51
|
Green AR, Reifler LM, Bayliss EA, Weffald LA, Boyd CM. Drugs Contributing to Anticholinergic Burden and Risk of Fall or Fall-Related Injury among Older Adults with Mild Cognitive Impairment, Dementia and Multiple Chronic Conditions: A Retrospective Cohort Study. Drugs Aging 2019; 36:289-297. [PMID: 30652263 DOI: 10.1007/s40266-018-00630-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND It is not known whether drugs with different anticholinergic ratings contribute proportionately to overall anticholinergic score. OBJECTIVES Our objective was to assess the risk of falls or fall-related injuries as a function of the overall anticholinergic score resulting from drugs with different anticholinergic ratings among people with impaired cognition. METHODS This was a retrospective cohort study of adults aged ≥ 65 years with mild cognitive impairment (MCI) or dementia and two or more additional chronic conditions (N = 10,698) in an integrated delivery system. Electronic health record data, including pharmacy fills and diagnosis claims, were used to assess anticholinergic medication use, quantified using the anticholinergic cognitive burden (ACB) scale, falls and fall-related injuries. RESULTS During a median follow-up of 366 days, 63% of the cohort used one or more ACB drug; 2015 (18.8%) people experienced a fall or fall-related injury. Among patients with a daily ACB score of 5, the greatest increase in risk of falls or fall-related injuries was seen when level 2 and level 3 drugs were used in combination [hazard ratio (HR) 2.06; 95% confidence interval (CI) 1.51-2.83]. Multiple ACB level 1 drugs taken together also increased the hazard of a fall or fall-related injury (HR 1.16; 95% CI 1.03-1.32). The risk of fall or fall-related injury as a function of exposure to ACB level 2 drugs (HR 1.56; 95% CI 1.16-2.10) was higher than that for ACB level 1 or 3 drugs. CONCLUSIONS The same daily ACB score was associated with a different degree of risk, depending on the ACB ratings of the individual drugs comprising the score. Combinations of level 2 and level 3 drugs had the greatest risk of fall or fall-related injury relative to other individuals with the same daily ACB score. Low-potency anticholinergic drugs taken together modestly increased the hazard of a fall or fall-related injury.
Collapse
Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th Floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA.
| | - Liza M Reifler
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA.,Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Linda A Weffald
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA.,University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th Floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA. .,Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
| |
Collapse
|
52
|
Nissan R, Brill S, Hershkovitz A. Association between anticholinergic drug prescription changes and rehabilitation outcome in post-acute hip fractured patients. Disabil Rehabil 2019; 42:2917-2922. [PMID: 30978127 DOI: 10.1080/09638288.2019.1576782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Purpose: To follow changes in anticholinergic drug prescriptions throughout hip fractured patients' rehabilitation; to assess whether a change in anticholinergic burden affects rehabilitation outcome.Methods: Retrospective study of 869 hip fractured patients admitted between January 2011 to October 2015, performed in a post-acute geriatric rehabilitation center. The Anticholinergic Cognitive Burden Scale quantified the anticholinergic burden. Main outcome measures: Functional Independence Measure, motor Functional Independence Measure, Montebello Rehabilitation Factor Score on motor Functional Independence Measure and length of stay. Multiple linear regression analysis tested for independent association between admission anticholinergic burden and anticholinergic burden change during rehabilitation, and rehabilitation outcomes.Results: One hundred and sixty two (18.7%) patients were prescribed additional anticholinergic medications upon discharge; 76 (8.7%) were prescribed fewer. Patients with high admission anticholinergic burden presented with a significantly higher rate of higher education, less likely to reside at home, less independent pre-fracture, exhibited a significantly lower admission and discharge Functional Independence Measure score, a lower Functional Independence Measure score change and a lower Montebello Rehabilitation Factor Score. Admission anticholinergic burden, but not changes in anticholinergic burden during rehabilitation, was found to be independently associated with rehabilitation outcome (discharge FIM score).Conclusions: High admission anticholinergic burden is associated with lower functional ability in hip fractured patients. Changes in anticholinergic drug prescription during rehabilitation were not associated with rehabilitation outcomes.Implications for rehabilitationClinicians should make an effort to reduce AC drug use in hip fractured patients on admission to post-acute rehabilitation.AC burden should be carefully monitored throughout the rehabilitation period and reduced whenever possible.When functional ability does not improve as expected, AC burden should be considered as an intervening factor.
Collapse
Affiliation(s)
- Ran Nissan
- Beit Rivka Geriatric Rehabilitation Center, Petach Tikva, Israel
| | - Shai Brill
- Beit Rivka Geriatric Rehabilitation Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Avital Hershkovitz
- Beit Rivka Geriatric Rehabilitation Center, Petach Tikva, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| |
Collapse
|
53
|
Jaggi A, Nazir J, Fatoye F, Siddiqui E, Choudhury N, Argoubi R, Ali M, de Ridder D, Drake MJ. Drug utilization patterns and healthcare resource use and costs in patients with neurogenic bladder in the United Kingdom: A retrospective primary care database study. Neurourol Urodyn 2019; 38:1278-1289. [PMID: 30924184 PMCID: PMC6850049 DOI: 10.1002/nau.23981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 01/29/2019] [Accepted: 03/01/2019] [Indexed: 12/02/2022]
Abstract
Aim To characterize patients with neurogenic bladder (NGB), their treatment patterns, healthcare resource utilization, and associated costs based on records from a primary care database in the United Kingdom. Methods This was a retrospective, descriptive, observational study of anonymized data from the Clinical Practice Research Datalink and Hospital Episode Statistics databases (selection period, 1 January 2004 to 31 December 2016). Adults with a definitive or probable diagnosis of NGB and ≥1 referral to a urologist were included. Results The study cohort included 3913 patients with definitive (n = 363) or probable (n = 3550) NGB. Patients had a mean of 8.6 (standard deviation [SD], 7.6) comorbidities, and mean Anticholinergic Cognitive Burden Scale score of 6.6 (SD, 5.9). During 12 months’ follow‐up, urinary tract infection (UTI) and urinary incontinence were the most common complications. Most patients (92.2%) received ≥1 prescription for an antimuscarinic agent or mirabegron, and 53.9% of patients received prescriptions for UTI‐specific antibiotics. The mean number of visits to a general practitioner for any cause was 67.7 (SD, 42.6) per individual. Almost half (46.7%) of the study cohort visited a specialist during the 12‐month follow‐up period, and 11.0% had ≥1 hospital admission. Total mean per patient costs for healthcare resource utilization was £2395. Conclusions The burden of illness, healthcare resource needs, and associated costs among patients with NGB are considerable. Drug prescribing patterns are consistent with the symptoms and complications of NGB, although increased awareness of drugs with anticholinergic activity among prescribers may help to reduce the cumulative anticholinergic burden in this vulnerable population.
Collapse
Affiliation(s)
- Ashley Jaggi
- Department of Health Professions, Manchester Metropolitan University, Manchester, United Kingdom.,Health Economics and Outcomes Research, Astellas Pharma Europe Ltd, Chertsey, United Kingdom
| | - Jameel Nazir
- Health Economics and Outcomes Research, Astellas Pharma Europe Ltd, Chertsey, United Kingdom
| | - Francis Fatoye
- Department of Health Professions, Manchester Metropolitan University, Manchester, United Kingdom
| | - Emad Siddiqui
- Health Economics and Outcomes Research, Astellas Pharma Europe Ltd, Chertsey, United Kingdom
| | - Nurul Choudhury
- Health Economics and Outcomes Research, Astellas Pharma Europe Ltd, Chertsey, United Kingdom
| | - Ramzi Argoubi
- Health Economics and Outcomes Research, Creativ-Ceutical SARL, Les Berges du lac, Tunisia
| | - Mahmood Ali
- Department of Health Professions, Manchester Metropolitan University, Manchester, United Kingdom.,Health Economics and Outcomes Research, Astellas Pharma Europe Ltd, Chertsey, United Kingdom
| | - Dirk de Ridder
- Department of Urology, Organ Systems, Development and Regeneration, University of Leuven, Leuven, Belgium
| | - Marcus J Drake
- School of Clinical Sciences, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| |
Collapse
|
54
|
Campbell NL, Perkins AJ, Khan BA, Gao S, Farber MO, Khan S, Wang S, Boustani MA. Deprescribing in the Pharmacologic Management of Delirium: A Randomized Trial in the Intensive Care Unit. J Am Geriatr Soc 2019; 67:695-702. [PMID: 30664239 DOI: 10.1111/jgs.15751] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 11/21/2018] [Accepted: 11/30/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Benzodiazepines and anticholinergics are risk factors for delirium in the intensive care unit (ICU). We tested the impact of a deprescribing intervention on short-term delirium outcomes. DESIGN Multisite randomized clinical trial. SETTING ICUs of three large hospitals. PARTICIPANTS Two hundred adults aged 18 years or older and admitted to an ICU with delirium, according to the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the ICU (CAM-ICU). Participants had a contraindication to haloperidol (seizure disorder or prolonged QT interval) or preference against haloperidol as a treatment for delirium, and were excluded for serious mental illness, stroke, pregnancy, or alcohol withdrawal. Participants were randomized to a deprescribing intervention or usual care. The intervention included electronic alerts combined with pharmacist support to deprescribe anticholinergics and benzodiazepines. MEASUREMENTS Primary outcomes were delirium duration measured by the CAM-ICU and severity measured by the Delirium Rating Scale Revised-98 (DRS-R-98) and the CAM-ICU-7; secondary outcomes included adverse events and mortality. RESULTS Participants had a mean age of 61.8 (SD = 14.3) years, 59% were female, and 52% were African American, with no significant differences in baseline characteristics between groups. No differences between groups were identified in the number exposed to anticholinergics (P = .219) or benzodiazepines (P = .566), the median total anticholinergic score (P = .282), or the median total benzodiazepine dose in lorazepam equivalents (P = .501). Neither median delirium/coma-free days (P = .361) nor median change in delirium severity scores (P = .582 for DRS-R-98; P = .333 for CAM-ICU-7) were different between groups. No differences in adverse events or mortality were identified. CONCLUSIONS When added to state-of-the-art clinical services, this deprescribing intervention had no impact on medication use in ICU participants. Given the age of the population, results of clinical outcomes may not be easily extrapolated to older adults. Nonetheless, improved approaches for deprescribing or preventing anticholinergics and benzodiazepines should be developed to determine the impact on delirium outcomes. J Am Geriatr Soc 67:695-702, 2019.
Collapse
Affiliation(s)
- Noll L Campbell
- Purdue University College of Pharmacy, West Lafayette, Indiana.,Indiana University Center for Aging Research, Indianapolis, Indiana.,Regenstrief Institute, Inc, Indianapolis, Indiana.,Indiana University Center for Health Innovation and Implementation Science and Indiana Clinical and Translational Sciences Institute, Indianapolis, Indiana.,Sandra Eskenazi Center for Brain Care Innovation at Eskenazi Health, Indianapolis, Indiana
| | - Anthony J Perkins
- Indiana University Center for Health Innovation and Implementation Science and Indiana Clinical and Translational Sciences Institute, Indianapolis, Indiana
| | - Babar A Khan
- Indiana University Center for Aging Research, Indianapolis, Indiana.,Regenstrief Institute, Inc, Indianapolis, Indiana.,Indiana University Center for Health Innovation and Implementation Science and Indiana Clinical and Translational Sciences Institute, Indianapolis, Indiana.,Sandra Eskenazi Center for Brain Care Innovation at Eskenazi Health, Indianapolis, Indiana.,Department of Medicine Indiana University School of Medicine, Indianapolis, Indiana
| | - Sujuan Gao
- Indiana University Center for Aging Research, Indianapolis, Indiana.,Regenstrief Institute, Inc, Indianapolis, Indiana.,Department of Medicine Indiana University School of Medicine, Indianapolis, Indiana
| | - Mark O Farber
- Department of Medicine Indiana University School of Medicine, Indianapolis, Indiana
| | - Sikandar Khan
- Indiana University Center for Aging Research, Indianapolis, Indiana.,Regenstrief Institute, Inc, Indianapolis, Indiana.,Department of Medicine Indiana University School of Medicine, Indianapolis, Indiana
| | - Sophia Wang
- Department of Medicine Indiana University School of Medicine, Indianapolis, Indiana.,Roudebush Veterans Administration Medical Center, Indianapolis, Indiana
| | - Malaz A Boustani
- Indiana University Center for Aging Research, Indianapolis, Indiana.,Regenstrief Institute, Inc, Indianapolis, Indiana.,Indiana University Center for Health Innovation and Implementation Science and Indiana Clinical and Translational Sciences Institute, Indianapolis, Indiana.,Sandra Eskenazi Center for Brain Care Innovation at Eskenazi Health, Indianapolis, Indiana.,Department of Medicine Indiana University School of Medicine, Indianapolis, Indiana
| |
Collapse
|
55
|
Culbertson VL, Rahman SE, Bosen GC, Caylor ML, Xu D. Use of a Bioinformatics-Based Toxicity Scoring System to Assess Serotonin Burden and Predict Population-Level Adverse Drug Events from Concomitant Serotonergic Drug Therapy. Pharmacotherapy 2019; 39:171-181. [PMID: 30620414 DOI: 10.1002/phar.2215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVE Numerous medications interact at serotonin (5-hydroxytryptamine [5-HT]) receptors directly or through off-target interactions, causing mild to severe serotonergic adverse drug events (ADEs), particularly among older adults. Our objective was to develop a novel molecular-based toxicity scoring system to assess serotonergic burden resulting from concurrently administered drugs. Quantitative methods to assess serotonergic burden may provide a useful clinical tool for improving pharmacotherapy. DESIGN Retrospective cohort study. DATA SOURCES PharMetrics Legacy health claims database (January 2001-December 2013) and ChEMBL bioactivity database. PATIENTS A 2-serotonergic drug exposure cohort (78,172 patients) and a 3-serotonergic drug exposure cohort (19,900 patients) were generated, and population-level statistics were collected. Nonexposure cohorts were created for each drug exposure cohort and matched in a 4:1 ratio for age, sex, and length of enrollment. MEASUREMENTS AND MAIN RESULTS Eight 5-HT medications were screened against multiple bioactivity databases to identify their off-target interactions at 5-HT receptors and serotonin reuptake transporter protein. A computational serotonin burden score (SBS) was derived from the receptor-specific interaction propensities reported from the comprehensive bioactivity screen. Linear regression was used to characterize associations between SBSs and combined total ADE incidence rate detected by International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes. A significantly greater incidence of 17 potential 5-HT-related ADEs was seen in exposed serotonergic drug cohorts (p<0.05). A positive correlation between SBS and overall ADE incidence rate in the 2-serotonergic drug exposure cohort (R2 = 0.69, p<0.34) and 3-drug cohort (R2 = 0.85, p<0.01) was observed. When both drug cohorts were combined, total drug SBSs strongly correlated with the composite 5-HT adverse event rate (R2 = 0.92, p<0.0001). Despite an increasing burden of illness, these data suggest that drug combinations with higher SBSs are associated with a higher rate of potential serotonergic ADEs. CONCLUSION In this test of concept, positive associations between SBSs and serotonin-related ADEs suggest that it may offer a pharmacologic-based foundation for developing risk assessment tools to assist in optimizing pharmacotherapy.
Collapse
Affiliation(s)
- Vaughn L Culbertson
- Kasiska Division of Health Sciences, Department of Pharmacy Practice and Administrative Sciences, College of Pharmacy, Idaho State University, Meridian, Idaho
| | - Shaikh Emdadur Rahman
- Kasiska Division of Health Sciences, Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, Idaho State University, Meridian, Idaho
| | - Grayson C Bosen
- Kasiska Division of Health Sciences, College of Pharmacy, Idaho State University, Meridian, Idaho
| | - Matthew L Caylor
- Kasiska Division of Health Sciences, Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, Idaho State University, Meridian, Idaho
| | - Dong Xu
- Kasiska Division of Health Sciences, Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, Idaho State University, Meridian, Idaho
| |
Collapse
|
56
|
Abstract
As the worldwide prevalence of dementia increases, there is a greater and more urgent need for all health care providers to understand how to evaluate and manage cognitive impairment. Many people presenting with a dementing illness have one or more reversible underlying conditions that worsen prognosis and, if treated, can improve cognitive function. This article reviews the major potentially reversible dementias, including the basic workup and management of each condition.
Collapse
Affiliation(s)
- Milta O Little
- Division of Geriatric Medicine, Department of Internal Medicine, Saint Louis University Health Center, 1402 South Grand Boulevard Room M238, St Louis, MO 63104, USA.
| |
Collapse
|
57
|
Andre L, Gallini A, Montastruc F, Coley N, Montastruc JL, Vellas B, Andrieu S, Gardette V. Anticholinergic exposure and cognitive decline in older adults: effect of anticholinergic exposure definitions in a 3-year analysis of the multidomain Alzheimer preventive trial (MAPT) study. Br J Clin Pharmacol 2018; 85:71-99. [PMID: 30098049 DOI: 10.1111/bcp.13734] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 06/19/2018] [Accepted: 07/27/2018] [Indexed: 01/02/2023] Open
Abstract
AIM The aim of the present study was to assess the association between anticholinergic (atropinic) burden and cognitive decline in older adults over the course of 3 years. METHODS We used data from Multidomain Alzheimer Preventive Trial (MAPT) study participants aged ≥70 years and at risk of cognitive decline. Cognitive function was assessed with a composite score [Mini-Mental State Examination (MMSE) orientation, Free and Cued Selective Reminding Test, Category Naming Test, Digit Symbol Substitution Test] at 12, 24 and 36 months. Participants declining by more than 0.236 points on the composite score (representing the lowest quintile of 1-year cognitive change) during any 1-year period were considered to have undergone cognitive decline. Anticholinergic exposure was defined by four methods for each of four anticholinergic scales (Anticholinergic Drug Scale, Anticholinergic Cognitive Burden, Anticholinergic Risk Scale, the Durán list). The association between cognitive decline and time-varying anticholinergic exposure [primary analysis using the Durán list and maximal anticholinergic score (0, 1 or 3)] was assessed using Cox proportional hazards models. Other cognitive decline definitions were used in sensitivity analyses. RESULTS At baseline, among 1396 patients included, 7.4-23.5% were exposed to anticholinergic agents, depending on the anticholinergic scale used. Sixty-four per cent of participants experienced cognitive decline during follow-up. Regardless of the anticholinergic scale/exposure measurement used, no significant association was observed with cognitive decline {primary analysis: compared with non-anticholinergic agent users, hazard ratio [HR] = 1.14 [95% confidence interval (CI) = 0.95, 1.38] for anticholinergic score = 1; HR = 0.92 [95% CI = 0.65, 1.30] for score = 3}. Results were stable in sensitivity analyses. CONCLUSION We found no significant association between anticholinergic exposure and cognitive decline in older adults using anticholinergic scales and definitions of exposure.
Collapse
Affiliation(s)
- Laurine Andre
- UMR INSERM 1027, Université de Toulouse, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), France.,Gérontopôle de Toulouse, Institut du Vieillissement, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France.,Service d'Epidémiologie, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France
| | - Adeline Gallini
- UMR INSERM 1027, Université de Toulouse, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), France.,Service d'Epidémiologie, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France
| | - François Montastruc
- UMR INSERM 1027, Université de Toulouse, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), France.,Service de Pharmacologie Médicale et Clinique, Centre Midi-Pyrénées de PharmacoVigilance, Pharmacoépidémiologie et d'Informations sur le Médicament, Centre Hospitalier Universitaire, Faculté de Médecine, Toulouse, France
| | - Nicola Coley
- UMR INSERM 1027, Université de Toulouse, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), France.,Service d'Epidémiologie, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France
| | - Jean-Louis Montastruc
- UMR INSERM 1027, Université de Toulouse, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), France.,Service de Pharmacologie Médicale et Clinique, Centre Midi-Pyrénées de PharmacoVigilance, Pharmacoépidémiologie et d'Informations sur le Médicament, Centre Hospitalier Universitaire, Faculté de Médecine, Toulouse, France
| | - Bruno Vellas
- UMR INSERM 1027, Université de Toulouse, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), France.,Gérontopôle de Toulouse, Institut du Vieillissement, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France
| | - Sandrine Andrieu
- UMR INSERM 1027, Université de Toulouse, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), France.,Service d'Epidémiologie, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France
| | - Virginie Gardette
- UMR INSERM 1027, Université de Toulouse, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), France.,Service d'Epidémiologie, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France
| | | |
Collapse
|
58
|
Ziad A, Olekhnovitch R, Ruiz F, Berr C, Bégaud B, Goldberg M, Zins M, Mura T. Anticholinergic drug use and cognitive performances in middle age: findings from the CONSTANCES cohort. J Neurol Neurosurg Psychiatry 2018; 89:1107-1115. [PMID: 30196250 PMCID: PMC6166611 DOI: 10.1136/jnnp-2018-318190] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 06/11/2018] [Accepted: 07/09/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND Previous studies have shown associations between the use of anticholinergics (AC) and cognitive performance in the elderly, considering AC as a homogeneous set of drugs. The present study aims to assess the relationship between exposure to AC drugs and cognitive performance in middle-aged adults according to AC potency and drug class. METHODS Our cross-sectional study used baseline data of 34 267 participants aged 45-70 from the Consultants des centres d'examen de santé de la sécurité sociale (CONSTANCES) cohort. The cumulative exposure to AC was measured using national reimbursement databases over the 3-year period preceding assessment of cognitive performance. Eight classes of AC drugs were differentiated. Episodic verbal memory, language abilities and executive functions were evaluated by validated neuropsychological tests. Analyses were controlled on lifestyle and health status variables. RESULTS This study showed a negative association between overall cumulative AC exposure and cognitive performances after adjustment. The use of drugs with possible AC effect according to the Anticholinergic Cognitive Burden scale (ACB-1 score) was only associated with executive functions. Analyses of AC exposure across drug classes showed a negative association between the use of AC antipsychotics and all cognitive functions assessed. Heterogeneous associations were found for the use of AC anxiolytics, AC opioids and AC drugs targeting the gastrointestinal tract or metabolism. We did not find significant associations between the use of antihistamines, antidepressants, cardiovascular system or other AC medications and cognitive function. CONCLUSION Association between AC drugs and cognitive performance was highly heterogeneous across drug classes; this heterogeneity will have to be considered by future studies.
Collapse
Affiliation(s)
- Abdelkrim Ziad
- ClinSearch -110, Malakoff, France.,Population-Based Epidemiological Cohorts Unit, UMS 011 Inserm-UVSQ, Paris, France.,Versailles Saint Quentin en-Yvelines University, Versailles, France.,Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U 1168, Paris, France
| | - Romain Olekhnovitch
- Population-Based Epidemiological Cohorts Unit, UMS 011 Inserm-UVSQ, Paris, France
| | | | - Claudine Berr
- INSERM, U1061, Neuropsychiatry: Epidemiological and Clinical Research, Montpellier, France.,Montpellier University Hospital, Montpellier University, Montpellier, France
| | - Bernard Bégaud
- INSERM, U1219-Pharmacoepidemiology, Université de Bordeaux, Bordeaux, France
| | - Marcel Goldberg
- Population-Based Epidemiological Cohorts Unit, UMS 011 Inserm-UVSQ, Paris, France.,Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U 1168, Paris, France.,Paris Descartes University, Paris, France
| | - Marie Zins
- Population-Based Epidemiological Cohorts Unit, UMS 011 Inserm-UVSQ, Paris, France.,Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U 1168, Paris, France.,Paris Descartes University, Paris, France
| | - Thibault Mura
- INSERM, U1061, Neuropsychiatry: Epidemiological and Clinical Research, Montpellier, France .,Montpellier University Hospital, Montpellier University, Montpellier, France
| |
Collapse
|
59
|
Green AR, Reifler LM, Boyd CM, Weffald LA, Bayliss EA. Medication Profiles of Patients with Cognitive Impairment and High Anticholinergic Burden. Drugs Aging 2018; 35:223-232. [PMID: 29404965 DOI: 10.1007/s40266-018-0522-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Drugs with anticholinergic properties are considered potentially inappropriate in patients with cognitive impairment because harms-including delirium, falls, and fractures-may outweigh benefits. OBJECTIVE To highlight opportunities to improve clinical decision making and care for patients with cognitive impairment and multiple chronic conditions, we identified distinct subgroups of patients with mild cognitive impairment (MCI) and dementia who had high cumulative anticholinergic burden and specific patterns of anticholinergic use. PATIENTS AND METHODS We conducted a retrospective cohort study in a not-for-profit, integrated delivery system. Participants included community-dwelling adults aged 65 years and older (n = 13,627) with MCI or dementia and at least two other chronic diseases. We calculated the Anticholinergic Cognitive Burden (ACB) score for each participant from pharmacy and electronic health record (EHR) data. Among individuals with a mean 12-month ACB score ≥ 2, we used agglomerative hierarchical clustering to identify groups or clusters of individuals with similar anticholinergic prescription patterns. RESULTS Twenty-four percent (3257 participants) had high anticholinergic burden, defined as an ACB score ≥ 2. Clinically meaningful clusters based upon anchoring medications or drug classes included a cluster of cardiovascular medications (n = 1497; 46%); two clusters of antidepressant medications (n = 633; 20%); and a cluster based on use of bladder antimuscarinics (n = 431; 13%). Several clusters comprised multiple central nervous system (CNS)-active drugs. CONCLUSIONS Cardiovascular and CNS-active medications comprise a substantial portion of anticholinergic burden in people with cognitive impairment and multiple chronic conditions. Antidepressants were highly prevalent. Clinical profiles elucidated by these clusters of anticholinergic medications can inform targeted approaches to care.
Collapse
Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th Floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA.
| | - Liza M Reifler
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Ave. Suite 300, Denver, CO, 80207, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th Floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Linda A Weffald
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Ave. Suite 300, Denver, CO, 80207, USA
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Ave. Suite 300, Denver, CO, 80207, USA.
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| |
Collapse
|
60
|
Yoshida M, Kato D, Nishimura T, Van Schyndle J, Uno S, Kimura T. Anticholinergic burden in the Japanese elderly population: Use of antimuscarinic medications for overactive bladder patients. Int J Urol 2018; 25:855-862. [DOI: 10.1111/iju.13758] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 05/08/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Masaki Yoshida
- Department of Urology; National Center for Geriatrics and Gerontology; Obu Japan
| | | | | | | | | | | |
Collapse
|
61
|
Welsh TJ, van der Wardt V, Ojo G, Gordon AL, Gladman JRF. Anticholinergic Drug Burden Tools/Scales and Adverse Outcomes in Different Clinical Settings: A Systematic Review of Reviews. Drugs Aging 2018; 35:523-538. [DOI: 10.1007/s40266-018-0549-z] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
62
|
Campbell NL, Lane KA, Gao S, Boustani MA, Unverzagt F. Anticholinergics Influence Transition from Normal Cognition to Mild Cognitive Impairment in Older Adults in Primary Care. Pharmacotherapy 2018; 38:511-519. [PMID: 29600808 DOI: 10.1002/phar.2106] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVE To determine the influence of anticholinergic medications on transitions in cognitive diagnosis of older adults in primary care. DESIGN This observational cohort study was conducted over a mean follow-up of 3.2 years. Anticholinergic exposure was defined by pharmacy dispensing and claims records. Cognitive diagnosis was performed by an expert panel at baseline and annually up to 4 years. DATA SOURCE Medication exposure and other clinical data were extracted from the Indiana Network for Patient Care (INPC). The cognitive diagnosis was derived from a cognitive screening and diagnosis study. PARTICIPANTS A total of 350 adults 65 years and older without dementia and receiving primary care in a safety net health care system. MEASUREMENT AND MAIN RESULTS Cognitive diagnosis followed a two-phase screening and consensus-based neuropsychiatric examination to determine a baseline diagnosis as normal cognition, mild cognitive impairment (MCI), or dementia, with a follow-up neuropsychiatric examination and consensus-based diagnosis repeated annually. The Anticholinergic Cognitive Burden scale was used to identify anticholinergics dispensed up to 10 years before enrollment and annually throughout the study. A total standard daily dose of anticholinergics was calculated by using pharmacy dispensing data from the INPC. Among 350 participants, a total of 978 diagnostic assessments were completed over a mean follow-up of 3.2 years. Compared with stable cognition, increasing use of strong anticholinergics calculated by total standard daily dose increased the odds of transition from normal cognition to MCI (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.01-1.31, p = 0.0342). Compared with stable MCI, strong anticholinergics did not influence the reversion of MCI to normal cognition (OR 0.95, 95% CI 0.86-1.05, p = 0.3266). CONCLUSION De-prescribing interventions in older adults with normal cognition should test anticholinergics as potentially modifiable risk factors for cognitive impairment.
Collapse
Affiliation(s)
- Noll L Campbell
- Purdue University College of Pharmacy, West Lafayette, IN.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, IN
| | - Kathleen A Lane
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Sujuan Gao
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN.,Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Malaz A Boustani
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, IN.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Fred Unverzagt
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
| |
Collapse
|
63
|
de Germay S, Lapeyre-Mestre M, Montastruc JL, Montastruc F. [Atropinic burden and anticholinergic drugs: Interest and application in clinical practice in the elderly]. Therapie 2018; 76:665-673. [PMID: 29625707 DOI: 10.1016/j.therap.2018.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 01/26/2018] [Accepted: 02/20/2018] [Indexed: 11/18/2022]
Abstract
Anticholinergic drugs (also called antimuscarinics or atropinics) increase the risk of falls, cognitive impairment and/or mortality in older patients. These drugs belong to the lists of potentially inappropriate medications in the elderly. The aim of this review was to present and discuss the different tools available to measure the atropinic risk in drug exposure of older patients. Several scales, developed from biological and/or clinical criteria, allow to classify anticholinergic drugs according to their atropinic potency and to assign to them an atropinic burden. Total atropinic burden of patient drug exposure can be calculated as the sum of atropinic score of each drug. Other tools include drug daily doses to better estimate the atropinic risk. These different methods are a precious help to decrease atropinic exposure in the elderly. Nevertheless, they have to be considered as upgradable and it is necessary to adapt them regularly according to the introduction of new drugs in clinical practice.
Collapse
Affiliation(s)
- Sibylle de Germay
- Service de pharmacologie médicale et clinique, centre hospitalier universitaire et faculté de médecine de Toulouse, 37, allées Jules-Guesde, 31000 Toulouse, France; UMR Inserm 1027, faculté de médecine, université de Toulouse, 31000 Toulouse, France.
| | - Maryse Lapeyre-Mestre
- Service de pharmacologie médicale et clinique, centre hospitalier universitaire et faculté de médecine de Toulouse, 37, allées Jules-Guesde, 31000 Toulouse, France; UMR Inserm 1027, faculté de médecine, université de Toulouse, 31000 Toulouse, France; Centre Midi-Pyrénées d'évaluation et d'information sur la pharmacodépendance et d'addictovigilance (CEIP-A), centre hospitalier universitaire de Toulouse, 31000 Toulouse, France
| | - Jean-Louis Montastruc
- Service de pharmacologie médicale et clinique, centre hospitalier universitaire et faculté de médecine de Toulouse, 37, allées Jules-Guesde, 31000 Toulouse, France; UMR Inserm 1027, faculté de médecine, université de Toulouse, 31000 Toulouse, France; Centre Midi-Pyrénées de pharmacovigilance, de pharmacoépidémiologie et d'informations sur le médicament et pharmacopôle Midi-Pyrénées, 31000 Toulouse, France
| | - François Montastruc
- Service de pharmacologie médicale et clinique, centre hospitalier universitaire et faculté de médecine de Toulouse, 37, allées Jules-Guesde, 31000 Toulouse, France; UMR Inserm 1027, faculté de médecine, université de Toulouse, 31000 Toulouse, France; Centre Midi-Pyrénées de pharmacovigilance, de pharmacoépidémiologie et d'informations sur le médicament et pharmacopôle Midi-Pyrénées, 31000 Toulouse, France
| |
Collapse
|
64
|
Fowler NR, Campbell NL, Pohl GM, Munsie LM, Kirson NY, Desai U, Trieschman EJ, Meiselbach MK, Andrews JS, Boustani MA. One‐Year Effect of the Medicare Annual Wellness Visit on Detection of Cognitive Impairment: A Cohort Study. J Am Geriatr Soc 2018; 66:969-975. [DOI: 10.1111/jgs.15330] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Nicole R. Fowler
- School of MedicineIndiana UniversityIndianapolis IN
- Regenstrief Institute, Center for Aging ResearchIndiana UniversityIndianapolis IN
- Sandra Eskenazi Center for Brain Care InnovationEskenazi HealthIndianapolis IN
| | - Noll L. Campbell
- School of MedicineIndiana UniversityIndianapolis IN
- Regenstrief Institute, Center for Aging ResearchIndiana UniversityIndianapolis IN
- Sandra Eskenazi Center for Brain Care InnovationEskenazi HealthIndianapolis IN
- College of PharmacyPurdue UniversityWest Lafayette IN
| | | | | | | | | | | | | | | | - Malaz A. Boustani
- School of MedicineIndiana UniversityIndianapolis IN
- Regenstrief Institute, Center for Aging ResearchIndiana UniversityIndianapolis IN
- Sandra Eskenazi Center for Brain Care InnovationEskenazi HealthIndianapolis IN
| |
Collapse
|
65
|
Rhee TG, Choi YC, Ouellet GM, Ross JS. National Prescribing Trends for High-Risk Anticholinergic Medications in Older Adults. J Am Geriatr Soc 2018; 66:1382-1387. [PMID: 29582410 DOI: 10.1111/jgs.15357] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To estimate prescribing tends of and correlates independently associated with high-risk anticholinergic prescriptions in adults aged 65 and older in office-based outpatient visits. DESIGN Repeated cross-sectional analysis. SETTING National Ambulatory Medical Care Survey (NAMCS). PARTICIPANTS A national sample of office-based physician visits by adults aged 65 and older from 2006 to 2015 (n=96,996 unweighted). MEASUREMENTS Prescriptions of high-risk anticholinergics, regardless of indication, were identified, and overall prescribing trends were estimated from 2006 to 2015. Stratified analyses of prescribing trends according to physician specialty and anticholinergic drug class were also performed. We used a multivariable logistic regression analysis to estimate the odds of high-risk anticholinergic prescription. RESULTS Between 2006 and 2015, a high-risk anticholinergic prescription was listed for 5,876 (6.2%) 96,996 visits of older adults, representative of 14.6 million total visits nationally. The most common drug classes were antidepressants, antimuscarinics, and antihistamines, which accounted for more than 70% of prescribed anticholinergics. Correlates independently associated with greater odds of receiving a high-risk anticholinergic prescription were female sex, the Southern geographic region, specific physician specialties (e.g., psychiatry, urology), receipt of 6 or more concomitantly prescribed medications, and related clinical diagnoses (e.g., urinary continence) (p<.01 for all). CONCLUSION The prevalence of high-risk anticholinergic prescriptions was stable over time but varied according to physician specialty and drug class. Quality prescribing should be promoted because safer alternatives are available.
Collapse
Affiliation(s)
- Taeho Greg Rhee
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale-New Haven Health System, New Haven, Connecticut
| | - Yookyung Christy Choi
- Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN
| | - Gregory M Ouellet
- Section of Geriatrics, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Health System, New Haven, Connecticut
- Section of General Internal Medicine, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
- Department of Health Policy and Management, School of Public Health, Yale University, New Haven, Connecticut
| |
Collapse
|
66
|
Holden RJ, Srinivas P, Campbell NL, Clark DO, Bodke KS, Hong Y, Boustani MA, Ferguson D, Callahan CM. Understanding older adults' medication decision making and behavior: A study on over-the-counter (OTC) anticholinergic medications. Res Social Adm Pharm 2018; 15:53-60. [PMID: 29559218 DOI: 10.1016/j.sapharm.2018.03.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/29/2018] [Accepted: 03/05/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Older adults purchase and use over-the-counter (OTC) medications with potentially significant adverse effects. Some OTC medications, such as those with anticholinergic effects, are relatively contraindicated for use by older adults due to evidence of impaired cognition and other adverse effects. OBJECTIVE To inform the design of future OTC medication safety interventions for older adults, this study investigated consumers' decision making and behavior related to OTC medication purchasing and use, with a focus on OTC anticholinergic medications. METHODS The study had a cross-sectional design with multiple methods. A total of 84 adults participated in qualitative research interviews (n = 24), in-store shopper observations (n = 39), and laboratory-based simulated OTC shopping tasks (n = 21). Simulated shopping participants also rank-ordered eight factors on their importance for OTC decision making. RESULTS Findings revealed that many participants had concerns about medication adverse effects, generally, but were not aware of age-related risk associated with the use of anticholinergic medications. Analyses produced a map of the workflow of OTC-related behavior and decision making as well as related barriers such as difficulty locating medications or comparing them to an alternative. Participants reported effectiveness, adverse effects or health risks, and price as most important to their OTC medication purchase and use decisions. A persona analysis identified two types of consumers: the habit follower, who frequently purchased OTC medications and considered them safe; and the deliberator, who was more likely to weigh their options and consider alternatives to OTC medications. CONCLUSION A conceptual model of OTC medication purchase and use is presented. Drawing on study findings and behavioral theories, the model depicts dual processes for OTC medication decision making - habit-based and deliberation-based - as well as the antecedents and consequences of decision making. This model suggests several design directions for consumer-oriented interventions to promote OTC medication safety.
Collapse
Affiliation(s)
- Richard J Holden
- Department of BioHealth Informatics, Indiana University School of Informatics and Computing - Indianapolis, IN, USA; Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA.
| | - Preethi Srinivas
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA
| | - Noll L Campbell
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA; Purdue University College of Pharmacy - Lafayette, IN, USA
| | - Daniel O Clark
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA; Indiana University School of Medicine - Indianapolis, IN, USA
| | - Kunal S Bodke
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA
| | - Youngbok Hong
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA; Indiana University Herron School of Art and Design - Indianapolis, IN, USA
| | - Malaz A Boustani
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA; Indiana University School of Medicine - Indianapolis, IN, USA; Indiana University Center for Health Innovation and Implementation Science, Indiana CTSI - Indianapolis, IN, USA
| | - Denisha Ferguson
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA
| | - Christopher M Callahan
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA; Indiana University School of Medicine - Indianapolis, IN, USA
| | | |
Collapse
|
67
|
Wang S, Allen D, Kheir YN, Campbell N, Khan B. Aging and Post-Intensive Care Syndrome: A Critical Need for Geriatric Psychiatry. Am J Geriatr Psychiatry 2018; 26:212-221. [PMID: 28716375 PMCID: PMC5711627 DOI: 10.1016/j.jagp.2017.05.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 05/29/2017] [Accepted: 05/29/2017] [Indexed: 01/31/2023]
Abstract
Because of the aging of the intensive care unit (ICU) population and an improvement in survival rates after ICU hospitalization, an increasing number of older adults are suffering from long-term impairments because of critical illness, known as post-intensive care syndrome (PICS). This article focuses on PICS-related cognitive, psychological, and physical impairments and the impact of ICU hospitalization on families and caregivers. The authors also describe innovative models of care for PICS and what roles geriatric psychiatrists could play in the future of this rapidly growing population.
Collapse
Affiliation(s)
- Sophia Wang
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN; Center of Health Innovation and Implementation Science, Center for Translational Science and Innovation, Indianapolis, IN; Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Hospital, Indianapolis, IN.
| | - Duane Allen
- Department of Internal Medicine, and Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - You Na Kheir
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
| | - Noll Campbell
- Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Hospital, Indianapolis, IN; Department of Pharmacy Practice, Purdue University School of Pharmacy, West Lafayette, IN; IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN
| | - Babar Khan
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN; Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Hospital, Indianapolis, IN; IU Center of Aging Research, Regenstrief Institute, Indianapolis, IN
| |
Collapse
|
68
|
Cognitive burden of anticholinergic medications in psychotic disorders. Schizophr Res 2017; 190:129-135. [PMID: 28390849 PMCID: PMC5628100 DOI: 10.1016/j.schres.2017.03.034] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 03/10/2017] [Accepted: 03/13/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients with psychotic disorders are often treated with numerous medications, many of which have anticholinergic activity. We assessed cognition in relation to the cumulative anticholinergic burden of multiple drugs included in treatment regimens of participants from the Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP) study. METHOD Clinically stable participants with schizophrenia (n=206), schizoaffective disorder (n=131), and psychotic bipolar disorder (n=146) were examined. Anticholinergic properties of all scheduled drugs were quantified using the Anticholinergic Drug Scale (ADS). ADS scores were summed across individual drugs to create a total ADS burden score for each participant and examined in relation to the Brief Assessment of Cognition in Schizophrenia (BACS). RESULTS Anticholinergic burden aggregated across all medications was inversely related to cognitive performance starting at ADS scores of 4 in participants with schizophrenia. Those with ADS scores ≥4 had lower composite BACS scores compared to those with ADS<4 (p=0.004). Among BACS subtests, Verbal Memory was the most adversely affected by high anticholinergic burden. Despite similar anticholinergic burden scores across groups, a significant threshold effect of anticholinergic burden was not detected in schizoaffective or psychotic bipolar disorder. CONCLUSION We identified an adverse effect threshold of anticholinergic burden on cognition in clinically stable participants with schizophrenia. This relationship was not identified in affective psychoses. Examination of other medications, doses, and clinical measures did not account for these findings. Patients with schizophrenia may have increased cognitive susceptibility to anticholinergic medications and the aggregate effects of one's medication regimen may be important to consider in clinical practice.
Collapse
|
69
|
Gerlach LB, Olfson M, Kales HC, Maust DT. Opioids and Other Central Nervous System-Active Polypharmacy in Older Adults in the United States. J Am Geriatr Soc 2017; 65:2052-2056. [PMID: 28467623 DOI: 10.1111/jgs.14930] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine patterns of and trends in contributions to central nervous system (CNS) polypharmacy, defined by the Beers Criteria as three or more CNS-active medications of each medication class, of adults aged 65 and older seen in U.S. outpatient medical practices. DESIGN National Ambulatory Medical Care Survey (2004-2013). SETTING U.S. outpatient medical care. PARTICIPANTS Visits by older adults to outpatient physicians (N = 97,910). MEASUREMENTS Visits including three or more CNS medications including antipsychotics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics (NBRAs), tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and opioids. The proportion of CNS polypharmacy that each medication class contributed during 2011 to 2013 was determined, and then logistic regression was used to determine trends from 2004 to 2013 in the contribution of individual medication classes to such polypharmacy. RESULTS Of recent CNS polypharmacy visits, 76.2% included an opioid, and 61.8% included a benzodiazepine; 66.0% of the polypharmacy visits with benzodiazepines included opioids, and 53.3% of the polypharmacy visits with opioids included benzodiazepines. Between 2011 and 2013, opioid and benzodiazepine co-prescribing occurred at approximately 1.50 million visits (95% confidence interval (CI) = 1.23-1.78 million) annually. From 2004 (reference) to 2013, the proportion of polypharmacy visits with opioids rose from 69.6% to 76.2% (adjusted odds ratio = 2.15, 95% CI = 1.19-3.91, P = .01), and the corresponding proportion that included benzodiazepines fell. Of the polypharmacy visits, the odds of SSRI, NBRA, and antipsychotic use were unchanged, and that of TCAs decreased. CONCLUSION In older adults, opioid use appears to be largely driving the recent national increase in CNS polypharmacy. Although concomitant use of opioids and benzodiazepines is associated with greater mortality, they are the most common contributors to CNS polypharmacy in older adults.
Collapse
Affiliation(s)
- Lauren B Gerlach
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Mark Olfson
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York.,New York State Psychiatric Institute, New York, New York
| | - Helen C Kales
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Donovan T Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan.,Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|