School of Medicine, Epidemiology and Informatics, Philadelphia, PA, USA
| | - Craig W Newcomb
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Biostatistics, University of Pennsylvania Perelman School of Medicine, Epidemiology and Informatics, Philadelphia, PA, USA
| | - Shelly L Gray
- Department of Pharmacy, University of Washington School of Pharmacy, Seattle, WA, USA
| | - Sean Hennessy
- Center for Real-world Effectiveness and Safety of Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Biostatistics, University of Pennsylvania Perelman School of Medicine, Epidemiology and Informatics, Philadelphia, PA, USA
| | - Charles E Leonard
- Center for Real-world Effectiveness and Safety of Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Biostatistics, University of Pennsylvania Perelman School of Medicine, Epidemiology and Informatics, Philadelphia, PA, USA
| | - Qing Liu
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Biostatistics, University of Pennsylvania Perelman School of Medicine, Epidemiology and Informatics, Philadelphia, PA, USA
| | - Daniel Weintraub
- Parkinson's Disease Research, Education and Clinical Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Allison W Willis
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Neurology Translational Center for Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Real-world Effectiveness and Safety of Therapeutics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Biostatistics, University of Pennsylvania Perelman School of Medicine, Epidemiology and Informatics, Philadelphia, PA, USA.
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Pham Nguyen TP, Gray SL, Newcomb CW, Liu Q, Hamedani AG, Weintraub D, Hennessy S, Willis AW. Potentially inappropriate medications in older adults with Parkinson disease before and after hospitalization for injury. Parkinsonism Relat Disord 2023; 114:105793. [PMID: 37567062 DOI: 10.1016/j.parkreldis.2023.105793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/25/2023] [Accepted: 07/30/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND Parkinson disease (PD) patients are at increased risk of serious injury, such as fall-related fractures. Prescription medications are a modifiable factor for injury risk. OBJECTIVES To determine the extent to which a serious injury requiring hospitalization affects prescribing of potentially inappropriate medications (PIMs) among older adults with PD. METHODS We conducted a quasi-experimental difference-in-difference (DID) study using 2013-2017 Medicare data. The cohort consisted of beneficiaries with PD hospitalized for injury versus for other reasons. PIMs were classified into PD and injury-relevant categories (CNS-active PIMs, PD motor symptom PIMs, PD non-motor symptom PIMs, PIMs that reduce bone mineral density). We estimated mean standardized daily doses (SDDs) of medications within each PIM category before and at 3, 6, and 12 months after hospitalization. We used generalized linear regression models to compare changes in mean SDDs for each PIM category between the injury and non-injury group at each timepoint, adjusting for biological, clinical and social determinants of health variables. RESULTS Both groups discontinued PIMs and/or reduced PIM doses after hospitalization. There were no between-group differences in mean SDD changes, after covariate adjustment, for any PIM category, except for the CNS-active PIMs category at 3 months (DID p-value = 0.00) and for the category of PIMs that reduce bone mineral density at all timepoints (DID p-values = 0.02, 0.04, 0.02 at 3, 6, and 12 months). CONCLUSIONS Similar patterns of PIM among persons with PD after hospitalization for serious injury versus for other reasons may represent a missed opportunity to deprescribe high-risk medications during care transitions.
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Affiliation(s)
- Thanh Phuong Pham Nguyen
- Department of Neurology Translational Center for Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Real-world Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Shelly L Gray
- Department of Pharmacy, University of Washington School of Pharmacy, Seattle, WA, USA
| | - Craig W Newcomb
- Center for Real-world Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Qing Liu
- Center for Real-world Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ali G Hamedani
- Department of Neurology Translational Center for Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Real-world Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Daniel Weintraub
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Parkinson's Disease Research, Education and Clinical Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Sean Hennessy
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Real-world Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Allison W Willis
- Department of Neurology Translational Center for Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Center for Real-world Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Parkinson's Disease Research, Education and Clinical Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA.
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Roytman S, Paalanen R, Griggs A, David S, Pongmala C, Koeppe RA, Scott PJH, Marusic U, Kanel P, Bohnen NI. Cholinergic system correlates of postural control changes in Parkinson's disease freezers. Brain 2023; 146:3243-3257. [PMID: 37086478 PMCID: PMC10393403 DOI: 10.1093/brain/awad134] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/16/2023] [Accepted: 04/06/2023] [Indexed: 04/24/2023] Open
Abstract
Postural instability and freezing of gait are the most debilitating dopamine-refractory motor impairments in advanced stages of Parkinson's disease because of increased risk of falls and poorer quality of life. Recent findings suggest an inability to efficaciously utilize vestibular information during static posturography among people with Parkinson's disease who exhibit freezing of gait, with associated changes in cholinergic system integrity as assessed by vesicular acetylcholine transporter PET. There is a lack of adequate understanding of how postural control varies as a function of available sensory information in patients with Parkinson's disease with freezing of gait. The goal of this cross-sectional study was to examine cerebral cholinergic system changes that associate with inter-sensory postural control processing features as assessed by dynamic computerized posturography and acetylcholinesterase PET. Seventy-five participants with Parkinson's disease, 16 of whom exhibited freezing of gait, underwent computerized posturography on the NeuroCom© Equitest sensory organization test platform, striatal dopamine, and acetylcholinesterase PET scanning. Findings demonstrated that patients with Parkinson's disease with freezing of gait have greater difficulty maintaining balance in the absence of reliable proprioceptive cues as compared to those without freezing of gait [β = 0.28 (0.021, 0.54), P = 0.034], an effect that was independent of disease severity [β = 0.16 (0.062, 0.26), P < 0.01] and age [β = 0.092 (-0.005, 0.19), P = 0.062]. Exploratory voxel-based analysis revealed an association between postural control and right hemispheric cholinergic network related to visual-vestibular integration and self-motion perception. High anti-cholinergic burden predicted postural control impairment in a manner dependent on right hemispheric cortical cholinergic integrity [β = 0.34 (0.065, 0.61), P < 0.01]. Our findings advance the perspective that cortical cholinergic system might play a role in supporting postural control after nigro-striatal dopaminergic losses in Parkinson's disease. Failure of cortex-dependent visual-vestibular integration may impair detection of postural instability in absence of reliable proprioceptive cues. Better understanding of how the cholinergic system plays a role in this process may augur novel treatments and therapeutic interventions to ameliorate debilitating symptoms in patients with advanced Parkinson's disease.
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Affiliation(s)
- Stiven Roytman
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Rebecca Paalanen
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Alexis Griggs
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Parkinson’s Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48109, USA
| | - Simon David
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Chatkaew Pongmala
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Morris K. Udall Center of Excellence for Parkinson’s Disease Research, University of Michigan, Ann Arbor, MI 48109, USA
| | - Robert A Koeppe
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Morris K. Udall Center of Excellence for Parkinson’s Disease Research, University of Michigan, Ann Arbor, MI 48109, USA
| | - Peter J H Scott
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Uros Marusic
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Institute for Kinesiology Research, Science and Research Centre Koper, 6000 Koper, Slovenia
- Department of Health Sciences, Alma Mater Europaea—ECM, 2000 Maribor, Slovenia
| | - Prabesh Kanel
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Parkinson’s Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48109, USA
- Morris K. Udall Center of Excellence for Parkinson’s Disease Research, University of Michigan, Ann Arbor, MI 48109, USA
| | - Nicolaas I Bohnen
- Department of Radiology, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI 48109, USA
- Parkinson’s Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48109, USA
- Morris K. Udall Center of Excellence for Parkinson’s Disease Research, University of Michigan, Ann Arbor, MI 48109, USA
- Neurology Service and GRECC, VA Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA
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Neilson LE, Quinn JF, Lim MM. Screening and Targeting Risk Factors for Prodromal Synucleinopathy: Taking Steps toward a Prescriptive Multi-modal Framework. Aging Dis 2023; 14:1243-1263. [PMID: 37307836 PMCID: PMC10389816 DOI: 10.14336/ad.2022.1024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 10/24/2022] [Indexed: 06/14/2023] Open
Abstract
As the prevalence of Parkinson's disease (PD) grows, so too does the population at-risk of developing PD, those in the so-called prodromal period. This period can span from those experiencing subtle motor deficits yet not meeting full diagnostic criteria or those with physiologic markers of disease alone. Several disease-modifying therapies have failed to show a neuroprotective effect. A common criticism is that neurodegeneration, even in the early motor stages, has advanced too far for neuro-restoration-based interventions to be effective. Therefore, identifying this early population is essential. Once identified, these patients could then potentially benefit from sweeping lifestyle modifications to alter their disease trajectory. Herein, we review the literature on risk factors for, and prodromal symptoms of, PD with an emphasis on ones which may be modifiable in the earliest possible stages. We propose a process for identifying this population and speculate on some strategies which may modulate disease trajectory. Ultimately, this proposal warrants prospective studies.
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Affiliation(s)
- Lee E Neilson
- Department of Neurology, Veterans Affairs Portland Healthcare System, Portland, OR 97239, USA.
- Department of Neurology, Oregon Health and Science University, Portland, OR 97239, USA
| | - Joseph F Quinn
- Department of Neurology, Veterans Affairs Portland Healthcare System, Portland, OR 97239, USA.
- Department of Neurology, Oregon Health and Science University, Portland, OR 97239, USA
| | - Miranda M Lim
- Department of Neurology, Veterans Affairs Portland Healthcare System, Portland, OR 97239, USA.
- Department of Neurology, Oregon Health and Science University, Portland, OR 97239, USA
- Department of Behavioral Neuroscience, Oregon Health and Science University, Portland, OR 97239, USA.
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, OR 97239, USA.
- Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, OR 97239, USA.
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10
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Carceles-Cordon M, Weintraub D, Chen-Plotkin AS. Cognitive heterogeneity in Parkinson's disease: A mechanistic view. Neuron 2023; 111:1531-1546. [PMID: 37028431 PMCID: PMC10198897 DOI: 10.1016/j.neuron.2023.03.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/22/2022] [Accepted: 03/13/2023] [Indexed: 04/09/2023]
Abstract
Cognitive impairment occurs in most individuals with Parkinson's disease (PD), exacting a high toll on patients, their caregivers, and the healthcare system. In this review, we begin by summarizing the current clinical landscape surrounding cognition in PD. We then discuss how cognitive impairment and dementia may develop in PD based on the spread of the pathological protein alpha-synuclein (aSyn) from neurons in brainstem regions to those in the cortical regions of the brain responsible for higher cognitive functions, as first proposed in the Braak hypothesis. We appraise the Braak hypothesis from molecular (conformations of aSyn), cell biological (cell-to-cell spread of pathological aSyn), and organ-level (region-to-region spread of aSyn pathology at the whole brain level) viewpoints. Finally, we argue that individual host factors may be the most poorly understood aspect of this pathological process, accounting for substantial heterogeneity in the pattern and pace of cognitive decline in PD.
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Affiliation(s)
- Marc Carceles-Cordon
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dan Weintraub
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alice S Chen-Plotkin
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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11
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Alabrahim OAA, Azzazy HMES. Polymeric nanoparticles for dopamine and levodopa replacement in Parkinson's disease. Nanoscale Adv 2022; 4:5233-5244. [PMID: 36540116 PMCID: PMC9724695 DOI: 10.1039/d2na00524g] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 11/03/2022] [Indexed: 06/17/2023]
Abstract
As the world's population ages, the incidence of Parkinson's disease (PD), the second most common neurological ailment, keeps increasing. It is estimated that 1% of the global population over the age of 60 has the disease. The continuous loss of dopaminergic neurons and the concomitant brain depletion of dopamine levels represent the hallmarks of PD. As a result, current PD therapies primarily target dopamine or its precursor (levodopa). Therapeutic approaches that aim to provide an exogenous source of levodopa or dopamine are hindered by their poor bioavailability and the blood-brain barrier. Nevertheless, the fabrication of many polymeric nanoparticles has been exploited to deliver several drugs inside the brain. In addition to a brief introduction of PD and its current therapeutic approaches, this review covers novel polymeric nanoparticulate drug delivery systems exploited lately for dopamine and levodopa replacement in PD.
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Affiliation(s)
- Obaydah Abd Alkader Alabrahim
- Graduate Nanotechnology Program, School of Sciences & Engineering, The American University in Cairo 11835 New Cairo Egypt
| | - Hassan Mohamed El-Said Azzazy
- Department of Chemistry, School of Sciences & Engineering, The American University in Cairo AUC Avenue, P. O. Box 74 New Cairo 11835 Egypt
- Department of Nanobiophotonics, Leibniz Institute for Photonic Technology Albert Einstein Str. 9 Jena 07745 Germany
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12
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Lisibach A, Gallucci G, Benelli V, Kälin R, Schulthess S, Beeler PE, Csajka C, Lutters M. Evaluation of the association of anticholinergic burden and delirium in older hospitalised patients - A cohort study comparing 19 anticholinergic burden scales. Br J Clin Pharmacol 2022; 88:4915-4927. [PMID: 35675080 PMCID: PMC9796852 DOI: 10.1111/bcp.15432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 01/07/2023] Open
Abstract
AIMS A recent review identified 19 anticholinergic burden scales (ABSs) but no study has yet compared the impact of all 19 ABSs on delirium. We evaluated whether a high anticholinergic burden as classified by each ABS is associated with incident delirium. METHOD We performed a retrospective cohort study in a Swiss tertiary teaching hospital using data from 2015-2018. Included were patients aged ≥65, hospitalised ≥48 hours with no stay >24 hours in intensive care. Delirium was defined twofold: (i) ICD-10 or CAM and (ii) ICD-10 or CAM or DOSS. Patients' cumulative anticholinergic burden score, calculated within 24 hours after admission, was classified using a binary (<3: low, ≥3: high burden) and a categorical approach (0: no, 0.5-3: low, ≥3: high burden). Association was analysed using multivariable logistic regression. RESULTS Over 25 000 patients (mean age 77.9 ± 7.6 years) were included. Of these, (i) 864 (3.3%) and (ii) 2770 (11.0%) developed delirium. Depending on the evaluated ABS, 4-63% of the patients were exposed to at least one anticholinergic drug. Out of 19 ABSs, (i) 14 and (ii) 16 showed a significant association with the outcomes. A patient with a high anticholinergic burden score had odds ratios (ORs) of 1.21 (95% confidence interval [CI]: 1.03-1.42) to 2.63 (95% CI: 2.28-3.03) for incident delirium compared to those with low or no burden. CONCLUSION A high anticholinergic burden within 24 hours after admission was significantly associated with incident delirium. Although prospective studies need to confirm these results, discontinuing or substituting drugs with a score of ≥3 at admission might be a targeted intervention to reduce incident delirium.
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Affiliation(s)
- Angela Lisibach
- Clinical Pharmacy, Department Medical ServicesCantonal Hospital of BadenBadenSwitzerland,Center for Research and Innovation in Clinical Pharmaceutical SciencesUniversity Hospital and University of LausanneLausanneSwitzerland,School of Pharmaceutical SciencesUniversity of GenevaGenevaSwitzerland,Institute of Pharmaceutical Sciences of Western Switzerland, University of GenevaUniversity of LausanneSwitzerland
| | - Giulia Gallucci
- Clinical Pharmacy, Department Medical ServicesCantonal Hospital of BadenBadenSwitzerland
| | - Valérie Benelli
- Clinical Pharmacy, Department Medical ServicesCantonal Hospital of BadenBadenSwitzerland
| | - Ramona Kälin
- Clinical Pharmacy, Department Medical ServicesCantonal Hospital of BadenBadenSwitzerland
| | - Sven Schulthess
- Clinical Pharmacy, Department Medical ServicesCantonal Hospital of BadenBadenSwitzerland
| | - Patrick E. Beeler
- Division of Occupational and Environmental Medicine, Epidemiology, Biostatistics and Prevention InstituteUniversity of Zurich & University Hospital ZurichZurichSwitzerland
| | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical SciencesUniversity Hospital and University of LausanneLausanneSwitzerland,School of Pharmaceutical SciencesUniversity of GenevaGenevaSwitzerland,Institute of Pharmaceutical Sciences of Western Switzerland, University of GenevaUniversity of LausanneSwitzerland
| | - Monika Lutters
- Clinical Pharmacy, Department Medical ServicesCantonal Hospital of BadenBadenSwitzerland,Swiss Federal Institute of TechnologyZurichSwitzerland
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13
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Abstract
Neuropsychiatric symptoms (NPSs) such as affective disorders, psychosis, behavioral changes, and cognitive impairment are common in Parkinson's disease (PD). However, NPSs remain under-recognized and under-treated, often leading to adverse outcomes. Their epidemiology, presentation, risk factors, neural substrate, and management strategies are incompletely understood. While psychological and psychosocial factors may contribute, hallmark PD neuropathophysiological changes, plus the associations between exposure to dopaminergic medications and occurrence of some symptoms, suggest a neurobiological basis for many NPSs. A range of psychotropic medications, psychotherapeutic techniques, stimulation therapies, and other non-pharmacological treatments have been studied, are used clinically, and are beneficial for managing NPSs in PD. Appropriate management of NPSs is critical for comprehensive PD care, from recognizing their presentations and timing throughout the disease course, to the incorporation of different therapeutic strategies (ie, pharmacological and non-pharmacological) that utilize a multidisciplinary approach.
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Affiliation(s)
- Daniel Weintraub
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
- Parkinson's Disease Research, Education and Clinical Center (PADRECC), Philadelphia Veterans Affairs Medical Center, Philadelphia, PA
| | - Dag Aarsland
- Department of Old Age Psychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England
- Centre for Age-Related Diseases, Stavanger University Hospital, Stavanger, Norway
| | - Roberta Biundo
- Department of General Psychology, University of Padua, Padua, Italy
- Study Center for Neurodegeneration (CESNE), Department of Neuroscience, University of Padua, Padua, Italy
| | - Roseanne Dobkin
- Department of Psychiatry, Rutgers-The State University of New Jersey, Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Jennifer Goldman
- Shirley Ryan AbilityLab, Parkinson's Disease and Movement Disorders, Chicago, IL
- Departments of Physical Medicine and Rehabilitation and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Simon Lewis
- ForeFront Parkinson's Disease Research Clinic, Brain and Mind Centre, School of Medical Sciences, University of Sydney, Sydney, New South Wales, Australia
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14
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Denfeld QE, Turrise S, MacLaughlin EJ, Chang PS, Clair WK, Lewis EF, Forman DE, Goodlin SJ. Preventing and Managing Falls in Adults With Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2022; 15:e000108. [PMID: 35587567 DOI: 10.1161/hcq.0000000000000108] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Falls and fear of falling are a major health issue and associated with high injury rates, high medical care costs, and significant negative impact on quality of life. Adults with cardiovascular disease are at high risk of falling. However, the prevalence and specific risks for falls among adults with cardiovascular disease are not well understood, and falls are likely underestimated in clinical practice. Data from surveys of patient-reported and medical record-based analyses identify falls or risks for falling in 40% to 60% of adults with cardiovascular disease. Increased fall risk is associated with medications, structural heart disease, orthostatic hypotension, and arrhythmias, as well as with abnormal gait and balance, physical frailty, sensory impairment, and environmental hazards. These risks are particularly important among the growing population of older adults with cardiovascular disease. All clinicians who care for patients with cardiovascular disease have the opportunity to recognize falls and to mitigate risks for falling. This scientific statement provides consensus on the interdisciplinary evaluation, prevention, and management of falls among adults with cardiac disease and the management of cardiovascular care when patients are at risk of falling. We outline research that is needed to clarify prevalence and factors associated with falls and to identify interventions that will prevent falls among adults with cardiovascular disease.
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15
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Nawaz H, Sargent L, Quilon H, Cloud LJ, Testa CM, Snider JD, Lageman SK, Baron MS, Berman BD, Zimmerman K, Price ET, Mukhopadhyay ND, Barrett MJ. Anticholinergic Medication Burden in Parkinson's Disease Outpatients. J Parkinsons Dis 2022; 12:599-606. [PMID: 34806617 DOI: 10.3233/jpd-212769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Individuals with Parkinson's disease (PD) may be especially vulnerable to future cognitive decline from anticholinergic medications. OBJECTIVE To characterize anticholinergic medication burden, determine the co-occurrence of anticholinergic and cholinesterase inhibitors, and to assess the correlations among anticholinergic burden scales in PD outpatients. METHODS We studied 670 PD outpatients enrolled in a clinic registry between 2012 and 2020. Anticholinergic burden was measured with the Anticholinergic Cognitive Burden Scale (ACB), Anticholinergic Drug Scale (ADS), Anticholinergic Risk Scale (ARS), and Drug Burden Index-Anticholinergic component (DBI-Ach). Correlations between scales were assessed with weighted kappa coefficients. RESULTS Between 31.5 to 46.3% of PD patients were taking medications with anticholinergic properties. Among the scales applied, the ACB produced the highest prevalence of medications with anticholinergic properties (46.3%). Considering only medications with definite anticholinergic activity (scores of 2 or 3 on ACB, ADS, or ARS), the most common anticholinergic drug classes were antiparkinsonian (8.2%), antipsychotic (6.4%), and urological (3.3%) medications. Cholinesterase inhibitors and medications with anticholinergic properties were co-prescribed to 5.4% of the total cohort. The most highly correlated scales were ACB and ADS (κ= 0.71), ACB and ARS (κ= 0.67), and ADS and ARS (κ= 0.55). CONCLUSION A high proportion of PD patients (20%) were either taking antiparkinsonian, urological, or antipsychotic anticholinergic medications or were co-prescribed anticholinergic medications and cholinesterase inhibitors. By virtue of its detection of a high prevalence of anticholinergic medication usage and its high correlation with other scales, our data support use of the ACB scale to assess anticholinergic burden in PD patients.
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Affiliation(s)
- Huma Nawaz
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Lana Sargent
- School of Nursing, Virginia Commonwealth University, Richmond, VA, USA.,Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA.,Geriatric Pharmacotherapy Program, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA.,Institute for Inclusion, Inquiry & Innovation (iCubed): Health & Wellness in Aging Populations Core, Richmond, VA, USA
| | | | - Leslie J Cloud
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Claudia M Testa
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Jon D Snider
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Sarah K Lageman
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA.,Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
| | - Mark S Baron
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA.,Southeast Veterans Affairs Parkinson's Disease Research, Education and Clinical Center (PADRECC), Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Brian D Berman
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Kristin Zimmerman
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA
| | - Elvin T Price
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA.,Geriatric Pharmacotherapy Program, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA.,Institute for Inclusion, Inquiry & Innovation (iCubed): Health & Wellness in Aging Populations Core, Richmond, VA, USA
| | - Nitai D Mukhopadhyay
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Matthew J Barrett
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
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16
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Smith MD, Tenison E, Hashim H, Ben-Shlomo Y, Henderson EJ. Neuromodulation for Storage Lower Urinary Tract Symptoms in Parkinson Disease: A Systematic Review. Neuromodulation 2022; 25:1076-1085. [PMID: 35300922 DOI: 10.1016/j.neurom.2022.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/23/2021] [Accepted: 01/08/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Bladder symptoms are common in Parkinson disease (PD), affecting quality of life. Medications commonly used such as antimuscarinics can cause frequently intolerable side effects, and therefore, new, better tolerated approaches are needed. Neuromodulation techniques have an established role in urologic disorders; these techniques include tibial nerve stimulation (TNS) and sacral neuromodulation (SNM), which are localized therapies lacking the side effects associated with medication. OBJECTIVES This study aimed to undertake a systematic review of the literature reporting the use of neuromodulation techniques for the treatment of bladder symptoms in PD and related conditions. MATERIALS AND METHODS A systematic search of data bases was conducted including MEDLINE, CENTRAL, and Web of Science. Studies were required to present specific outcomes for individuals with PD for neuromodulation interventions. RESULTS Ten primary studies were identified concerning detailed outcomes of neuromodulation on bladder symptoms in PD, including seven for TNS, one for SNM, and one using transcranial magnetic stimulation (TMS). Two further mixed cohort studies documented minimal data on individuals with PD. All studies demonstrated benefit in a range of outcome measures following neuromodulation. Two randomized sham-controlled studies were carried out using TNS, with one clearly demonstrating superiority over sham, although difficulties with achieving believable yet ineffective sham treatment are highlighted. Further studies reported limited, uncontrolled outcomes of SNM in patients with PD, demonstrating benefit. CONCLUSIONS Evidence from case series suggests benefit from TNS in PD, with limited literature on SNM or TMS. Placebo effect from neuromodulation is a concern, and only limited controlled data exist. Future well-designed and sham-controlled studies need to be completed to provide definitive data on the benefit of neuromodulation in PD. Definitively proving the utility of a neuromodulation modality will allow better treatment of bladder symptoms without the need for pharmacologic measures that cause side effects.
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17
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18
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Sumbul-Sekerci B, Bilgic B, Pasin O, Emre M, Hanagasi HA. Anticholinergic Burden, Polypharmacy, and Cognition in Parkinson's Disease Patients with Mild Cognitive Impairment: A Cross-Sectional Observational Study. Dement Geriatr Cogn Disord 2022; 51:386-395. [PMID: 36273437 PMCID: PMC9909708 DOI: 10.1159/000526863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/30/2022] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Anticholinergic burden may be an important risk factor for the cognitive impairment. Especially in polypharmacy, even drugs with low anticholinergic effects may contribute to a significant anticholinergic burden. The drugs with anticholinergic effects are used in treatment of motor and nonmotor symptoms of Parkinson's disease (PD). Therefore, it is important to screen for polypharmacy and anticholinergic burden in PD patients with mild cognitive impairment (MCI). METHODS This cross-sectional study was conducted with 58 patients with PD. PD-MCI was diagnosed according to MDS Level 2 Comprehensive Assessment. Cognitive performance (attention - working memory, executive functions, language, memory, and visuospatial functions) of patients was evaluated. The anticholinergic burden was scored by Anticholinergic Cognitive Burden (ACB) Scale, Anticholinergic Risk Scale (ARS), and Anticholinergic Drug Scale (ADS). RESULTS There was no significant difference in anticholinergic burden between PD-MCI and PD-normal cognition. A significant concordance was observed between ACB, ARS, and ADS scores (p < 0.001; Kendall's W = 0.653). While the variable predicting anticholinergic burden was the total number of drugs for ACB and ADS scales, it was the number of antiparkinson drugs for ARS scale. CONCLUSION Patients with PD are at high risk for polypharmacy and anticholinergic burden. Anticholinergic burden should be considered in the selection of drugs, especially for comorbidities in patients with PD. No significant correlation was found between the cognition and anticholinergic burden in patients with PD-MCI. Although the risk scores of antiparkinson and other drugs were different among the 3 scales, significant concordance was observed between scales.
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Affiliation(s)
- Betul Sumbul-Sekerci
- Department of Clinical Pharmacy, Faculty of Pharmacy, Bezmialem Vakıf University, Istanbul, Turkey
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
- *Betul Sumbul-Sekerci,
| | - Basar Bilgic
- Behavioral Neurology and Movement Disorders Unit, Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozge Pasin
- Department of Biostatistics, Faculty of Medicine, Bezmialem Vakıf University, Istanbul, Turkey
| | - Murat Emre
- Behavioral Neurology and Movement Disorders Unit, Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Hasmet A. Hanagasi
- Behavioral Neurology and Movement Disorders Unit, Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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19
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Barrett MJ, Sargent L, Nawaz H, Weintraub D, Price ET, Willis AW. Antimuscarinic Anticholinergic Medications in Parkinson Disease: To Prescribe or Deprescribe? Mov Disord Clin Pract 2021; 8:1181-1188. [PMID: 34765683 DOI: 10.1002/mdc3.13347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/10/2021] [Accepted: 08/17/2021] [Indexed: 12/13/2022] Open
Abstract
The relative importance of antimuscarinic anticholinergic medications for Parkinson's disease (PD) declined after the introduction of levodopa, such that anticholinergic medications are now much more likely to be prescribed for clinical indications other than parkinsonism. Recent studies have found an association between anticholinergic medication exposure and future risk of dementia in older individuals and those with PD. These findings provide a further reason to avoid the use of anticholinergic medications to treat motor symptoms of PD. More importantly, they raise the question of whether one of the goals of PD treatment should be to deprescribe all medications with anticholinergic properties, regardless of their indication, to reduce dementia risk. In this review, we discuss the use of anticholinergic medications in PD, the evidence supporting the association between anticholinergic medications and future dementia risk, and the potential implications of these findings for clinical care in PD.
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Affiliation(s)
- Matthew J Barrett
- Department of Neurology Virginia Commonwealth University Richmond Virginia USA
| | - Lana Sargent
- School of Nursing Virginia Commonwealth University Richmond Virginia USA.,Department of Pharmacotherapy and Outcomes Science, School of Pharmacy Virginia Commonwealth University Richmond Virginia USA.,Geriatric Pharmacotherapy Program, School of Pharmacy Virginia Commonwealth University Richmond Virginia USA.,Institute for Inclusion Inquiry and Innovation (iCubed): Health and Wellness in Aging Populations Core Richmond Virginia USA
| | - Huma Nawaz
- Department of Neurology Virginia Commonwealth University Richmond Virginia USA
| | - Daniel Weintraub
- Department of Neurology University of Pennsylvania School of Medicine Philadelphia Pennsylvania USA.,Parkinson's Disease Research, Education and Clinical Center Corporal Michael J. Crescenz VA Medical Center Philadelphia Pennsylvania USA.,Department of Psychiatry University of Pennsylvania School of Medicine Philadelphia Pennsylvania USA
| | - Elvin T Price
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy Virginia Commonwealth University Richmond Virginia USA.,Geriatric Pharmacotherapy Program, School of Pharmacy Virginia Commonwealth University Richmond Virginia USA.,Institute for Inclusion Inquiry and Innovation (iCubed): Health and Wellness in Aging Populations Core Richmond Virginia USA
| | - Allison W Willis
- Department of Neurology University of Pennsylvania School of Medicine Philadelphia Pennsylvania USA.,Center for Pharmacoepidemiology Research and Training, Department of Epidemiology University of Pennsylvania School of Medicine Philadelphia Pennsylvania USA.,Department of Biostatistics, Epidemiology and Informatics University of Pennsylvania School of Medicine Philadelphia Pennsylvania USA
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20
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Bohnen NI, Kanel P, Koeppe RA, Sanchez-Catasus CA, Frey KA, Scott P, Constantine GM, Albin RL, Müller MLTM. Regional cerebral cholinergic nerve terminal integrity and cardinal motor features in Parkinson's disease. Brain Commun 2021; 3:fcab109. [PMID: 34704022 PMCID: PMC8196256 DOI: 10.1093/braincomms/fcab109] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 01/21/2023] Open
Abstract
Clinical effects of anti-cholinergic drugs implicate cholinergic systems alterations in the pathophysiology of some cardinal motor impairments in Parkinson’s disease. The topography of affected cholinergic systems deficits and motor domain specificity are poorly understood. Parkinson's disease patients (n = 108) underwent clinical and motor assessment and vesicular acetylcholine transporter [18F]-fluoroethoxybenzovesamicol PET imaging. Volumes-of-interest-based analyses included detailed thalamic and cerebellar parcellations. Successful PET sampling for most of the small-sized parcellations was available in 88 patients. A data-driven approach, stepwise regression using the forward selection method, was used to identify cholinergic brain regions associating with cardinal domain-specific motor ratings. Regressions with motor domain scores for model-selected regions followed by confounder analysis for effects of age of onset, duration of motor disease and levodopa equivalent dose were performed. Among 7 model-derived regions associating with postural instability and gait difficulties domain scores three retained significance in confounder variable analysis: medial geniculate nucleus (standardized β = −0.34, t = −3.78, P = 0.0003), lateral geniculate nucleus (β = −0.32, t = −3.4, P = 0.001) and entorhinal cortex (β = −0.23, t = −2.6, P = 0.011). A sub-analysis of non-episodic postural instability and gait difficulties scores demonstrated significant effects of the medial geniculate nucleus, entorhinal cortex and globus pallidus pars interna. Among 6 tremor domain model-selected regions two regions retained significance in confounder variable analysis: cerebellar vermis section of lobule VIIIb (β = −0.22, t = −2.4, P = 0.021) and the putamen (β = −0.23, t = −2.3, P = 0.024). None of the three model-selected variables for the rigidity domain survived confounder analysis. Two out of the four model-selected regions for the distal limb bradykinesia domain survived confounder analysis: globus pallidus pars externa (β = 0.36, t = 3.9, P = 0.0097) and the paracentral lobule (β = 0.26, t = 2.5, P = 0.013). Emphasizing the utility of a systems-network conception of the pathophysiology of Parkinson's disease cardinal motor features, our results are consistent with specific deficits in basal forebrain corticopetal, peduncupontine-laterodorsal tegmental complex, and medial vestibular nucleus cholinergic pathways, against the background of nigrostriatal dopaminergic deficits, contributing significantly to postural instability, gait difficulties, tremor and distal limb bradykinesia cardinal motor features of Parkinson’s disease. Our results suggest significant and distinct consequences of degeneration of cholinergic peduncupontine-laterodorsal tegmental complex afferents to both segments of the globus pallidus. Non-specific regional cholinergic nerve terminal associations with rigidity scores likely reflect more complex multifactorial signalling mechanisms with smaller contributions from cholinergic pathways.
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Affiliation(s)
- Nicolaas I Bohnen
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA.,Department of Neurology, University of Michigan, Ann Arbor, MI 48105, USA.,Neurology Service and GRECC, Veterans Administration Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA.,Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI 48105, USA.,Parkinson's Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48105, USA
| | - Prabesh Kanel
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA.,Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI 48105, USA
| | - Robert A Koeppe
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA.,Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI 48105, USA
| | - Carlos A Sanchez-Catasus
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA.,Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI 48105, USA
| | - Kirk A Frey
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA.,Department of Neurology, University of Michigan, Ann Arbor, MI 48105, USA
| | - Peter Scott
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA
| | - Gregory M Constantine
- Department of Mathematics, University of Pittsburgh, Pittsburgh, PA 15260, USA.,Department of Statistics, University of Pittsburgh, Pittsburgh, PA 15260, USA.,The McGowen Institute for Regenerative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15260, USA
| | - Roger L Albin
- Department of Neurology, University of Michigan, Ann Arbor, MI 48105, USA.,Neurology Service and GRECC, Veterans Administration Ann Arbor Healthcare System, Ann Arbor, MI 48105, USA.,Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI 48105, USA.,Parkinson's Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48105, USA
| | - Martijn L T M Müller
- Department of Radiology, University of Michigan, Ann Arbor, MI 48105, USA.,Morris K. Udall Center of Excellence for Parkinson's Disease Research, University of Michigan, Ann Arbor, MI 48105, USA.,Parkinson's Foundation Research Center of Excellence, University of Michigan, Ann Arbor, MI 48105, USA.,Critical Path Institute, Tucson, AZ 85718, USA
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21
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Iarkov A, Mendoza C, Echeverria V. Cholinergic Receptor Modulation as a Target for Preventing Dementia in Parkinson's Disease. Front Neurosci 2021; 15:665820. [PMID: 34616271 PMCID: PMC8488354 DOI: 10.3389/fnins.2021.665820] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 08/26/2021] [Indexed: 12/20/2022] Open
Abstract
Parkinson’s disease (PD) is a neurodegenerative condition characterized by the loss of dopaminergic neurons in the substantia nigra pars compacta (SNpc) in the midbrain resulting in progressive impairment in cognitive and motor abilities. The physiological and molecular mechanisms triggering dopaminergic neuronal loss are not entirely defined. PD occurrence is associated with various genetic and environmental factors causing inflammation and mitochondrial dysfunction in the brain, leading to oxidative stress, proteinopathy, and reduced viability of dopaminergic neurons. Oxidative stress affects the conformation and function of ions, proteins, and lipids, provoking mitochondrial DNA (mtDNA) mutation and dysfunction. The disruption of protein homeostasis induces the aggregation of alpha-synuclein (α-SYN) and parkin and a deficit in proteasome degradation. Also, oxidative stress affects dopamine release by activating ATP-sensitive potassium channels. The cholinergic system is essential in modulating the striatal cells regulating cognitive and motor functions. Several muscarinic acetylcholine receptors (mAChR) and nicotinic acetylcholine receptors (nAChRs) are expressed in the striatum. The nAChRs signaling reduces neuroinflammation and facilitates neuronal survival, neurotransmitter release, and synaptic plasticity. Since there is a deficit in the nAChRs in PD, inhibiting nAChRs loss in the striatum may help prevent dopaminergic neurons loss in the striatum and its pathological consequences. The nAChRs can also stimulate other brain cells supporting cognitive and motor functions. This review discusses the cholinergic system as a therapeutic target of cotinine to prevent cognitive symptoms and transition to dementia in PD.
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Affiliation(s)
- Alexandre Iarkov
- Laboratorio de Neurobiología, Facultad de Ciencias de la Salud, Universidad San Sebastián, Concepción, Chile
| | - Cristhian Mendoza
- Laboratorio de Neurobiología, Facultad de Ciencias de la Salud, Universidad San Sebastián, Concepción, Chile
| | - Valentina Echeverria
- Laboratorio de Neurobiología, Facultad de Ciencias de la Salud, Universidad San Sebastián, Concepción, Chile.,Research & Development Service, Bay Pines VA Healthcare System, Bay Pines, FL, United States
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22
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Valladales-Restrepo LF, Peña-Verjan NM, Vargas-Díaz K, Machado-Alba JE. Potentially inappropriate prescriptions of antipsychotic and anticholinergic drugs in patients with Parkinson's disease. Neurodegener Dis Manag 2021; 11:361-371. [PMID: 34525848 DOI: 10.2217/nmt-2021-0021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Aim: The objective was to determine the prevalence of the potentially inappropriate antipsychotics and anticholinergics used in patients with Parkinson's disease. Materials & methods: A cross-sectional study identified the prescription of antipsychotics, anticholinergics and drugs for the treatment of Parkinson's disease. The anticholinergic burden was evaluated, and quetiapine and clozapine were considered to be adequate antipsychotics. Results: 2965 patients with Parkinson's disease were identified. The presence of psychiatric disorders and other neurological pathologies was associated with a greater probability of receiving potentially inappropriate antipsychotic prescriptions. The presence of greater number of comorbidities was associated with a greater probability of receiving anticholinergics. Conclusion: Older age and associated comorbidities, especially psychiatric and neurological comorbidities, increase the likelihood of patients with Parkinson's disease being prescribed antipsychotics and anticholinergics.
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Affiliation(s)
- Luis Fernando Valladales-Restrepo
- Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia.,Semillero de investigación en Farmacología Geriátrica, Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, 660003, Risaralda, Colombia.,Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Risaralda, Colombia
| | - Nathalia Marcela Peña-Verjan
- Semillero de investigación en Farmacología Geriátrica, Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, 660003, Risaralda, Colombia
| | - Katherine Vargas-Díaz
- Semillero de investigación en Farmacología Geriátrica, Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, 660003, Risaralda, Colombia
| | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Risaralda, Colombia
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23
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Ogawa Y, Hirai T, Mihara K. A meta-analysis of observational studies on anticholinergic burden and fracture risk: evaluation of conventional burden scales. J Pharm Health Care Sci 2021; 7:30. [PMID: 34465380 DOI: 10.1186/s40780-021-00213-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/10/2021] [Indexed: 11/29/2022] Open
Abstract
Background Anticholinergic burden potentially increases the risk of fracture. Although there are various anticholinergic burden scales, little is known about the inter-scale compatibility regarding the relationship of anticholinergic burden with fracture risk. We performed meta-analysis to examine the association of fracture risk with anticholinergic burden measured using various scales. Methods Primary literature was retrieved from PubMed (1966 to March, 2021), the Cochrane Library (1974 to March, 2021), Scopus (1970 to March, 2021), and Ichushi-web (1983 to March, 2021). Cohort and case-control studies that evaluated the association between any fracture and anticholinergic drugs were included. Additionally, we included studies in which patients were administered anticholinergic drugs included on the anticholinergic risk scale (ARS), anticholinergic cognitive burden (ACB), anticholinergic drug scale, or drug burden index-anticholinergic component. Random effects models were used to calculate pooled relative risk (RR) and 95% confidence interval (CI) due to heterogeneity among the studies. Publication bias was examined by funnel plots and the Begg’s test. Results A total of 49 datasets from 10 studies were included in the meta-analysis. Six of the 10 studies included only patients aged over 65 years, who accounted for 93% of the total study population (453,186/487,247). Meta-analysis indicated a positive relationship between use of anticholinergic drugs and fracture risk, regardless of the anticholinergic burden scale used. However, the relationship between anticholinergic burden and fracture risk varied depending on the scale used. Fracture risk increased linearly with increasing anticholinergic burden measured using ARS. ARS 1 point was associated with 28% increase in fracture risk, ARS 1–2 point(s) with 39%, ARS 2 points with 54%, ARS 3 points with 66%, and ARS ≥ 4 points with 77%. On the other hand, ACB 1 point and ACB 2 points were associated with similar fracture risk (pooled RR [95% CI]: overall; 1.28 [1.18–1.39], 1 point; 1.12 [1.06–1.18], 2 points; 1.15 [1.08–1.23]). Conclusions This result suggests that the relationship between anticholinergic drug burden and fracture risk may differ depending on the anticholinergic burden scale used. Supplementary Information The online version contains supplementary material available at 10.1186/s40780-021-00213-y.
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24
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Ward LM, Stanley B, Greenlaw N, Cooper SA, Pacitti C, Henderson A, Gibson J, Kinnear D. Risk of anticholinergic burden in adults with intellectual disabilities: a Scottish retrospective cohort study of n = 17 220. J Intellect Disabil Res 2021; 65:813-830. [PMID: 34169610 DOI: 10.1111/jir.12861] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/25/2021] [Accepted: 05/26/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Several drugs have anticholinergic side effects that are associated with adverse health outcomes. Anticholinergic burden studies in adults with intellectual disabilities (ID) have focused exclusively on older adults. This study investigates anticholinergic burden and its associations in adults with ID of all ages (17-94 years). METHODS Adults with ID (n = 4 305), each with three general population age-sex-neighbourhood-matched controls (n = 12 915), were linked to their prescribed medications with anticholinergic effects between 2009 and 2017. Analyses were undertaken using logistic regression models. RESULTS Adults with ID were more likely to be prescribed any anticholinergic medicines, odds ratio (OR) = 1.49 (1.38-1.59), especially 'very strong' risk medicines, OR = 2.59 (2.39-2.81); 48.5% had very high total anticholinergic burden (3+) compared with 35.4% of the general population, OR = 1.77 (1.64-1.90). This group difference was greater for males, OR = 2.02 (1.84-2.22), than females, OR = 1.48 (1.33-1.65). Adults with ID had significantly higher odds of having very high total anticholinergic burden up to 75 years old, with the greatest group effect occurring in younger ages, 17-24-year-olds, OR = 3.05 (2.39-3.89), and the extent of the difference decreased as age increased. The main effect of neighbourhood deprivation showed greater group differences with increasing affluence of neighbourhood. Results examining only the ID group showed that very high total anticholinergic burden was greatest for females, OR = 1.21 (1.07-1.37), and those over age 55, and extent of neighbourhood deprivation was not significant. CONCLUSIONS Adults with ID are at higher risk of anticholinergic burden than the general population, especially young adults. Overall anticholinergic burden increased with age, but burden was high across all ages in the ID group. Very high total anticholinergic burden is prevalent across all types of neighbourhoods for the adults with ID, in contrast to the steeper gradient seen in the general population. Adults with ID have increased likelihood of unintended adverse effects, regardless of potential confounds, so clinicians undertaking medication reviews need to consider anticholinergic side effects and cumulative burden across concomitant medications, including in young adults with ID, not just older adults, and particularly women.
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Affiliation(s)
- L M Ward
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - B Stanley
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - N Greenlaw
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - S-A Cooper
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - C Pacitti
- NHS Greater Glasgow & Clyde, Leverndale Hospital, Glasgow, UK
| | - A Henderson
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - J Gibson
- School of Medicine, Dentistry and Nursing, Glasgow Dental Hospital and School, Glasgow, UK
| | - D Kinnear
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
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25
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Abstract
ABSTRACT BACKGROUND: Persons with Parkinson disease (PD) have complex care needs that may benefit from enhanced nursing care provided in Magnet-designated hospitals. Our primary objective was to determine whether an association exists between hospital Magnet status and patient safety events for PD inpatients in the United States. METHODS: We conducted a retrospective cohort study using the Nationwide Inpatient Sample and Agency for Healthcare Research and Quality databases from 2000 to 2010. Parkinson disease diagnosis and demographic variables were retrieved, along with Magnet designation and other hospital characteristics. Inpatient mortality and preventable adverse events in hospitals with and without Magnet status were then compared using relevant Agency for Healthcare Research and Quality patient safety indicators. RESULTS: Between 2000 and 2010, 493 760 hospitalizations among PD patients were identified. Of those, 40 121 (8.1%) occurred at one of 389 Magnet hospitals. When comparing PD patients in Magnet versus non-Magnet hospitals, demographic characteristics were similar. Multivariate regression models adjusting for patient and hospital characteristics identified a 21% reduction in mortality among PD inpatients in Magnet hospitals (adjusted odds ratio [AOR], 0.79; 95% confidence interval [CI], 0.74-0.85). PD inpatients in Magnet hospitals also had a lower odds of experiencing any patient safety indicator (AOR, 0.74; 95% CI, 0.68-0.79), pressure ulcers (AOR, 0.60; 95% CI, 0.55-0.67), death from a low mortality condition (AOR, 0.74; 95% CI, 0.68-0.79), and a higher odds of postoperative bleeding (AOR, 1.45; 95% CI, 1.04-2.04). CONCLUSIONS: PD patients had a reduced risk of inpatient mortality and several nursing-sensitive patient safety events, highlighting the possible benefits of Magnet status on inpatient safety in PD.
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26
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Stewart C, Taylor-Rowan M, Soiza RL, Quinn TJ, Loke YK, Myint PK. Anticholinergic burden measures and older people's falls risk: a systematic prognostic review. Ther Adv Drug Saf 2021; 12:20420986211016645. [PMID: 34104401 PMCID: PMC8170331 DOI: 10.1177/20420986211016645] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/18/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction Several adverse outcomes have been associated with anticholinergic burden (ACB), and these risks increase with age. Several approaches to measuring this burden are available but, to date, no comparison of their prognostic abilities has been conducted. This PROSPERO-registered systematic review (CRD42019115918) compared the evidence behind ACB measures in relation to their ability to predict risk of falling in older people. Methods Medline (OVID), EMBASE (OVID), CINAHL (EMBSCO) and PsycINFO (OVID) were searched using comprehensive search terms and a validated search filter for prognostic studies. Inclusion criteria included: participants aged 65 years and older, use of one or more ACB measure(s) as a prognostic factor, cohort or case-control in design, and reporting falls as an outcome. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. Results Eight studies reporting temporal associations between ACB and falls were included. All studies were rated high risk of bias in ⩾1 QUIPS tool categories, with five rated high risk ⩾3 categories. All studies (274,647 participants) showed some degree of association between anticholinergic score and increased risk of falls. Findings were most significant with moderate to high levels of ACB. Most studies (6/8) utilised the anticholinergic cognitive burden scale. No studies directly compared two or more ACB measures and there was variation in how falls were measured for analysis. Conclusion The evidence supports an association between moderate to high ACB and risk of falling in older people, but no conclusion can be made regarding which ACB scale offers best prognostic value in older people. Plain language summary A review of published studies to explore which anticholinergic burden scale is best at predicting the risk of falls in older people Introduction: One third of older people will experience a fall. Falls have many consequences including fractures, a loss of independence and being unable to enjoy life. Many things can increase the chances of having a fall. This includes some medications. One type of medication, known as anticholinergic medication, may increase the risk of falls. These medications are used to treat common health issues including depression and bladder problems. Anticholinergic burden is the term used to describe the total effects from taking these medications. Some people may use more than one of these medications. This would increase their anticholinergic burden. It is possible that reducing the use of these medications could reduce the risk of falls. We need to carry out studies to see if this is possible. To do this, we need to be able to measure anticholinergic burden. There are several scales available, but we do not know which is best.Methods: We wanted to answer: 'Which anticholinergic scale is best at predicting the risk of falling in older people?'. We reviewed studies that could answer this. We did this in a systematic way to capture all published studies. We restricted the search in several ways. We only included studies relevant to our question.Results: We found eight studies. We learned that people who are moderate to high users of these medications (often people who will use more than one of these medications) had a higher risk of falling. It was less clear if people who have a lower burden (often people who only use one of these medications) had an increased risk of falling. The low number of studies prevented us from determining if one scale was better than another.Conclusion: These findings suggest that we should reduce use of these medications. This could reduce the number falls and improve the well-being of older people.
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Affiliation(s)
- Carrie Stewart
- Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, Rm 1.128, Polwarth Building, Foresterhill Health Campus, Aberdeen, AB25 2ZD, UK
| | - Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Roy L Soiza
- Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Phyo Kyaw Myint
- Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, UK
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27
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Paz RM, Murer MG. Mechanisms of Antiparkinsonian Anticholinergic Therapy Revisited. Neuroscience 2021; 467:201-17. [PMID: 34048797 DOI: 10.1016/j.neuroscience.2021.05.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 01/15/2023]
Abstract
Before the advent of L-DOPA, the gold standard symptomatic therapy for Parkinson's disease (PD), anticholinergic drugs (muscarinic receptor antagonists) were the preferred antiparkinsonian therapy, but their unwanted side effects associated with impaired extrastriatal cholinergic function limited their clinical utility. Since most patients treated with L-DOPA also develop unwanted side effects such as L-DOPA-induced dyskinesia (LID), better therapies are needed. Recent studies in animal models demonstrate that optogenetic and chemogenetic manipulation of striatal cholinergic interneurons (SCIN), the main source of striatal acetylcholine, modulate parkinsonism and LID, suggesting that restoring SCIN function might serve as a therapeutic option that avoids extrastriatal anticholinergics' side effects. However, it is still unclear how the altered SCIN activity in PD and LID affects the striatal circuit, whereas the mechanisms of action of anticholinergic drugs are still not fully understood. Recent animal model studies showing that SCINs undergo profound changes in their tonic discharge pattern after chronic L-DOPA administration call for a reexamination of classical views of how SCINs contribute to PD symptoms and LID. Here, we review the recent advances on the circuit implications of aberrant striatal cholinergic signaling in PD and LID in an effort to provide a comprehensive framework to understand the effects of anticholinergic drugs and with the aim of shedding light into future perspectives of cholinergic circuit-based therapies.
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28
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Williams G, Maroufy V, Rasmy L, Brown D, Yu D, Zhu H, Talebi Y, Wang X, Thomas E, Zhu G, Yaseen A, Miao H, Leon Novelo L, Zhi D, DeSantis SM, Zhu H, Yamal JM, Aguilar D, Wu H. Vasopressor treatment and mortality following nontraumatic subarachnoid hemorrhage: a nationwide electronic health record analysis. Neurosurg Focus 2021; 48:E4. [PMID: 32357322 DOI: 10.3171/2020.2.focus191002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 02/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Subarachnoid hemorrhage (SAH) is a devastating cerebrovascular condition, not only due to the effect of initial hemorrhage, but also due to the complication of delayed cerebral ischemia (DCI). While hypertension facilitated by vasopressors is often initiated to prevent DCI, which vasopressor is most effective in improving outcomes is not known. The objective of this study was to determine associations between initial vasopressor choice and mortality in patients with nontraumatic SAH. METHODS The authors conducted a retrospective cohort study using a large, national electronic medical record data set from 2000-2014 to identify patients with a new diagnosis of nontraumatic SAH (based on ICD-9 codes) who were treated with the vasopressors dopamine, phenylephrine, or norepinephrine. The relationship between the initial choice of vasopressor therapy and the primary outcome, which was defined as in-hospital death or discharge to hospice care, was examined. RESULTS In total, 2634 patients were identified with nontraumatic SAH who were treated with a vasopressor. In this cohort, the average age was 56.5 years, 63.9% were female, and 36.5% of patients developed the primary outcome. The incidence of the primary outcome was higher in those initially treated with either norepinephrine (47.6%) or dopamine (50.6%) than with phenylephrine (24.5%). After adjusting for possible confounders using propensity score methods, the adjusted OR of the primary outcome was higher with dopamine (OR 2.19, 95% CI 1.70-2.81) and norepinephrine (OR 2.24, 95% CI 1.80-2.80) compared with phenylephrine. Sensitivity analyses using different variable selection procedures, causal inference models, and machine-learning methods confirmed the main findings. CONCLUSIONS In patients with nontraumatic SAH, phenylephrine was significantly associated with reduced mortality in SAH patients compared to dopamine or norepinephrine. Prospective randomized clinical studies are warranted to confirm this finding.
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Affiliation(s)
| | | | - Laila Rasmy
- 3School of Biomedical Informatics, University of Texas Health Science Center, Houston, Texas
| | | | - Duo Yu
- 2School of Public Health, and
| | - Hai Zhu
- 2School of Public Health, and
| | | | | | | | - Gen Zhu
- 2School of Public Health, and
| | | | | | | | - Degui Zhi
- 2School of Public Health, and.,3School of Biomedical Informatics, University of Texas Health Science Center, Houston, Texas
| | | | | | | | - David Aguilar
- 1McGovern Medical School.,2School of Public Health, and
| | - Hulin Wu
- 2School of Public Health, and.,3School of Biomedical Informatics, University of Texas Health Science Center, Houston, Texas
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29
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Rawle MJ, McCue L, Sampson EL, Davis D, Vickerstaff V. Anticholinergic Burden Does Not Influence Delirium Subtype or the Delirium-Mortality Association in Hospitalized Older Adults: Results from a Prospective Cohort Study. Drugs Aging 2021; 38:233-242. [PMID: 33415708 PMCID: PMC7914229 DOI: 10.1007/s40266-020-00827-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Anticholinergic burden (ACB) is associated with an increased risk of delirium in the older population outside of the acute hospital setting. In acute settings, delirium is associated with increased mortality, and this association is greater with full syndromal delirium (FSD) than with subsyndromal delirium (SSD). Little is known about the impact of ACB on delirium prevalence or subtype in hospitalized older adults or the impact on mortality in this population. OBJECTIVES Our objectives were to determine whether ACB moderates associations between the subtype of delirium experienced by hospitalized older adults and to explore factors (including ACB) that might moderate consequent associations between delirium and mortality in hospital inpatients. METHODS We conducted a retrospective analysis of a cohort of 784 older adults with unplanned admission to a North London acute medical unit between June and December 2007. Univariate regression analyses were performed to explore associations between ACB, as represented by the Anticholinergic Burden Scale (ACBS), delirium subtype (FSD vs. SSD), and mortality. RESULTS The mean age of the sample was 83 ± standard deviation (SD) 7.4 years, and the majority of patients were female (59%), lived in their own homes (71%), were without dementia (75%), and died between hospital admission and the end of the 2-year follow-up period (59%). Mean length of admission was 13.2 ± 14.4 days. Prescription data revealed an ACBS score of 1 in 26% of the cohort, of 2 in 12%, and of ≥ 3 in 16%. The mean total ACBS score for the cohort was 1.1 ± 1.4 (range 0-9). Patients with high ACB on admission were more likely to have severe dementia, to have multiple comorbidities, and to live in residential care. Higher ACB was not associated with delirium of either subtype in hospitalized older adults. Delirium itself was associated with increased mortality, and greater associations were seen in FSD (hazard ratio [HR] 2.27; 95% confidence interval [CI] 1.70-3.01) than in SSD (HR 1.58; 95% CI 1.2-2.09); however, ACB had no impact on this relationship. CONCLUSIONS ACB was not found to be associated with increased delirium of either subtype or to have a demonstrable impact on mortality in delirium. Prior suggestions of links between ACB and mortality in similar populations may be mediated by higher levels of functional dependence, greater levels of residential home residence, or an increased prevalence of dementia in this population.
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Affiliation(s)
- Mark James Rawle
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
- Whipps Cross University Hospital, London, UK
| | - Laura McCue
- Marie Curie Palliative Care Research Department, UCL, London, UK
| | - Elizabeth L. Sampson
- Marie Curie Palliative Care Research Department, UCL, London, UK
- Barnet, Enfield and Haringey Mental Health Trust, London, UK
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing at UCL, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, UCL, London, UK
- Research Department of Primary Care and Population Health, UCL, London, UK
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Lozano-Ortega G, Schermer CR, Walker DR, Szabo SM, Rogula B, Deighton AM, Gooch KL, Campbell NL. Fall/Fracture-Related Healthcare Costs and Their Association with Cumulative Anticholinergic Burden in People with Overactive Bladder. Pharmacoecon Open 2021; 5:45-55. [PMID: 32291728 PMCID: PMC7895881 DOI: 10.1007/s41669-020-00215-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Falls/fractures are major causes of morbidity and mortality among older adults and the resulting health consequences generate a substantial economic burden. Risk factors are numerous and include overactive bladder (OAB) and anticholinergic use. OBJECTIVES We aimed to estimate the impact of falls/fractures on all-cause healthcare resource utilization and costs, according to levels of cumulative anticholinergic burden, among individuals with OAB. METHODS Among a US cohort of adults with OAB (identified based on medical claims for OAB or OAB-specific medications), the frequency of resource utilization (outpatients visits, medication use, and hospitalizations) was examined according to level of anticholinergic burden. Anticholinergic burden was assessed cumulatively using a published measure, and categorized as no, low, medium, or high. Resource utilization prior to and after a fall/fracture was compared. Generalized linear models were used to examine overall and incremental changes in healthcare resource utilization and costs by fall/fracture status, and annual costs were predicted according to age, sex, fall/fracture status, and level of anticholinergic burden. RESULTS The mean age of the OAB cohort (n = 154,432) was 56 years, 68% were female, and baseline mean anticholinergic burden was 266.7 (i.e. a medium level of burden); a fall/fracture was experienced by 9.9% of the cohort. All estimates of resource utilization were higher among those with higher levels of anticholinergic burden, regardless of fall/fracture status, and higher for all levels of anticholinergic burden after a fall/fracture. Among those with a fall/fracture, the highest predicted annual costs were observed among those aged 66-75 years with high anticholinergic burden (US$22,408 for males, US$22,752 for females). CONCLUSIONS Falls/fractures were associated with higher costs, which increased with increasing anticholinergic burden.
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Affiliation(s)
- Greta Lozano-Ortega
- Broadstreet Health Economics and Outcomes Research, 203-343 Railway St, Vancouver, BC, V6A 1A4, Canada
| | - Carol R Schermer
- Medical Affairs, Americas, Astellas Pharmaceutical Global Development Inc., Northbrook, IL, USA
| | - David R Walker
- Medical Affairs, Americas, Astellas Pharmaceutical Global Development Inc., Northbrook, IL, USA
| | - Shelagh M Szabo
- Broadstreet Health Economics and Outcomes Research, 203-343 Railway St, Vancouver, BC, V6A 1A4, Canada.
| | - Basia Rogula
- Broadstreet Health Economics and Outcomes Research, 203-343 Railway St, Vancouver, BC, V6A 1A4, Canada
| | - Alison M Deighton
- Broadstreet Health Economics and Outcomes Research, 203-343 Railway St, Vancouver, BC, V6A 1A4, Canada
| | - Katherine L Gooch
- Medical Affairs, Americas, Astellas Pharmaceutical Global Development Inc., Northbrook, IL, USA
| | - Noll L Campbell
- College of Pharmacy, Purdue University, West Lafayette, IN, USA
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Jenner P, Mori A, Aradi SD, Hauser RA. Istradefylline - a first generation adenosine A 2A antagonist for the treatment of Parkinson's disease. Expert Rev Neurother 2021; 21:317-333. [PMID: 33507105 DOI: 10.1080/14737175.2021.1880896] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction It is now accepted that Parkinson's disease (PD) is not simply due to dopaminergic dysfunction, and there is interest in developing non-dopaminergic approaches to disease management. Adenosine A2A receptor antagonists represent a new way forward in the symptomatic treatment of PD.Areas covered In this narrative review, we summarize the literature supporting the utility of adenosine A2A antagonists in PD with a specific focus on istradefylline, the most studied and only adenosine A2A antagonist currently in clinical use.Expert opinion: At this time, the use of istradefylline in the treatment of PD is limited to the management of motor fluctuations as supported by the results of randomized clinical trials and evaluation by Japanese and USA regulatory authorities. The relatively complicated clinical development of istradefylline was based on classically designed studies conducted in PD patients with motor fluctuations on an optimized regimen of levodopa plus adjunctive dopaminergic medications. In animal models, there is consensus that a more robust effect of istradefylline in improving motor function is produced when combined with low or threshold doses of levodopa rather than with high doses that produce maximal dopaminergic improvement. Exploration of istradefylline as a 'levodopa sparing' strategy in earlier PD would seem warranted.
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Affiliation(s)
- Peter Jenner
- Institute of Pharmaceutical Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Akihisa Mori
- Medical Affairs Department, Kyowa Kirin Co Ltd, Otemachi, Chiyoda-ku, Tokyo, Japan
| | - Stephen D Aradi
- Department of Neurology, University of South Florida, Tampa, Florida, USA
| | - Robert A Hauser
- Department of Neurology, University of South Florida, Tampa, Florida, USA
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Lisibach A, Benelli V, Ceppi MG, Waldner-Knogler K, Csajka C, Lutters M. Quality of anticholinergic burden scales and their impact on clinical outcomes: a systematic review. Eur J Clin Pharmacol 2021; 77:147-162. [PMID: 33011824 DOI: 10.1007/s00228-020-0299x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 09/10/2020] [Indexed: 05/23/2023]
Abstract
PURPOSE Older people are at risk of anticholinergic side effects due to changes affecting drug elimination and higher sensitivity to drug's side effects. Anticholinergic burden scales (ABS) were developed to quantify the anticholinergic drug burden (ADB). We aim to identify all published ABS, to compare them systematically and to evaluate their associations with clinical outcomes. METHODS We conducted a literature search in MEDLINE and EMBASE to identify all published ABS and a Web of Science citation (WoS) analysis to track validation studies implying clinical outcomes. Quality of the ABS was assessed using an adapted AGREE II tool. For the validation studies, we used the Newcastle-Ottawa Scale and the Cochrane tool Rob2.0. The validation studies were categorized into six evidence levels based on the propositions of the Oxford Center for Evidence-Based Medicine with respect to their quality. At least two researchers independently performed screening and quality assessments. RESULTS Out of 1297 records, we identified 19 ABS and 104 validations studies. Despite differences in quality, all ABS were recommended for use. The anticholinergic cognitive burden (ACB) scale and the German anticholinergic burden scale (GABS) achieved the highest percentage in quality. Most ABS are validated, yet validation studies for newer scales are lacking. Only two studies compared eight ABS simultaneously. The four most investigated clinical outcomes delirium, cognition, mortality and falls showed contradicting results. CONCLUSION There is need for good quality validation studies comparing multiple scales to define the best scale and to conduct a meta-analysis for the assessment of their clinical impact.
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Affiliation(s)
- Angela Lisibach
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland.
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University Hospital and University of Lausanne, Lausanne, Switzerland.
- School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, University of Geneva, Geneva, Switzerland.
| | - Valérie Benelli
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
| | - Marco Giacomo Ceppi
- Department of Neurorehabilitation, RehaClinic, Bad Zurzach, Switzerland
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | | | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University Hospital and University of Lausanne, Lausanne, Switzerland.
- School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, University of Geneva, Geneva, Switzerland.
| | - Monika Lutters
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
- Swiss Federal Institute of Technology, Zurich, Switzerland
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Fadare JO, Obimakinde AM, Aina FO, Araromi EJ, Adegbuyi TA, Osasona OE, Agbesanwa TA. Anti-Cholinergic Drug Burden Among Ambulatory Elderly Patients in a Nigerian Tertiary Healthcare Facility. Front Pharmacol 2021; 12:580152. [PMID: 33584317 PMCID: PMC7878669 DOI: 10.3389/fphar.2021.580152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 01/04/2021] [Indexed: 01/25/2023] Open
Abstract
Background: The use of drugs with anticholinergic effects among elderly patients is associated with adverse clinical outcomes. There is paucity of information about anticholinergic drug burden among Nigerian elderly population. Objectives: To determine the anticholinergic drug burden among elderly Nigerian patients. Methods: This was a retrospective cross-sectional study conducted among elderly patients (aged 65 and above) who visited the Family Medicine outpatients' clinics of the Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria between July 1 and October 31, 2018. Information extracted from the case files included patient's age, sex, diagnoses, and list of prescribed medications. Medicines with anticholinergic effects were identified and scored using the anticholinergic drug burden calculator (http://www.acbcalc.com). Results: The medical records of 400 patients were analyzed with females accounting for 60.5% of the study population. The mean age of participants was 73 ± 7.4 years with only 28 (7%) of patients having more than two co-morbid conditions. Polypharmacy was identified in 152 (38%) of the patients while 147 (36.7%) had drugs with anticholinergic effects prescribed. The anticholinergic burden was high in 60 (15%) patients. Polypharmacy was significantly associated with having more than two diagnosed conditions and high anticholinergic burden (p value of < 0 .001 and 0.013 respectively). There was significant correlation between total number of prescribed drugs and count of diagnoses (r = 0.598; p < 0 .000) and between total number of prescribed drugs and number of drugs with anticholinergic effects (r = 0 .196; p < 0 .000). Conclusion: The anticholinergic burden in this group of elderly Nigerian patients was low; majority (67%) had no exposure to drugs with anticholinergic effects with only 15% having high anticholinergic burden. Polypharmacy and multiple diagnosed conditions were positively associated with high anticholinergic burden. Based on the positive and significant correlations found in this study, a reduction in the number of prescribed medicines especially those with significant anticholinergic effects used for secondary indications may lessen the anticholinergic burden among the elderly.
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Affiliation(s)
- Joseph O. Fadare
- Department of Pharmacology and Therapeutics, College of Medicine, Ekiti State University, Ado-Ekiti, Nigeria
- Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
| | - Abimbola Margaret Obimakinde
- Department of Community Medicine, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Family Medicine, University College Hospital Ibadan, Ibadan, Nigeria
| | - Felix O. Aina
- Department of Family Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
| | - Ebisola J. Araromi
- Department of Pharmacology and Therapeutics, College of Medicine, Ekiti State University, Ado-Ekiti, Nigeria
| | | | - Oluwatoba E. Osasona
- Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
| | - Tosin A. Agbesanwa
- Department of Family Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
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Abstract
AIM The aim of the study was to explore extrinsic and behavioral risks for falls in older adults with Parkinson's disease (PD). BACKGROUND Falls that cause injury and disability in people with PD are common. Understanding the role of extrinsic and behavioral factors is important for fall prevention. DESIGN Integrative literature review with search of CINAHL, MEDLINE, and SCOPUS and ancestry searching was performed. METHODS The methodology of Whittemore and Knafl guided the review; ten studies were included. FINDINGS Falls occur indoors and outdoors, commonly during daily activities in familiar home environments, but also when out in the community. Common challenges include uneven and unfamiliar environments and risky behavior like hurrying. CONCLUSION Extrinsic risk factors combined with behavioral and intrinsic factors contribute to falls in people with PD both at home and in the community. CLINICAL RELEVANCE Rehabilitation of people with PD should include assessment of falls, function, extrinsic risk factors, and fit with their environment to develop fall prevention plans.
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Abraham DS, Pham Nguyen TP, Hennessy S, Gray SL, Xie D, Weintraub D, Willis AW. Annual Prevalence of Use of Potentially Inappropriate Medications for Treatment of Affective Disorders in Parkinson's Disease. Am J Geriatr Psychiatry 2021; 29:35-47. [PMID: 32553997 PMCID: PMC7671949 DOI: 10.1016/j.jagp.2020.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/06/2020] [Accepted: 05/13/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To examine the national prevalence of pharmacological treatment of affective disorders in older adults with Parkinson's disease (PD), and determine the prevalence and risk factors for receipt of an American Geriatrics Society Beers Criteria® defined potentially inappropriate medication (PIM) for affective disorder treatment. DESIGN Cross-sectional analysis of 2014 Medicare data. SETTING Research Identifiable File data from the Centers for Medicare and Medicaid Services. PARTICIPANTS Individuals ≥65 years of age with PD whose inpatient, outpatient, and prescription care is administered through the U.S. Medicare Program. MEASUREMENTS The 2014 prevalence of affective (i.e., depressive and anxiety) disorders was calculated. We assessed prescription fills for affective disorder treatment and classified prescriptions according to PIM status. Patient and clinician factors associated with PIM prescriptions were determined. RESULTS Of 84,323 beneficiaries with PD, 15.1% had prevalent depression only, 7.5% had anxiety only, and 8.5% had comorbid depression and anxiety. Among those with depression only, 80.7% were treated in 2014 (12.8% of treated received at least one PIM). The annual treatment prevalence was 62.9% (75.9% PIM) and 93.1% (63.9% PIM) in the anxiety only and comorbid group, respectively. In most groups, PIM use was less likely among men and those with dementia; geriatricians were less likely to prescribe PIMs. CONCLUSION Treatment of affective disorders in persons diagnosed with PD is high. PIM use is also common, particularly in persons with anxiety. Future research will quantify the potential effects of these PIMs on clinical and patient outcomes.
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Affiliation(s)
- Danielle S Abraham
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, DW, AWW), Philadelphia, PA; Department of Neurology Translational Center for Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, AWW), Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, SH, DX, AWW), Philadelphia, PA; Department of Biostatics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, SH, DX, AWW), Philadelphia, PA.
| | - Thanh Phuong Pham Nguyen
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, DW, AWW), Philadelphia, PA; Department of Neurology Translational Center for Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, AWW), Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, SH, DX, AWW), Philadelphia, PA; Department of Biostatics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, SH, DX, AWW), Philadelphia, PA
| | - Sean Hennessy
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, SH, DX, AWW), Philadelphia, PA; Department of Biostatics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, SH, DX, AWW), Philadelphia, PA
| | - Shelly L Gray
- Department of Pharmacy, University of Washington School of Pharmacy, (SLG), Seattle, WA
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, SH, DX, AWW), Philadelphia, PA; Department of Biostatics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, SH, DX, AWW), Philadelphia, PA
| | - Daniel Weintraub
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, DW, AWW), Philadelphia, PA; Parkinson's Disease Research, Education and Clinical Center, Corporal Michael J. Crescenz VA Medical Center, (DW), Philadelphia, PA; Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, (DW), Philadelphia, PA
| | - Allison W Willis
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, DW, AWW), Philadelphia, PA; Department of Neurology Translational Center for Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, AWW), Philadelphia, PA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, SH, DX, AWW), Philadelphia, PA; Department of Biostatics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, (DSA, TPPN, SH, DX, AWW), Philadelphia, PA
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Reinold J, Schäfer W, Christianson L, Barone-Adesi F, Riedel O, Pisa FE. Anticholinergic Burden and Fractures: A Systematic Review with Methodological Appraisal. Drugs Aging 2020; 37:885-897. [PMID: 33094444 PMCID: PMC7704512 DOI: 10.1007/s40266-020-00806-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2020] [Indexed: 11/28/2022]
Abstract
Introduction Medications with anticholinergic activity (MACs) are used to treat diseases common in older adults. Evidence on the association between anticholinergic burden (AB) and increased risk of fractures and osteoporosis or reduced bone mineral density (BMD) is inconsistent. Our aim was to conduct a systematic review of observational studies on AB with fractures and osteoporosis or reduced BMD and provide methodological appraisal of included studies. Methods We searched MEDLINE, EMBASE, Science Citation Index and CENTRAL as well as grey literature from database inception up to August 2020. Eligibility criteria were: observational design, AB-exposure measured through a scale, fracture of any type or osteoporosis or reduced BMD as outcome, and reported measure of association between exposure and outcome. No restrictions related to time, language or type of data were applied. Eligibility and risk of bias assessment as well as data extraction were performed independently by two reviewers. Risk of bias of the included studies was assessed using the Newcastle–Ottawa Scale and the RTI Item Bank. Results The majority of the nine included studies had low risk of bias but heterogeneous methodology. No study used a new user design. Seven studies reported an increased risk of fractures associated with AB. In four studies using the Anticholinergic Risk Scale (ARS), adjusted risk of fractures was increased by 2–61% for ARS = 1, by 0–97% for ARS = 2, by 19–84% for ARS = 3, and by 56–96% for ARS ≥ 4; in three studies the ARS was aggregated, risk increased by 39% for ARS = 1–2 and 17% for ARS = 2–3. Two studies reported increased risk of fractures of 14 and 52% in the highest AB-category and one study reported that change in ARS of ≥ 3 during hospitalization was associated with a 321% increased risk in fractures. Two studies did not find an association between AB and fractures. The association between AB and osteoporosis or reduced BMD could only be assessed in two studies, one reporting increased risk of lower BMD at Ward’s triangle, the other reporting no association between AB and BMD T-score change at the femoral neck. Discussion Our study suggests an association between AB and increased risk of fractures with possible dose-exposure gradient in studies using the ARS. The low number of studies and heterogeneity of methods calls for the conduct of more studies. Plain language summary We conducted a study investigating the risk of fractures associated with anticholinergic burden, which is the result of taking one or more medication with anticholinergic activity. The results of our study suggest that persons who experience anticholinergic burden might have a higher risk of fractures. However, since we were only able to include nine studies, more studies conducted in a similar way are needed. Electronic supplementary material The online version of this article (10.1007/s40266-020-00806-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jonas Reinold
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany.
| | - Wiebke Schäfer
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
| | - Lara Christianson
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
| | - Francesco Barone-Adesi
- Department of Translational Medicine, University of Eastern Piedmont, Via Solaroli 17, 28100, Novara, Italy
| | - Oliver Riedel
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
| | - Federica Edith Pisa
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
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Lisibach A, Benelli V, Ceppi MG, Waldner-Knogler K, Csajka C, Lutters M. Quality of anticholinergic burden scales and their impact on clinical outcomes: a systematic review. Eur J Clin Pharmacol 2020; 77:147-162. [PMID: 33011824 PMCID: PMC7803697 DOI: 10.1007/s00228-020-02994-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 09/10/2020] [Indexed: 12/13/2022]
Abstract
Purpose Older people are at risk of anticholinergic side effects due to changes affecting drug elimination and higher sensitivity to drug’s side effects. Anticholinergic burden scales (ABS) were developed to quantify the anticholinergic drug burden (ADB). We aim to identify all published ABS, to compare them systematically and to evaluate their associations with clinical outcomes. Methods We conducted a literature search in MEDLINE and EMBASE to identify all published ABS and a Web of Science citation (WoS) analysis to track validation studies implying clinical outcomes. Quality of the ABS was assessed using an adapted AGREE II tool. For the validation studies, we used the Newcastle-Ottawa Scale and the Cochrane tool Rob2.0. The validation studies were categorized into six evidence levels based on the propositions of the Oxford Center for Evidence-Based Medicine with respect to their quality. At least two researchers independently performed screening and quality assessments. Results Out of 1297 records, we identified 19 ABS and 104 validations studies. Despite differences in quality, all ABS were recommended for use. The anticholinergic cognitive burden (ACB) scale and the German anticholinergic burden scale (GABS) achieved the highest percentage in quality. Most ABS are validated, yet validation studies for newer scales are lacking. Only two studies compared eight ABS simultaneously. The four most investigated clinical outcomes delirium, cognition, mortality and falls showed contradicting results. Conclusion There is need for good quality validation studies comparing multiple scales to define the best scale and to conduct a meta-analysis for the assessment of their clinical impact. Electronic supplementary material The online version of this article (10.1007/s00228-020-02994-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Angela Lisibach
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland. .,Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University Hospital and University of Lausanne, Lausanne, Switzerland. .,School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, University of Geneva, Geneva, Switzerland.
| | - Valérie Benelli
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
| | - Marco Giacomo Ceppi
- Department of Neurorehabilitation, RehaClinic, Bad Zurzach, Switzerland.,Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | | | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University Hospital and University of Lausanne, Lausanne, Switzerland. .,School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, University of Geneva, Geneva, Switzerland.
| | - Monika Lutters
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland.,Swiss Federal Institute of Technology, Zurich, Switzerland
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Rajan R, Saini A, Verma B, Choudhary N, Gupta A, Vishnu VY, Bhatia R, Singh MB, Srivastava AK, Srivastava MVP. Anticholinergics May Carry Significant Cognitive and Gait Burden in Parkinson's Disease. Mov Disord Clin Pract 2020; 7:803-809. [PMID: 33043076 DOI: 10.1002/mdc3.13032] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/26/2020] [Accepted: 07/13/2020] [Indexed: 12/30/2022] Open
Abstract
Background Anticholinergic drugs are associated with significant cognitive and other adverse events in older adults, including those with Parkinson's disease (PD). Anticholinergic effects are considered lesser in younger individuals and the burden and outcomes in younger patients with PD are unknown. Objectives To determine the cumulative anticholinergic burden in a cohort of younger of patients with PD and to correlate the same with cognitive impairment and freezing of gait (FOG). Methods We conducted a cross-sectional study to identify the cumulative anticholinergic burden from medications prescribed to patients with PD. Two standard scales, the Anticholinergic Cognitive Burden (ACB) scale and the ACB score, were used to calculate the anticholinergic burden from prescriptions. We identified commonly prescribed drugs contributing to anticholinergic effects and correlated the cumulative ACB score with cognitive impairment (Movement Disorder Society-Unified Parkinson's Disease Rating Scale item 1.1) and FOG (Movement Disorder Society-Unified Parkinson's Disease Rating Scale items 2.13 and 3.11). Results We recruited 287 patients with PD (68.9% male) with a mean age of 56.9 ± 11.8 years and a duration of symptoms 6.3 ± 6.9 years. Median ACB score was 4 (range 0-12). A total of 164 (58.4%) patients had total ACB score > 3. ACB score > 3 was independently associated with cognitive impairment (Odds Ratio, 2.55; 95% confidence interval, 1.43-4.53; P < 0.001) and FOG using patient-reported measures (Odds Ratio, 3.192; 95% Confidence Interval, 1.68-6.07; P < 0.001) and objective measures (odds ratio, 2.41; 95% confidence interval, 1.27-4.6, P = 0.007). Conclusion Patients with PD are exposed to significant anticholinergic burden from drugs prescribed for PD and non-PD indications. Higher anticholinergic burden is associated with cognitive impairment and FOG even in younger patients with PD.
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Affiliation(s)
- Roopa Rajan
- Department of Neurology All India Institute of Medical Sciences New Delhi India
| | - Arti Saini
- Department of Neurology All India Institute of Medical Sciences New Delhi India
| | - Bhawna Verma
- Department of Neurology All India Institute of Medical Sciences New Delhi India
| | - Nishu Choudhary
- Department of Neurology All India Institute of Medical Sciences New Delhi India
| | - Anu Gupta
- Department of Neurology All India Institute of Medical Sciences New Delhi India
| | | | - Rohit Bhatia
- Department of Neurology All India Institute of Medical Sciences New Delhi India
| | - Mamta B Singh
- Department of Neurology All India Institute of Medical Sciences New Delhi India
| | - Achal K Srivastava
- Department of Neurology All India Institute of Medical Sciences New Delhi India
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Abraham DS, Pham Nguyen TP, Hennessy S, Weintraub D, Gray SL, Xie D, Willis AW. Frequency of and risk factors for potentially inappropriate medication use in Parkinson's disease. Age Ageing 2020; 49:786-792. [PMID: 32255485 DOI: 10.1093/ageing/afaa033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/16/2019] [Accepted: 01/01/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND impairments in neurotransmitter pathways put Parkinson's disease (PD) patients at risk for drug-disease interactions and adverse medication events. OBJECTIVE to determine the prevalence and risk factors for potentially inappropriate medication (PIM) prescriptions, as defined by the 2015 Beers List, in PD. METHODS cross-sectional analysis was conducted on 2014 Medicare beneficiaries with PD who had parts A, B and D coverage. The prevalence of PIM prescriptions for older adults was determined overall, and specifically for medications that can exacerbate motor symptoms or cognitive impairment in PD. Logistic regression models were constructed to determine the association between age, sex, race, geography and poverty with PIM prescriptions. RESULTS the final sample included 458,086 beneficiaries. In 2014, 35.8% of beneficiaries with PD filled a prescription for at least one PIM for older adults. In total, 8.7% of beneficiaries received a PIM that could exacerbate motor symptoms and 29.0% received a PIM that could worsen cognitive impairment. After adjustment, in all models, beneficiaries who were younger, female, white, urban-dwelling and eligible for Medicaid benefits were more likely to receive a PIM. CONCLUSION PIM prescriptions are not uncommon in PD, particularly for medications that can exacerbate cognitive impairment. Future research will examine underlying drivers of sex and other disparities in PIM prescribing. Additional studies are needed to understand the impact of PIMs on disease symptoms, healthcare utilisation and patient outcomes.
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Affiliation(s)
- Danielle S Abraham
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Department of Neurology Translational Center for Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Department of Biostatics, Epidemiology, and Informatics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Thanh Phuong Pham Nguyen
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Department of Neurology Translational Center for Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Department of Biostatics, Epidemiology, and Informatics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Sean Hennessy
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Department of Biostatics, Epidemiology, and Informatics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Daniel Weintraub
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Parkinson’s Disease Research, Education and Clinical Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Shelly L Gray
- Department of Pharmacy, University of Washington School of Pharmacy, Seattle, WA, USA
| | - Dawei Xie
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Department of Biostatics, Epidemiology, and Informatics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Allison W Willis
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Department of Neurology Translational Center for Excellence for Neuroepidemiology and Neurological Outcomes Research, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Department of Biostatics, Epidemiology, and Informatics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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Egberts A, Moreno-Gonzalez R, Alan H, Ziere G, Mattace-Raso FUS. Anticholinergic Drug Burden and Delirium: A Systematic Review. J Am Med Dir Assoc 2020; 22:65-73.e4. [PMID: 32703688 DOI: 10.1016/j.jamda.2020.04.019] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To investigate the association between anticholinergic drug burden (ADB), measured with anticholinergic drug scales, and delirium and delirium severity. DESIGN Systematic review. SETTING AND PARTICIPANTS All available studies. METHODS A systematic literature search was performed in Medline, Embase, PsycINFO, Web of Science, CINAHL, Cochrane library, and Google Scholar. Studies evaluating the association between ADB (measured as a total score) and delirium or delirium severity, published in English, were eligible for inclusion. RESULTS Sixteen studies, including 148,756 persons, were included. Fifteen studies investigated delirium. ADB was measured with the Anticholinergic Risk Scale (ARS, n = 5), the Anticholinergic Cognitive Burden Scale (ACB, n = 6), the list of Chew (n = 1), the Anticholinergic Drug Scale (ADS, n = 5), a modified version of the ARS (n = 1), and a modified version of the ACB (n = 1). A high ADB, measured with the ARS, was associated with delirium (5/5). Also with the modified version of the ARS and ACB, an association was found between a high ADB and delirium during 3-month (1/1) and 1-year follow-up (1/1), respectively. When ADB was assessed with other scales, the results were inconclusive, with only 1 positive association for the ACB (1/6) and ADS (1/5) each. The possible association between ADB and delirium severity has also been investigated (ADS n = 2, Summers Drug Risk Number n = 1). One study found an association between a high ADB, measured with the ADS, and an increase in severity of delirium. CONCLUSIONS AND IMPLICATIONS ADB assessed with the ARS is consistently associated with delirium. The association found between the modified versions of the ARS and ACB and delirium needs confirmation. When ADB was assessed with other scales, the findings were inconclusive. The current findings suggest that the ARS might be a useful tool to identify patients at increased risk for delirium.
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Affiliation(s)
- Angelique Egberts
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Hospital Pharmacy, Franciscus Gasthuis and Vlietland, Rotterdam and Schiedam, the Netherlands.
| | - Rafael Moreno-Gonzalez
- Section of Geriatric Medicine, Department of Internal Medicine, Bellvitge University Hospital, Barcelona, Spain
| | - Hava Alan
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Gijsbertus Ziere
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Francesco U S Mattace-Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Neo S, Wong SYA, Ng HL, Li W, Tay KY, Au WL, Tan LCS. Evolution of Initial Pharmacologic Treatment of Newly Diagnosed Parkinson's Disease Patients over a Decade in Singapore. Parkinsons Dis 2020; 2020:6293124. [PMID: 32318260 DOI: 10.1155/2020/6293124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/11/2020] [Indexed: 11/17/2022]
Abstract
Objective The aim of this study is to compare Parkinson's disease (PD) treatment practices by movement disorder (MD) specialists across a decade, and to determine the factors that influence drug choice for the motor symptoms of PD in newly diagnosed drug-naïve patients. Methods This prospective temporal analysis included patients seen at the National Neuroscience Institute in Singapore and diagnosed with PD by MD specialists in the years 2007 and 2017. Primary outcomes were use of specific PD drugs and changes in drug-prescribing patterns. Descriptive analyses and multivariable logistic regression models determined the extent to which patient characteristics were associated with type of PD treatment. Results Of 230 patients with PD (mean (SD) age, 66.7 (10.3) years), 131 (57.0%) were male. From 2007 to 2017, the use of ergot dopamine agonists and anticholinergics decreased from 19.3% to 2.0% (P < 0.001) and from 12.0% to 2.7% (P = 0.004), respectively. The use of monoamine oxidase B inhibitors (MAOBI) increased from 13.3% to 25.2% (P = 0.033). The use of levodopa (LD)-sparing strategies decreased nonsignificantly from 33.7% to 24.5% (P = 0.133). Overall, 196 (85.2%) patients were initiated on symptomatic monotherapy, with LD being the most commonly prescribed. MAOBI was the most common drug used in combination therapy. Age ≤70 (adjusted OR, 11.9; 95% CI, 4.5–31.5) and Hoehn and Yahr (HY) stage <2 (adjusted OR, 3.4; 95% CI, 1.5–7.7) were independent factors for LD-sparing strategies. Non-LD prescriptions (13 of 92; 14.1%) were more likely to be discontinued compared to LD ones (6 of 149; 4.0%) (P = 0.005). Conclusions Drug-prescribing patterns in PD have changed significantly through the last decade, influenced by emerging evidence and reports of adverse drug effects. Choosing drugs based on the patient's age and disease severity remain sound guiding principles across the years. It is important that international and national guidelines for pharmacotherapy in PD be updated consistently throughout different socioeconomic settings to optimize care.
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Tkaczynska Z, Becker S, Maetzler W, Timmers M, Van Nueten L, Sulzer P, Salvadore G, Schäffer E, Brockmann K, Streffer J, Berg D, Liepelt-Scarfone I. Executive Function Is Related to the Urinary Urgency in Non-demented Patients With Parkinson's Disease. Front Aging Neurosci 2020; 12:55. [PMID: 32210789 PMCID: PMC7069351 DOI: 10.3389/fnagi.2020.00055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 02/18/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction: Evidence suggests urinary urgency is associated with cognitive impairment in a subtype of Parkinson’s disease (PD) patients. This study investigates if cognitive impairment independently predicts the presence of urinary dysfunction. Methods: We report data of 189 idiopathic PD patients, excluding those with concomitant diseases or medication interacting with bladder function. A standardized questionnaire was used to define the presence of urinary urgency. All patients underwent a comprehensive motor, cognitive non-motor and health-related quality of life (HRQoL) assessment. Multivariable linear regression analysis was performed to identify independent variables characterizing urinary urgency in PD (PD-UU), which were assigned as discriminant features to estimate their individual contribution to the phenotype of the PD-UU group. Results: Of 189 PD patients, 115 (60.8%) reported PD-UU. The linear regression analysis showed that among cognitive domains, executive function (EF; p = 0.04) had a significant negative association with PD-UU. In a second model, scores of the Montreal Cognitive Assessment (MoCA) significantly differentiated between study groups (p = 0.007) and also non-motor symptom (NMS) burden (p < 0.001). The third model consisted of reports of HRQoL, of which stigma was the only subscale of the Parkinson’s Disease Questionnaire (PDQ-39) differentiating between patients with and without PD-UU (p = 0.02). The linear discriminant analysis provided evidence that the combination of EF, NMS burden, nocturia, and stigma discriminated between groups with 72.4% accuracy. Conclusion: In our large, non-demented PD cohort, urinary urgency was associated with executive dysfunction (EF), supporting a possible causative link between both symptoms. A combination of neuropsychological and non-motor aspects identified patients with PD-UU with high discriminative accuracy.
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Affiliation(s)
- Zuzanna Tkaczynska
- Department of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,German Center for Neurodegenerative Diseases (DZNE), University of Tübingen, Tübingen, Germany
| | - Sara Becker
- Department of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,German Center for Neurodegenerative Diseases (DZNE), University of Tübingen, Tübingen, Germany
| | - Walter Maetzler
- Department of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,Department of Neurology, Christian-Albrechts-University, Kiel, Germany
| | - Maarten Timmers
- Janssen Research and Development, Janssen-Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium.,Reference Center for Biological Markers of Dementia (BIODEM), Institute Born-Bunge, University of Antwerp, Antwerp, Belgium
| | - Luc Van Nueten
- Janssen Research and Development, Janssen-Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium
| | - Patricia Sulzer
- Department of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,German Center for Neurodegenerative Diseases (DZNE), University of Tübingen, Tübingen, Germany
| | - Giacomo Salvadore
- Janssen Research and Development LLC, Janssen-Pharmaceutical Companies of Johnson & Johnson, Titusville, NJ, United States
| | - Eva Schäffer
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany
| | - Kathrin Brockmann
- Department of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,German Center for Neurodegenerative Diseases (DZNE), University of Tübingen, Tübingen, Germany
| | - Johannes Streffer
- Janssen Research and Development, Janssen-Pharmaceutical Companies of Johnson & Johnson, Beerse, Belgium.,Reference Center for Biological Markers of Dementia (BIODEM), Institute Born-Bunge, University of Antwerp, Antwerp, Belgium
| | - Daniela Berg
- German Center for Neurodegenerative Diseases (DZNE), University of Tübingen, Tübingen, Germany.,Department of Neurology, Christian-Albrechts-University, Kiel, Germany
| | - Inga Liepelt-Scarfone
- Department of Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany.,German Center for Neurodegenerative Diseases (DZNE), University of Tübingen, Tübingen, Germany
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McDonald C, Rees J, Winge K, Newton JL, Burn DJ. Bladder training for urinary tract symptoms in Parkinson disease: A randomized controlled trial. Neurology 2020; 94:e1427-e1433. [PMID: 32054791 PMCID: PMC7274915 DOI: 10.1212/wnl.0000000000008931] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 10/03/2019] [Indexed: 01/23/2023] Open
Abstract
Objective To assess the feasibility and efficacy of bladder training for troublesome lower urinary tract symptoms (LUTS) in Parkinson disease (PD). Methods In this single-center, single-blinded, randomized controlled trial, participants with a history of PD and LUTS were randomized to a 12-week bladder training program (BT) or conservative advice (CA). Outcome measures included a 3-day volume frequency diary, International Consultation on Incontinence Questionnaire (ICIQ)–Overactive Bladder Module, and ICIQ—Quality of Life Module. Co–primary endpoints were (1) patient perception of change and (2) change in number of urgency episodes at 12 weeks. Secondary endpoints included change in ICIQ scores, number of micturitions, and volume voided. Results Thirty-eight participants were randomized (18 to CA, 20 to BT). Both CA and BT were associated with significant improvements in volume voided, number of micturitions, symptom severity scores, and measures of quality of life (all p < 0.05). At 12 weeks, compared to CA, BT was associated with significant superiority on patient perception of improvement (p = 0.001), significantly greater reductions in number of voids in 24 hours (mean decrease 2.3 ± 0.8 voids vs 0.3 ± 0.5 [p < 0.05]), and greater reductions in interference with daily life (2.1 ± 0.8 point improvement vs 0.3 ± 0.7 point deterioration [p < 0.05]). BT was not associated with change in urgency episodes (mean change 2.4 ± 1.5 urgency episodes vs 3.5 ± 1.5 [p NS]). At 20 weeks, BT remained associated with greater improvement in interference in daily life. Loss of significance in other measures may reflect loss of power from loss to follow-up. Conclusion This controlled trial demonstrated the potential benefits of BT for LUTS in PD. Classification of evidence This study provides Class III evidence that for patients with PD and LUTS, BT significantly increased patient perception of improvement but did not significantly reduce urgency episodes.
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Affiliation(s)
- Claire McDonald
- From Gateshead Health (C.M.) and Newcastle Upon Tyne Hospitals (J.R., J.L.N.), NHS Foundation Trust; Faculty of Medical Sciences (C.M., J.L.N., D.J.B.), Newcastle University, UK; and Zealand University Hospital (K.W.), Roskilde, Denmark.
| | - Jackie Rees
- From Gateshead Health (C.M.) and Newcastle Upon Tyne Hospitals (J.R., J.L.N.), NHS Foundation Trust; Faculty of Medical Sciences (C.M., J.L.N., D.J.B.), Newcastle University, UK; and Zealand University Hospital (K.W.), Roskilde, Denmark
| | - Kristian Winge
- From Gateshead Health (C.M.) and Newcastle Upon Tyne Hospitals (J.R., J.L.N.), NHS Foundation Trust; Faculty of Medical Sciences (C.M., J.L.N., D.J.B.), Newcastle University, UK; and Zealand University Hospital (K.W.), Roskilde, Denmark
| | - Julia L Newton
- From Gateshead Health (C.M.) and Newcastle Upon Tyne Hospitals (J.R., J.L.N.), NHS Foundation Trust; Faculty of Medical Sciences (C.M., J.L.N., D.J.B.), Newcastle University, UK; and Zealand University Hospital (K.W.), Roskilde, Denmark
| | - David J Burn
- From Gateshead Health (C.M.) and Newcastle Upon Tyne Hospitals (J.R., J.L.N.), NHS Foundation Trust; Faculty of Medical Sciences (C.M., J.L.N., D.J.B.), Newcastle University, UK; and Zealand University Hospital (K.W.), Roskilde, Denmark
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Suehs BT, Caplan EO, Hayden J, Ng DB, Gaddy RR. The Relationship Between Anticholinergic Exposure and Falls, Fractures, and Mortality in Patients with Overactive Bladder. Drugs Aging 2019; 36:957-67. [PMID: 31359329 DOI: 10.1007/s40266-019-00694-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Understanding risk factors associated with falls is important for optimizing care and quality of life for older patients. OBJECTIVE Our objective was to determine the relationship between anticholinergic exposure and falls, fractures, and all-cause mortality. METHODS An observational retrospective cohort study was conducted using administrative claims data from 1 January 2007 to 30 September 2015. Individuals aged 65-89 years newly diagnosed or treated for overactive bladder (OAB) were identified. Index date was the first OAB diagnosis or OAB medication prescription claim. Follow-up began on the index date and continued until death, disenrollment, or end of study period. The Anticholinergic Cognitive Burden (ACB) scale was used to define and quantify daily anticholinergic exposure and intensity. The primary study outcome was a combined endpoint of falls or fractures. All-cause mortality was a secondary endpoint. RESULTS There were 113,311 patients with mean age of 74.8 ± standard deviation (SD) 6.2 years included. Current anticholinergic exposure was associated with a 1.28-fold increased hazard of a fall/fracture (95% confidence interval [CI] 1.23-1.32) compared with unexposed person-time, and past exposure was associated with a 1.14-fold increased hazard of a fall/fracture (95% CI 1.12-1.17). Compared with unexposed person-time, low-, moderate-, and high-intensity anticholinergic exposure was associated with a 1.04-fold (95% CI 1.00-1.07), 1.13-fold (95% CI 1.09-1.17), and 1.31-fold (95% CI 1.26-1.36) increased hazard of falls/fractures, respectively. A similar pattern was observed for all-cause mortality. CONCLUSIONS Anticholinergic exposure is associated with an increased risk of falls or fractures in older patients and is an important consideration when evaluating treatment options for such patients with OAB.
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Abstract
Parkinson's disease (PD) is a condition that predominantly affects older people. It is imperative that clinical management considers the other significant illnesses that people with PD accumulate as they age in conjunction with their resilience to cope with physiological change. Multimorbidity and frailty act synergistically to heighten the risk of adverse outcomes for older people with PD. These states are associated with increased likelihood of hospitalization, polypharmacy, adverse drug effects including the anticholinergic burden of medications, drug-disease and drug-drug interactions. Management should be integrated, holistic and individualised to meticulously balance the risks of interventions considering the vulnerability of the individual to recover from disturbance to their environmental, physical and cognitive equilibrium.
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Affiliation(s)
- Emma Tenison
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Emily J. Henderson
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- Older People’s Unit, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Bath, United Kingdom
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Ali S, Peterson GM, Bereznicki LR, Salahudeen MS. Association between anticholinergic drug burden and mortality in older people: a systematic review. Eur J Clin Pharmacol 2020; 76:319-35. [PMID: 31832732 DOI: 10.1007/s00228-019-02795-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/05/2019] [Indexed: 01/29/2023]
Abstract
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.
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Hwang S, Jun K, Ah Y, Han E, Chung JE, Lee J. Impact of anticholinergic burden on emergency department visits among older adults in Korea: A national population cohort study. Arch Gerontol Geriatr 2019; 85:103912. [DOI: 10.1016/j.archger.2019.103912] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/20/2019] [Accepted: 07/09/2019] [Indexed: 11/19/2022]
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Bloem BR, Ypinga JHL, Willis A, Canning CG, Barker RA, Munneke M, De Vries NM. Using Medical Claims Analyses to Understand Interventions for Parkinson Patients. J Parkinsons Dis 2019; 8:45-58. [PMID: 29254108 PMCID: PMC5836412 DOI: 10.3233/jpd-171277] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The scientific evidence to support the value of a range of non-pharmacological interventions for people with Parkinson’s disease (PD) is increasing. However, showing unequivocally that specific interventions are better than usual care is not straightforward because of generic drawbacks of clinical trials. Here, we address these challenges, specifically related to the context of evaluating complex non-pharmacological interventions for people with PD. Moreover, we discuss the potential merits of undertaking “real world” analyses using medical claims data. We illustrate this approach by discussing an interesting recent publication in The Lancet Neurology, which used such an approach to demonstrate the value of specialized physiotherapy for PD patients, over and above usual care physiotherapy.
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Affiliation(s)
- Bastiaan R Bloem
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands
| | - Jan H L Ypinga
- Department Care Purchasing, CZ Groep, Goes, The Netherlands
| | - Allison Willis
- Departments of Neurology and of Biostatistics, Epidemiology and Informatics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Colleen G Canning
- Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney, Australia
| | - Roger A Barker
- Department of Clinical Neurosciences, John van Geest Centre for Brain Repair, University of Cambridge, UK
| | - Marten Munneke
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands
| | - Nienke M De Vries
- Department of Neurology, Radboud University Medical Center, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands
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Abstract
Parkinson's disease (PD) and other synucleinopathies, namely dementia with Lewy bodies (DLB) and multiple system atrophy (MSA), are common degenerative neurological disorders that share synuclein pathology. Although certain cardinal features of parkinsonism, including bradykinesia and rigidity, respond well to levodopa, axial features, such as gait and balance impairment, are less reliably responsive to dopaminergic therapy and surgical interventions. Consequently, falls are common in PD and other synucleinopathies and are a major contributor toward injury and loss of independence. This underscores the need for appropriate fall risk assessment and implementation of preventative measures in all patients with parkinsonism. The aim of this review is therefore to explore modifiable and non-modifiable risk factors for falls in synucleinopathies. We next review and evaluate the evidence for pharmacological, nonpharmacological, and surgical approaches for fall prevention, and emphasize individualized and multifaceted approaches.
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Kumar S, Hasan SS, Wong PS, Chong DWK, Kairuz T. Anticholinergic Burden, Sleep Quality and Health Outcomes in Malaysian Aged Care Home Residents. Pharmacy (Basel) 2019; 7:pharmacy7040143. [PMID: 31652680 PMCID: PMC6958496 DOI: 10.3390/pharmacy7040143] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 12/24/2022] Open
Abstract
The use of anticholinergic medications by residents in aged care homes is associated with increased risk of adverse effects. These include cognitive impairment, sleep disturbances, and falls, and necessitate increased healthcare visits and the associated burden on healthcare systems. The objective of this study was to investigate associations between anticholinergic burden and health outcomes such as independence in activities for daily living, frailty, quality of life, and sleep quality. The study was conducted among residents in Malaysian aged care homes, aged 60 years and above. Anticholinergic burden was calculated using the Anticholinergic Cognitive Burden (ACB) scale. Health outcome measures included independence, assessed using the Katz Activities for Daily Living scale (Katz ADL); quality of life, assessed using the Older People’s Quality of Life Questionnaire (OPQOL); frailty, assessed using the Groningen Frailty Index (GFI); and sleep quality, measured using the Pittsburg Sleep Quality Index (PSQI). Just over one-third (36%) of the study population was exposed to at least one medication with anticholinergic effect. An increased anticholinergic cognitive burden was associated with frailty (p = 0.031), sleep latency (p = 0.007), and sleep disturbances (p = 0.015). Further studies are required to assess the effect of prolonged exposure to anticholinergic medications on health outcomes.
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Affiliation(s)
- Suresh Kumar
- Department of Pharmacy Practice, International Medical University, Kuala Lumpur 57000, Malaysia.
| | - Syed Shahzad Hasan
- Department of Pharmacy, University of Huddersfield, Huddersfield HD1 3DH, UK.
| | - Pei Se Wong
- Department of Pharmacy Practice, International Medical University, Kuala Lumpur 57000, Malaysia.
| | - David Weng Kwai Chong
- Department of Pharmacy Practice, International Medical University, Kuala Lumpur 57000, Malaysia.
| | - Therese Kairuz
- School of Biomedical Sciences and Pharmacy, University of Newcastle, New South Wales 2308, Australia.
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