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Sørensen SR, Frederiksen JD, Anru PL, Masud T, Petrovic M, Rosholm JU, Ryg J. Use of Drugs with Anticholinergic Properties at Hospital Admission Associated with Mortality in Older Patients: A Danish Nationwide Register-Based Cohort Study. Drugs Real World Outcomes 2021; 9:129-140. [PMID: 34414558 PMCID: PMC8844340 DOI: 10.1007/s40801-021-00270-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Use of drugs with anticholinergic properties (DAP) has a negative impact on older people. OBJECTIVE Our aim was to examine the association between DAP at hospital admission and mortality in older patients. PATIENTS AND METHODS We performed a nationwide population-based cohort study including patients aged ≥ 65 years admitted to Danish geriatric medicine departments during 2005-2014. National health registers were used to link with individual-level data. Patients were followed to emigration, death, or study termination (31 December 2015). DAP was defined as medications included in the anticholinergic cognitive burden (ACB) scale, which assigns each DAP a score between 1 and 3. The individual ACB score was calculated and the number of DAP counted. We used Cox proportional-hazard regressions to estimate the crude and adjusted hazard ratios adjusting for age, activities of daily living, marital status, index admission period, BMI, and prior hospitalizations (model 1), and additionally Charlson Comorbidity Index (model 2). RESULTS We included 74,589 patients aged (median [IQR]) 83 (77-88) years. Use of one or more DAP (62.5%) was associated with increased mortality compared with those with no use (p < 0.001). In the fully adjusted model 2, compared with no use, higher mortality risks (HR [95% CI]) were seen with ACB score of 2 and number of DAP ≥ 5 for 30-day (1.46 [1.32-1.61] and 1.46 [1.09-1.95]), 1-year (1.34 [1.28-1.41] and 1.48 [1.29-1.70]), and overall mortality (1.27 [1.23-1.31] and 1.44 [1.31-1.59]), respectively. CONCLUSIONS Use of DAP at hospital admission is associated with short- and long-term mortality in geriatric patients. Deprescribing studies are warranted to study whether the impact on mortality can be attenuated.
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Affiliation(s)
- Søren Ramsdal Sørensen
- Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jeppe Dalskov Frederiksen
- Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Pavithra Laxsen Anru
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
| | - Tahir Masud
- Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Geriatric Department, Nottingham University Hospital, Nottingham, UK
| | - Mirko Petrovic
- Deaprtment of Geriatrics, Ghent University Hospital, Ghent, Belgium
| | - Jens-Ulrik Rosholm
- Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark.
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
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Mur J, Cox SR, Marioni RE, Muniz-Terrera G, Russ TC. Increase in anticholinergic burden from 1990 to 2015: Age-period-cohort analysis in UK biobank. Br J Clin Pharmacol 2021; 88:983-993. [PMID: 34409635 DOI: 10.1111/bcp.15045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/28/2021] [Accepted: 08/07/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The use of prescription drugs with anticholinergic properties has been associated with multiple negative health outcomes in older people. Moreover, recent evidence suggests that associated adverse effects may occur even decades after stopping anticholinergic use. Despite the implicated importance of examining longitudinal patterns of anticholinergic prescribing for different age groups, few such data are available. METHODS We performed an age-period-cohort (APC) analysis to study trends in an aggregate measure of anticholinergic burden between the years 1990 and 2015, utilising data from >220 000 UK Biobank participants with linked prescription data from primary care. RESULTS Anticholinergic burden in the sample increased up to 9-fold over 25 years and was observed for both period and age effects across most classes of drugs. The greatest increase was seen in the prescribing of antidepressants. Female sex, lower education and greater deprivation were associated with greater anticholinergic burden. CONCLUSIONS The increase in anticholinergic prescribing is mostly due to an increase in polypharmacy and is attributable to both ageing of participants and period-related changes in prescribing practices. Research is needed to clarify the implications of rising anticholinergic use for public health and to contextualise this rise in light of other relevant prescribing practices.
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Affiliation(s)
- Jure Mur
- Lothian Birth Cohorts Group, Department of Psychology, University of Edinburgh, Edinburgh, UK.,Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK.,Alzheimer Scotland Dementia Research Centre, University of Edinburgh, Edinburgh, UK
| | - Simon R Cox
- Lothian Birth Cohorts Group, Department of Psychology, University of Edinburgh, Edinburgh, UK
| | - Riccardo E Marioni
- Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Graciela Muniz-Terrera
- Edinburgh Dementia Prevention, University of Edinburgh, Edinburgh, UK.,Division of Psychiatry, Centre for Clinical Brain Science, University of Edinburgh, Edinburgh, UK
| | - Tom C Russ
- Alzheimer Scotland Dementia Research Centre, University of Edinburgh, Edinburgh, UK.,Edinburgh Dementia Prevention, University of Edinburgh, Edinburgh, UK.,Division of Psychiatry, Centre for Clinical Brain Science, University of Edinburgh, Edinburgh, UK
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Anticholinergic Burden and Associated Healthcare Resource Utilization in Older Adults with Overactive Bladder. Drugs Aging 2021; 38:911-920. [PMID: 34386936 PMCID: PMC8484210 DOI: 10.1007/s40266-021-00884-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2021] [Indexed: 10/28/2022]
Abstract
BACKGROUND Bladder anticholinergics are the most widely used drugs to treat overactive bladder (OAB) but can contribute to cumulative anticholinergic burden, which may be associated with adverse outcomes. OBJECTIVE This study aimed to evaluate the association between cumulative anticholinergic burden and healthcare resource utilization (HRU) and costs in older adults with OAB. MATERIALS AND METHODS This was a retrospective, observational study that used data from the UK Clinical Practice Research Datalink (CPRD) GOLD database. Participants were aged ≥ 65 years with ≥ 3 years of continuous enrolment before and ≥ 2 years after the index date (date of OAB diagnosis or first prescription for any OAB drug between 1 April 2007 and 31 December 2015). The primary endpoint was the association between cumulative anticholinergic burden (assessed using the Anticholinergic Cognitive Burden [ACB] scale during the 3-year pre-index period) and HRU (GP consultations, specialist referrals, urological tests, hospital admissions) over the 2-year post-index period. RESULTS Data from 23,561 adults were included in the analysis. Mean (SD) ACB scores in the pre- and post-index periods were 1.0 (1.1) and 2.4 (1.7), respectively; urological drugs contributed most (58.8%) to the latter. For the primary endpoint, higher pre-index ACB scores were associated with higher post-index HRU and costs. Mean (SD) ACB scores in the post-index period were 1.2 (1.3) and 2.5 (1.7) in those treated with mirabegron (beta-3 agonist) or bladder anticholinergics, respectively. LIMITATIONS The generalizability of the results outside the UK is unclear. CONCLUSIONS In older adults with OAB, higher anticholinergic burden before initiating OAB drugs is associated with higher HRU and costs. When making treatment decisions in older adults, consideration should be given to assessing the existing anticholinergic burden and using OAB treatments that do not add to this burden.
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Ruiz SJ, Cevallos V, Baskaran D, Mintzer MJ, Ruiz JG. The cross-sectional association of frailty with past and current exposure to strong anticholinergic drugs. Aging Clin Exp Res 2021; 33:2283-2289. [PMID: 33180283 DOI: 10.1007/s40520-020-01742-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 10/19/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Anticholinergic drugs may contribute to frailty by impairing cognitive and physical functions. Strong anticholinergic drugs in particular may have adverse effects among older adults. OBJECTIVES Determine the association between frailty and the use of strong anticholinergic drugs among older US Veterans. METHODS This is a cross-sectional study of community-dwelling Veterans 65 years and older who had determinations of frailty status. Prescription data for patients using strong anticholinergic medications (never/past/current) was obtained via electronic health records. A 31-item VA Frailty Index (VA-FI) was generated at the time of the assessment. We dichotomized the groups into non-frail (FI = < 0.21) and frail (FI ≥ 0.21) patients. We used binomial logistic regression to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Frailty was the dependent variable and use of strong anticholinergic drugs was the independent variable. Multivariate adjustment was conducted for age, gender, race, ethnicity, marital status, and BMI. RESULTS Population sample consisted of 17,084 Veterans who were 71.05% Caucasian, 97.34% male, and with a mean age 75.60 (SD = 8.04) years. Among the population, 9940 (58.18%) patients had no previous use of strong anticholinergic drugs, whereas 5182 (30.33%) had past exposure and 1962 (11.49%) had current exposure. In binomial logistic regression, individuals with past (OR 3.27, 95% CI 3.03-3.54, p < 0.0005) or current (OR 4.78, 95% CI 4.30-5.31, p < 0.0005) exposure showed a higher association with frailty as compared to individuals who were never exposed. CONCLUSIONS Past and current use of strong anticholinergic drugs were associated with frailty in older Veterans. These results suggest that screening for frailty in patients with past or current exposure to strong anticholinergic medications may be necessary for proper management.
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Affiliation(s)
- Sergio J Ruiz
- Miami VA Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Veterans Successful Aging for Frail Elders (VSAFE), 1201 NW 16th Street, Miami, FL, 33125, USA
| | - Victor Cevallos
- Miami VA Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Veterans Successful Aging for Frail Elders (VSAFE), 1201 NW 16th Street, Miami, FL, 33125, USA
| | - Dhanya Baskaran
- Miami VA Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Veterans Successful Aging for Frail Elders (VSAFE), 1201 NW 16th Street, Miami, FL, 33125, USA
| | - Michael J Mintzer
- Miami VA Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Veterans Successful Aging for Frail Elders (VSAFE), 1201 NW 16th Street, Miami, FL, 33125, USA
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jorge G Ruiz
- Miami VA Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Veterans Successful Aging for Frail Elders (VSAFE), 1201 NW 16th Street, Miami, FL, 33125, USA.
- University of Miami Miller School of Medicine, Miami, FL, USA.
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Jakob MO, Kofoed-Branzk M, Deshpande D, Murugan S, Klose CSN. An Integrated View on Neuronal Subsets in the Peripheral Nervous System and Their Role in Immunoregulation. Front Immunol 2021; 12:679055. [PMID: 34322118 PMCID: PMC8312561 DOI: 10.3389/fimmu.2021.679055] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/15/2021] [Indexed: 12/21/2022] Open
Abstract
The peripheral nervous system consists of sensory circuits that respond to external and internal stimuli and effector circuits that adapt physiologic functions to environmental challenges. Identifying neurotransmitters and neuropeptides and the corresponding receptors on immune cells implies an essential role for the nervous system in regulating immune reactions. Vice versa, neurons express functional cytokine receptors to respond to inflammatory signals directly. Recent advances in single-cell and single-nuclei sequencing have provided an unprecedented depth in neuronal analysis and allowed to refine the classification of distinct neuronal subsets of the peripheral nervous system. Delineating the sensory and immunoregulatory capacity of different neuronal subsets could inform a better understanding of the response happening in tissues that coordinate physiologic functions, tissue homeostasis and immunity. Here, we summarize current subsets of peripheral neurons and discuss neuronal regulation of immune responses, focusing on neuro-immune interactions in the gastrointestinal tract. The nervous system as a central coordinator of immune reactions and tissue homeostasis may predispose for novel promising therapeutic approaches for a large variety of diseases including but not limited to chronic inflammation.
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Affiliation(s)
- Manuel O Jakob
- Department of Microbiology, Infectious Diseases and Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Michael Kofoed-Branzk
- Department of Microbiology, Infectious Diseases and Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Divija Deshpande
- Department of Microbiology, Infectious Diseases and Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Shaira Murugan
- Department of BioMedical Research, Group of Visceral Surgery and Medicine, University of Bern, Bern, Switzerland
| | - Christoph S N Klose
- Department of Microbiology, Infectious Diseases and Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Oudewortel L, van der Roest HG, Onder G, Wijnen VJM, Liperoti R, Denkinger M, Finne-Soveri H, Topinková E, Henrard JC, van Gool WA. The Association of Anticholinergic Drugs and Delirium in Nursing Home Patients With Dementia: Results From the SHELTER Study. J Am Med Dir Assoc 2021; 22:2087-2092. [PMID: 34197793 DOI: 10.1016/j.jamda.2021.05.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 05/12/2021] [Accepted: 05/29/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Drugs with anticholinergic properties are associated with an increased prevalence of delirium, especially in older persons. The aim of this study was to evaluate the association between the use of this class of drugs in nursing home (NH) patients and prevalence of delirium, particularly in people with dementia. DESIGN Cross-sectional multicenter study. SETTING AND PARTICIPANTS 3924 nursing home patients of 57 nursing homes in 7 European countries participating in the Services and Health for Elderly in Long TERmcare (SHELTER) project. METHODS Descriptive statistics, calculation of percentage, and multivariable logistic analysis were applied to describe the relationship between anticholinergic drug use and prevalence of delirium in NH patients. The Anticholinergic Risk Scale (ARS) and the Anticholinergic Burden Scale (ACB) were used to calculate the anticholinergic load. RESULTS 54% of patients with dementia and 60% without dementia received at least 1 anticholinergic drug according to the ACB. The prevalence of delirium was higher in the dementia group (21%) compared with the nondementia group (11%). Overall, anticholinergic burden according to the ACB and ARS was associated with delirium both in patients with and without dementia, with odds ratios ranging from 1.07 [95% confidence interval (CI) 0.94-1.21] to 1.26 (95% CI 1.11-1.44). These associations reached statistical significance only in the group of patients with dementia. Among patients with dementia, delirium prevalence increased only modestly with increasing anticholinergic burden according to the ACB, from 20% (with none or minimal anticholinergic burden) to 25% (with moderate burden) and 27% delirium (with strong burden scores). CONCLUSIONS AND IMPLICATIONS The ACB scale is relatively capable to detect anticholinergic side effects, which are positively associated with prevalence of delirium in NH patients. Given the modest nature of this association, strong recommendations are currently not warranted, and more longitudinal studies are needed.
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Affiliation(s)
- Letty Oudewortel
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Amsterdam, the Netherlands.
| | - Henriëtte G van der Roest
- Department on Aging, Netherlands Institute of Mental Health and Addiction (Trimbos Institute), Utrecht, the Netherlands
| | - Graziano Onder
- Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Viona J M Wijnen
- Psychogeriatric Observation Unit, Institution for Mental Health Care, Parnassia Groep, the Netherlands
| | - Rosa Liperoti
- Fondazione Policlinico Universitario A. Gemelli IRCCS and Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michael Denkinger
- Agaplesion Bethesda Clinic, Geriatric Centre Ulm/Alb-Donau, Ulm University, Ulm, Germany
| | - Harriet Finne-Soveri
- Department of Welfare, National Institute for Health and Welfare, Helsinki, Finland
| | - Eva Topinková
- Department of Geriatrics, First Faculty of Medicine, Charles University, Prague, Czech Republic; Faculty of Health and Social Sciences, University of South Bohemia, Ceske Budejovice, Czech Republic
| | - Jean-Claude Henrard
- Research Unit Health-Environment-Ageing, Versailles-Saint-Quentin en Yvelines University, Paris, France
| | - Willem A van Gool
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Neilson V, Palmer S. The effectiveness of a multidisciplinary frailty team in reducing anticholinergic burden in frail older patients: A quantitative service evaluation. Geriatr Nurs 2021; 42:943-947. [PMID: 34130126 DOI: 10.1016/j.gerinurse.2021.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/10/2021] [Accepted: 04/13/2021] [Indexed: 01/19/2023]
Affiliation(s)
- Victoria Neilson
- Royal United Hospitals Bath NHS Foundation Trust, Bath, BA1 3NG, United Kingdom.
| | - Shea Palmer
- Musculoskeletal Rehabilitation, Faculty of Health and Applied Sciences University of West of England, Glenside Campus, Blackberry Hill, Stapleton, Bristol, BS16 1DD, UK
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Soysal T, Akın S, Durmuş NŞ, Gökçekuyu BM, Özer FF, Zararsız GE. Comparison of Anticholinergic Burden Measured with Three Different Anticholinergic Risk Scales and Association with Cognitive and Physical Functions in Older Adults. Arch Gerontol Geriatr 2021; 96:104451. [PMID: 34130072 DOI: 10.1016/j.archger.2021.104451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/30/2021] [Accepted: 05/24/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Tuba Soysal
- Erciyes University Faculty of Medicine, Department of Internal Medicine, Division of Geriatrics, Kayseri, 38090, Turkey.
| | - Sibel Akın
- Erciyes University Faculty of Medicine, Department of Internal Medicine, Division of Geriatrics, Kayseri, 38090, Turkey
| | - Nurdan Şentürk Durmuş
- Erciyes University Faculty of Medicine, Department of Internal Medicine, Division of Geriatrics, Kayseri, 38090, Turkey
| | - Bilge Müge Gökçekuyu
- Erciyes University Faculty of Medicine, Department of Internal Medicine, Division of Geriatrics, Kayseri, 38090, Turkey
| | - Firuzan Fırat Özer
- Erciyes University Faculty of Medicine, Department of Internal Medicine, Division of Geriatrics, Kayseri, 38090, Turkey
| | - Gözde Ertürk Zararsız
- Erciyes University Faculty of Medicine, Department of Biostatistics, Kayseri, 38090, Turkey
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Rodríguez-Ramallo H, Báez-Gutiérrez N, Prado-Mel E, Alfaro-Lara ER, Santos-Ramos B, Sánchez-Fidalgo S. Association between Anticholinergic Burden and Constipation: A Systematic Review. Healthcare (Basel) 2021; 9:healthcare9050581. [PMID: 34068348 PMCID: PMC8153334 DOI: 10.3390/healthcare9050581] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022] Open
Abstract
The association between anticholinergic burden and constipation is not well defined and documented; for this reason, a systematic review was carried out in five databases (Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and Scopus), including studies assessing the correlation between anticholinergic burden, and constipation between January 2006 and December 2020. Data extraction was conducted independently by two researchers. Abstracts and titles were reviewed to determine eligibility for review with eligible articles read in full. From 2507 identified articles, 11 were selected for this review: six cross-sectional studies, four retrospective cohort studies, and a post hoc analysis of a randomized clinical trial. Overall, nine studies reported at least one statistical association between anticholinergic burden and constipation, finding 13 positive results out of 24 association measurements. A total of 211,921 patients were studied. The association between constipation and anticholinergic burden could be demonstrated in studies including 207,795 patients. Most studies were not designed to find differences in constipation prevalence and did not adjust the results by confounding factors. Our findings suggest that a correlation between anticholinergic burden and constipation exists. Higher quality-evidence studies are needed, including analysis that considers confounding factors, such as other non-pharmacological causes of constipation.
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Affiliation(s)
- Héctor Rodríguez-Ramallo
- Pharmacy Department, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (H.R.-R.); (N.B.-G.); (E.P.-M.); (B.S.-R.)
| | - Nerea Báez-Gutiérrez
- Pharmacy Department, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (H.R.-R.); (N.B.-G.); (E.P.-M.); (B.S.-R.)
| | - Elena Prado-Mel
- Pharmacy Department, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (H.R.-R.); (N.B.-G.); (E.P.-M.); (B.S.-R.)
| | - Eva Rocío Alfaro-Lara
- Pharmacy Department, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (H.R.-R.); (N.B.-G.); (E.P.-M.); (B.S.-R.)
- Correspondence:
| | - Bernardo Santos-Ramos
- Pharmacy Department, Hospital Universitario Virgen del Rocío, 41013 Seville, Spain; (H.R.-R.); (N.B.-G.); (E.P.-M.); (B.S.-R.)
| | - Susana Sánchez-Fidalgo
- Department of Preventive Medicine and Public Health, Universidad de Sevilla, 41009 Seville, Spain;
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Jenraumjit R, Somboon J, Chainan S, Chuenchom P, Wongpakaran N, Wongpakaran T. Drug-related problems of antipsychotics in treating delirium among elderly patients: A real-world observational study. J Clin Pharm Ther 2021; 46:1274-1280. [PMID: 33768628 DOI: 10.1111/jcpt.13423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 03/01/2021] [Accepted: 03/12/2021] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Delirium is more common and life-threatening among the elderly. Currently, no other medications, including antipsychotics, have been approved for delirium. The number of practice guidelines recommends antipsychotics to be the first option among selected patients. This study aimed to identify the type of drug-related problems (DRPs) concerning antipsychotics use among elderly patients with delirium. METHODS A retrospective observational study was conducted by collecting data from 2013 to 2016 in Maharaj Nakorn Chiang Mai Hospital, Thailand. Inpatients who were 60 years and over, diagnosed with delirium by ICD-10 diseases coding F05.X and treated with antipsychotics for delirium were included. A modified version of the American Society of Hospital Pharmacists classification criteria (mASHP-delirium) was used. RESULTS AND DISCUSSION A total of 379 patients were enrolled. Mean daily dose of haloperidol (oral) was 1.06 ± 1.33 mg, haloperidol (intramuscular) 2.71 ± 1.88 mg, haloperidol (intravenous; IV) 3.42 ± 1.97 mg, risperidone was 0.71 ± 0.52 mg, and quetiapine was 19.26 ± 15.63 mg. Among all, 427 events were classified as DRPs. The most common DRPs included inappropriate duration, dose, route of administration or dosage form accounting for the 416 events (97.4%), followed by actual adverse drug reactions (extrapyramidal symptoms; EPS), 6 events (1.4%) and potential drug-drug interactions for 5 events (1.2%). Of those 416 events, 200 events (48.1%) antipsychotics were continued after discharge and continued for more than 10 days. Dosage exceeding initial dose or maximum daily dose accounted for 179 events (43.0%). Other DRPs such as inappropriate route haloperidol IV and receiving the extended-release dosage form of quetiapine involve 26 (6.3%) and 11 (2.6%) events, respectively. WHAT IS NEW AND CONCLUSION To the best of our knowledge, this is the first study using mASHP-delirium to identify DRPs of antipsychotics in treating delirium among elderly patients. Several DRPs were found that might lead to severe adverse drug reactions, particularly EPS and QTc interval prolongation. However, all DRPs could be prevented by developing antipsychotic setting protocols and specialty consulting systems to communicate among healthcare providers caring for vulnerable groups of patients. In addition, a prospective pharmacist intervention is required.
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Affiliation(s)
- Rewadee Jenraumjit
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Jinjuta Somboon
- Department of Pharmacy, Phayamengrai Hospital, Chiang Rai, Thailand
| | | | - Pao Chuenchom
- Department of Pharmacy, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand
| | - Nahathai Wongpakaran
- Geriatric Psychiatry Unit, Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Tinakon Wongpakaran
- Geriatric Psychiatry Unit, Department of Psychiatry, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Krüger C, Schäfer I, van den Bussche H, Bickel H, Fuchs A, Gensichen J, König HH, Maier W, Mergenthal K, Riedel-Heller SG, Schön G, Weyerer S, Wiese B, von Renteln-Kruse W, Langebrake C, Scherer M. Anticholinergic drug burden according to the anticholinergic drug scale and the German anticholinergic burden and their impact on cognitive function in multimorbid elderly German people: a multicentre observational study. BMJ Open 2021; 11:e044230. [PMID: 33757948 PMCID: PMC7993236 DOI: 10.1136/bmjopen-2020-044230] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The aims of our study were to examine the anticholinergic drug use and to assess the association between anticholinergic burden and cognitive function in the multimorbid elderly patients of the MultiCare cohort. SETTING MultiCare was conducted as a longitudinal cohort study in primary care, located in eight different study centres in Germany. PARTICIPANTS 3189 patients (59.3% female). PRIMARY AND SECONDARY OUTCOME MEASURES Baseline data were used for the following analyses. Drugs were classified according to the well-established anticholinergic drug scale (ADS) and the recently published German anticholinergic burden (German ACB). Cognitive function was measured using a letter digit substitution test (LDST) and a mixed-effect multivariate linear regression was performed to calculate the influence of anticholinergic burden on the cognitive function. RESULTS Patients used 1764 anticholinergic drugs according to ADS and 2750 anticholinergics according to the German ACB score (prevalence 38.4% and 53.7%, respectively). The mean ADS score was 0.8 (±1.3), and the mean German ACB score was 1.2 (±1.6) per patient. The most common ADS anticholinergic was furosemide (5.8%) and the most common ACB anticholinergic was metformin (13.7%). The majority of the identified anticholinergics were drugs with low anticholinergic potential: 80.2% (ADS) and 73.4% (ACB), respectively. An increasing ADS and German ACB score was associated with reduced cognitive function according to the LDST (-0.26; p=0.008 and -0.24; p=0.003, respectively). CONCLUSION Multimorbid elderly patients are in a high risk for using anticholinergic drugs according to ADS and German ACB score. We especially need to gain greater awareness for the contribution of drugs with low anticholinergic potential from the cardiovascular system. As anticholinergic drug use is associated with reduced cognitive function in multimorbid elderly patients, the importance of rational prescribing and also deprescribing needs to be further evaluated. TRIAL REGISTRATION NUMBER ISRCTN89818205.
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Affiliation(s)
- Caroline Krüger
- Department of Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ingmar Schäfer
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hendrik van den Bussche
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Horst Bickel
- Department of Psychiatry, Technical University of Munich, Munich, Germany
| | - Angela Fuchs
- Institute of General Practice, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Jochen Gensichen
- Institute of General Practice and Family Medicine, Ludwig-Maximilians-Universitat Munich, Munich, Germany
- Institut for General Practice, Jena University Hospital, Jena, Germany
| | - Hans-Helmut König
- Department for Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Maier
- Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany
| | - Karola Mergenthal
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Siegfried Weyerer
- Department of Medical Faculty Mannheim/Heidelberg, Central Institute of Mental Health, Mannheim, Germany
| | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Wolfgang von Renteln-Kruse
- Department of Research, Albertinen-Haus Zentrum fur Geriatrie und Gerontologie Medizinisch-Geriatrische Klinik, Hamburg, Germany
| | - Claudia Langebrake
- Department of Hospital Pharmacy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Scherer
- Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Anticholinergic load and delirium in end-of-life patients. Eur J Clin Pharmacol 2021; 77:1419-1424. [PMID: 33733683 DOI: 10.1007/s00228-021-03125-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Delirium is a neuropsychiatric syndrome associated with negative outcomes, including worsening of cognitive and functional status and an increased burden on patients and caregivers. Medications with anticholinergic effect have been associated with delirium symptoms, but the relationship is still debated. OBJECTIVE To assess the relation between delirium and anticholinergic load according to the hypothesis that the cumulative anticholinergic burden increases the risk of delirium. METHODS This retrospective cross-sectional study was conducted in a sample of end-of-life patients in a hospice or living at home between February and August 2019. Delirium was diagnosed on admission using the 4 'A's Test (4AT) and each patient's anticholinergic burden was measured with the Anticholinergic Cognitive Burden (ACB) scale. RESULTS Of the 461 eligible for analysis, 124 (26.9%) had delirium. Anticholinergic medications were associated with an increased risk of delirium in univariate (OR (95% CI) 1.26 (1.16-1.38), p < 0.0001) and multivariate models adjusted for age, sex, dementia, tumors, Karnofsky Performance Status (KPS) score, days of palliative assistance, and setting (OR (95% CI) 1.16 (1.05-1.28), p < 0.0001). Patients with delirium had a greater anticholinergic burden than those without, with a dose-effect relationship between total ACB score and delirium. Patients who scored 4 or more had 2 or 3 times the risk of delirium than those not taking anticholinergic drugs. The dose-response relationship was maintained in the multivariate model. CONCLUSIONS Anticholinergic drugs may influence the development of delirium due to the cumulative effect of multiple medications with modest antimuscarinic activity.
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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: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [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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Rice SD, Kim N, Farris C. Anticholinergic Cognitive Burden in Older People Over Acute Admission. Sr Care Pharm 2021; 36:104-111. [PMID: 33509334 DOI: 10.4140/tcp.n.2021.104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE: To evaluate the change of geriatric anticholinergic cognitive burden (ACB) over acute admission for fall, fracture, or altered mental status (AMS) with a secondary endpoint of associated 30-day all-cause readmission.<br/> DESIGN: Retrospective, single-center chart review.<br/> SETTING: An academic, 636-bed level-I trauma and tertiary care hospital in Texas.<br/> PATIENTS, PARTICIPANTS: Participants at least 65 years of age admitted for acute fall, fracture, or AMS between January 1, 2014, and August 31, 2018. A total of 265 participants were included; average age was 83 years, with 56% female.<br/> MAIN OUTCOME MEASURES: Change in ACB of home medications from hospital admission to discharge.<br/> RESULTS: At admission, ACB averaged 2.6 with 43.4% of participants having clinically significant scores, defined as ACB greater than or equal to 3. Overall, ACB decreased by 0.1 by discharge with 63.8% and 13.9% of participants having no change and increases in their ACB over admission, respectively. Clinically significant anticholinergic burden at discharge was significantly associated with 30-day all-cause readmission (P<0.001).<br/> CONCLUSIONS: Anticholinergic burden in older people admitted for fall, fracture, or AMS is not consistently intervened upon in this acute care setting. Strategies to optimize deprescribing in this setting are needed.
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Affiliation(s)
- Shannon D Rice
- 1The University of Texas at Tyler Ben and Maytee Fisch College of Pharmacy, Tyler, Texas
| | - Nina Kim
- 2HEOR Evidence and Strategy Generation, Novo Nordisk, Plainsboro Township, New Jersey
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Martignon C, Pedrinolla A, Ruzzante F, Giuriato G, Laginestra FG, Bouça-Machado R, Ferreira JJ, Tinazzi M, Schena F, Venturelli M. Guidelines on exercise testing and prescription for patients at different stages of Parkinson's disease. Aging Clin Exp Res 2021; 33:221-246. [PMID: 32514871 DOI: 10.1007/s40520-020-01612-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 05/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Exercise is highly recommended in patients with Parkinson's disease (PD). Exercise-induced amelioration of motor, non-motor, and drug-induced symptoms are widely known. However, specific guidelines on exercise testing and prescription in PD are lacking. OBJECTIVE This study reviews the literature on exercise-based approaches to the management of symptoms at each stage of the disease and evaluate: (1) the most suitable clinical exercise testing; (2) training programs based on testing outcomes and PD stage; (3) the effects of exercise on antiparkinsonian drugs and to suggest the most effective exercise-medication combination. METHODS A systematic search was conducted using the databases MEDLINE, Google Scholar and, Cochrane Library using "Parkinson's Disease AND Physical therapy", "Training AND Parkinson", "Exercise", "Exercise AND Drug" as key words. In addition, references list from the included articles were searched and cross-checked to identify any further potentially eligible studies. RESULTS Of a total of 115 records retrieved, 50 (43%) were included. From these, 23 were included under the rubric "exercise testing"; 20 focused on the effectiveness of different types of exercise in PD motor-functional symptoms and neuroprotective effects, throughout disease progression, were included under the rubric "training protocol prescription"; and 7 concern the rubric "interaction between exercise and medication", although none reported consistent results. CONCLUSIONS Despite the lack of standardized parameters for exercise testing and prescription, all studies agree that PD patients should be encouraged to regularly train according to their severity-related limitations and their personalized treatment plan. In this manuscript, specific guidelines for tailored clinical testing and prescription are provided for each stage of PD.
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Sargent L, Nalls M, Amella EJ, Mueller M, Lageman SK, Bandinelli S, Colpo M, Slattum PW, Singleton A, Ferrucci L. Anticholinergic Drug Induced Cognitive and Physical Impairment: Results from the InCHIANTI Study. J Gerontol A Biol Sci Med Sci 2021; 75:995-1002. [PMID: 30590397 DOI: 10.1093/gerona/gly289] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The aims of this study were to evaluate the relationship between anticholinergic drug burden (ACB) cognitive impairment, physical frailty, and cognitive frailty, and to determine if ACB is predictive of these phenotypes when modeled with biological and genomic biomarkers. METHODS In a retrospective cohort study, a total of 1,453 adults aged 20-102 years were used to examine ACB as a predictor for cognitive impairment, physical frailty, and cognitive frailty. Anticholinergic burden is examined as a predictor for all phenotypes in a cross-sectional analysis using logistic, ordinal regression models, and Extreme Gradient Boosting for population predictive modeling. RESULTS A significant association was found between ACB and cognitive decline (p = .02), frailty (p < .001), and cognitive frailty (p < .001). The odds of cognitive impairment increased by 1.21 (95% confidence interval [CI] = 1.06-1.37, p < .001), odds of being frail increased by 1.33 (95% CI = 1.18-1.50, p < .001), and odds of having cognitive frailty increased by 1.36 (95% CI = 1.21-1.54, p < .001). Population modeling results indicated ACB score as one of the stronger predictors for cognitive impairment, physical frailty, and cognitive frailty with area under the curves ranging from 0.81 to 0.88. CONCLUSIONS Anticholinergic medications are a potentially modifiable risk factor for the prevention of cognitive and physical decline. Identification of reversible causes for cognitive and physical impairment is critical for the aging population. These findings encourage new research that may lead to effective interventions for deprescribing programs for the prevention of cognitive and physical decline in older adults.
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Affiliation(s)
- Lana Sargent
- Laboratory of Neurogenetics, National Institute on Aging, National Institutes of Health, Bethesda, Maryland.,Virginia Commonwealth University School of Nursing, Richmond, Virginia.,Medical University of South Carolina School of Nursing, Charleston, South Carolina
| | - Mike Nalls
- Laboratory of Neurogenetics, National Institute on Aging, National Institutes of Health, Bethesda, Maryland.,Department of Neurology, Virginia Commonwealth School of Medicine, Richmond, Virginia
| | - Elaine J Amella
- Medical University of South Carolina School of Nursing, Charleston, South Carolina
| | - Martina Mueller
- Medical University of South Carolina School of Nursing, Charleston, South Carolina
| | - Sarah K Lageman
- Laboratory of Clinical Epidemiology, InCHIANTI Study Group, Local Health Unit Tuscany Center, Florence, Italy
| | | | - Marco Colpo
- Data Tecnica International, Glen Echo, Maryland
| | - Patricia W Slattum
- Department of Pharmacotherapy & Outcome Science, Virginia Commonwealth School of Pharmacy, Richmond, Virginia
| | - Andrew Singleton
- Laboratory of Neurogenetics, National Institute on Aging, National Institutes of Health, Bethesda, Maryland
| | - Luigi Ferrucci
- Longitudinal Studies Section, Translational Gerontology Branch, National Institute on Aging, Baltimore, Maryland
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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] [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] [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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Lavrador M, Castel-Branco MM, Cabral AC, Veríssimo MT, Figueiredo IV, Fernandez-Llimos F. Association between anticholinergic burden and anticholinergic adverse outcomes in the elderly: Pharmacological basis of their predictive value for adverse outcomes. Pharmacol Res 2020; 163:105306. [PMID: 33248197 DOI: 10.1016/j.phrs.2020.105306] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 01/25/2023]
Abstract
The use of anticholinergic drugs and other drugs with anticholinergic activity is highly prevalent in older people. Cumulative anticholinergic effects, known as anticholinergic burden, are associated with important peripheral and central adverse effects and outcomes. Several methods have been developed to quantify anticholinergic burden and to estimate the risk of adverse anticholinergic effects. Serum anticholinergic activity (SAA) and anticholinergic burden scoring systems are the most commonly used methods to predict the occurrence of important negative outcomes. These tools could guide clinicians in making more rational prescriptions to enhance patient safety, especially in older people. However, the literature has reported conflicting results about the predictive ability of these tools. The majority of these instruments ignore relevant pharmacologic aspects such as the doses used, differential muscarinic receptor subtype affinities, and blood-brain barrier permeability. To increase the clinical relevance of these tools, mechanistic and clinical pharmacology should collaborate. This narrative review describes the rational and pharmacological basis of anticholinergic burden tools and provides insight about their predictive value for adverse outcomes.
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Affiliation(s)
- Marta Lavrador
- University of Coimbra, Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal.
| | - M Margarida Castel-Branco
- University of Coimbra, Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal.
| | - Ana C Cabral
- University of Coimbra, Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal.
| | - Manuel T Veríssimo
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; University of Coimbra, Faculty of Medicine, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal.
| | - Isabel V Figueiredo
- University of Coimbra, Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal.
| | - Fernando Fernandez-Llimos
- University of Porto, Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy. Rua Jorge Viterbo 228, 4050-313 Porto, Portugal; CINTESIS - Center for Health Technology and Services Research, University of Porto, Porto, Portugal.
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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] [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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Attoh-Mensah E, Loggia G, Schumann-Bard P, Morello R, Descatoire P, Marcelli C, Chavoix C. Adverse Effects of Anticholinergic Drugs on Cognition and Mobility: Cutoff for Impairment in a Cross-Sectional Study in Young-Old and Old-Old Adults. Drugs Aging 2020; 37:301-310. [PMID: 31930459 DOI: 10.1007/s40266-019-00743-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Drugs with anticholinergic properties are commonly prescribed in older adults despite growing evidence of their adverse outcomes. Several issues regarding these detrimental effects remain unresolved, such as the putative existence of a threshold above which anticholinergic drug consumption impairs cognitive or mobility performance. OBJECTIVES We aimed to investigate the number of anticholinergic drugs and the anticholinergic burden that leads to mobility or cognitive impairment and compare the effects in community-dwelling older adults in two age groups ("young-old" 55-74 vs. "old-old" ≥ 75 years). METHODS In a cross-sectional study, we identified drugs with anticholinergic (antimuscarinic) properties using the Anticholinergic Drug Scale. Cognition was assessed using the Mini Mental State Examination (MMSE) and the Trail Making Test (TMT-A and TMT-B), and mobility was assessed using the Timed Up and Go (TUG) test. RESULTS The study population consisted of 177 volunteers, 114 of whom were classed as young-old and 63 were classed as old-old adults. Despite the lack of cutoff values for impaired outcomes in young-old adults, impaired MMSE were significantly more numerous in users than in nonusers of anticholinergic drugs. In old-old adults, receiver operating characteristic (ROC) curve analysis indicated that taking a single anticholinergic drug per day was associated with impaired TMT-B completion time, TMT difference score (B-A), and TUG scores. The cutoff for anticholinergic burden was also one for these same outcomes. Based on these cutoff values, multivariate logistic regressions in old-old adults showed that the increased risk of impaired cognition and mobility was independent of confounding factors, including comorbidities. They also suggested that anticholinergic drugs would affect mobility through executive functions. CONCLUSIONS Drugs with anticholinergic (antimuscarinic) properties are associated with cognitive impairment in individuals as young as 55 years, and only one such drug per day, regardless of its anticholinergic burden, is associated with both impaired cognition and impaired mobility in old-old adults. Therefore, wherever possible, clinicians should avoid prescribing drugs with anticholinergic properties.
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Affiliation(s)
- Elpidio Attoh-Mensah
- INSERM, UniCaen, U1075, COMETE, PFRS, Normandie University, 2 rue des Rochambelles, 14000, Caen Cedex, France
| | - Gilles Loggia
- INSERM, UniCaen, U1075, COMETE, PFRS, Normandie University, 2 rue des Rochambelles, 14000, Caen Cedex, France
- Department of Geriatrics, CHU Caen, 14000, Caen, France
| | - Pascale Schumann-Bard
- INSERM, UniCaen, U1075, COMETE, PFRS, Normandie University, 2 rue des Rochambelles, 14000, Caen Cedex, France
| | - Rémy Morello
- Department of Statistics and Clinical Research, CHU Caen, 14000, Caen, France
| | - Pablo Descatoire
- INSERM, UniCaen, U1075, COMETE, PFRS, Normandie University, 2 rue des Rochambelles, 14000, Caen Cedex, France
- Department of Geriatrics, CHU Caen, 14000, Caen, France
| | - Christian Marcelli
- INSERM, UniCaen, U1075, COMETE, PFRS, Normandie University, 2 rue des Rochambelles, 14000, Caen Cedex, France
- Department of Rheumatology, CHU Caen, 14000, Caen, France
| | - Chantal Chavoix
- INSERM, UniCaen, U1075, COMETE, PFRS, Normandie University, 2 rue des Rochambelles, 14000, Caen Cedex, France.
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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: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [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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Kulthanan K, Ungprasert P, Tuchinda P, Chularojanamontri L, Rujitharanawong C, Kiratiwongwan R, Jantanapornchai N, Hawro T, Maurer M. Symptomatic Dermographism: A Systematic Review of Treatment Options. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3141-3161. [DOI: 10.1016/j.jaip.2020.05.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/04/2020] [Accepted: 05/16/2020] [Indexed: 11/29/2022]
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Michels G, Sieber CC, Marx G, Roller-Wirnsberger R, Joannidis M, Müller-Werdan U, Müllges W, Gahn G, Pfister R, Thürmann PA, Wirth R, Fresenborg J, Kuntz L, Simon ST, Janssens U, Heppner HJ. [Geriatric intensive care : Consensus paper of DGIIN, DIVI, DGAI, DGGG, ÖGGG, ÖGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG]. Med Klin Intensivmed Notfmed 2020; 115:393-411. [PMID: 31278437 DOI: 10.1007/s00063-019-0590-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.
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Affiliation(s)
- Guido Michels
- Klinik III für Innere Medizin, Herzzentrum, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - Cornel C Sieber
- Institut für Biomedizin des Alterns, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nürnberg, Deutschland
| | - Gernot Marx
- Klinik für Operative Intensivmedizin und Intermediate Care, Medizinische Fakultät, RWTH Aachen, Aachen, Deutschland
| | | | - Michael Joannidis
- Gemeinsame Einrichtung für Internistische Intensiv- und Notfallmedizin, Department Innere Medizin, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Ursula Müller-Werdan
- Klinik für Geriatrie und Altersmedizin, Evangelisches Geriatriezentrum Berlin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Wolfgang Müllges
- Neurologische Klinik und Poliklinik, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Georg Gahn
- Neurologische Klinik, Städtisches Klinikum Karlsruhe gGmbH, Karlsruhe, Deutschland
| | - Roman Pfister
- Klinik III für Innere Medizin, Herzzentrum, Universität zu Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Petra A Thürmann
- Lehrstuhl für Klinische Pharmakologie, Helios Universitätsklinkum Wuppertal, Universität Witten/Herdecke, Wuppertal, Deutschland
| | - Rainer Wirth
- Klinik für Altersmedizin und Frührehabilitation, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Deutschland
| | - Jana Fresenborg
- Seminar für Allgemeine BWL und Management im Gesundheitswesen, Universität zu Köln, Köln, Deutschland
| | - Ludwig Kuntz
- Seminar für Allgemeine BWL und Management im Gesundheitswesen, Universität zu Köln, Köln, Deutschland
| | - Steffen T Simon
- Zentrum für Palliativmedizin, Uniklinik Köln, Köln, Deutschland
| | - Uwe Janssens
- Klinik für Innere Medizin und Internistische Intensivmedizin, St.-Antonius-Hospital Eschweiler, Eschweiler, Deutschland
| | - Hans Jürgen Heppner
- Institut für Biomedizin des Alterns, Friedrich-Alexander-Universität Erlangen-Nürnberg, Nürnberg, Deutschland
- Geriatrische Klinik und Tagesklinik, Lehrstuhl für Geriatrie, HELIOS Klinikum Schwelm, Universität Witten/Herdecke, Schwelm, Deutschland
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Pattern of treatment of behavioural and psychological symptoms of dementia and pain: evidence on pharmacoutilization from a large real-world sample and from a centre for cognitive disturbances and dementia. Eur J Clin Pharmacol 2020; 77:241-249. [PMID: 32935181 PMCID: PMC7803691 DOI: 10.1007/s00228-020-02995-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/10/2020] [Indexed: 01/06/2023]
Abstract
Purpose Data concerning the number of diagnoses and of the drugs prescribed to patients affected by dementia are still scarce. Here we test whether or not (1) prescription of symptomatic drugs against Alzheimer’s disease (AD) may approximate the number of patients affected by dementia in Italy and (2) adherence to this treatment affects the pattern of prescription of drugs (i.e. antipsychotics and antidepressants) for behavioural and psychological symptoms of dementia (BPSD) and the previously reported limited prescription of analgesics. Methods This retrospective observational study concerns 84,235 subjects older than 60 years and registered in the provincial prescription database of the health district of Cosenza accounting for a population of 298,000 inhabitants. The prescribing pattern of antipsychotics, antidepressants, and analgesics has been investigated in patients receiving concurrent prescriptions of acetylcholinesterase inhibitors (AChEI) and/or memantine. Data from a single centre for cognitive disturbances and dementia (CDCD) in the same health district were used to explore at which stage dementia was diagnosed. The study was approved by Calabria Region Ethical Committee no. 31/2017 and registered on October 31, 2017. Results The data show that 859 patients are treated with AChEI and/or memantine; 420 patients (48.89%) receive at least 80% of the recommended medications. CDCD data indicate a delay in dementia diagnosis, which often was made when the patients were moderately to severely demented (Mini Mental State Examination, MMSE ≤ 20). Adherence did not influence prescription of most of the drugs explored, but use of non-steroidal anti-inflammatory drugs was higher in non-adherent patients. Antipsychotics and antidepressants are frequently used (20.61–20.71% and 42.37–51.43%, respectively), and this, at least in part, might stem from the observed under-treatment of chronic pain (opioids are prescribed in the 4.76% and 12.46% of adherent and non-adherent patients and gabapentin and pregabalin are used in the 4.29% and 4.07% of adherent and non-adherent patients respectively), resulting in more frequent BPSD. 16.43% of patients receive antipsychotics for longer than 6–12 weeks. Conclusion This 2-year period study, including a wide cohort of community demented patients, shows that dementia is diagnosed late and that prevalence of BPSD prescriptions is high and not impacted by adherence to anti-dementia drugs. The rate of prescription of potentially harmful antipsychotics and antidepressants appears to be high though whether the concomitantly observed limited prescription of analgesics might be a contributing factor needs to be further investigated. Our data support the development of strategies to improve the management of BPSD.
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Ogawa Y, Nibe F, Ogawa R, Sakoh M. Anticholinergic and Sedative Drug Burden and Functional Recovery after Cerebrovascular Accident: A Retrospective Descriptive Study. Prog Rehabil Med 2020; 5:20200010. [PMID: 32789278 PMCID: PMC7365194 DOI: 10.2490/prm.20200010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 05/07/2020] [Indexed: 11/23/2022] Open
Abstract
Objectives: Medications with anticholinergic or sedative effects induce impaired cognitive and
physical performances. The aim of this study was to evaluate the associations of
anticholinergic and sedative drug burden with recovery of physical function and
activities of daily living in patients admitted to a Japanese rehabilitation hospital
after cerebrovascular accidents. Methods: We retrospectively reviewed the medical records of patients aged 18 years or older who
had undergone the inpatient rehabilitation program for cerebrovascular disease in Nerima
Ken-ikukai Hospital. Patients who did not complete the rehabilitation program because of
acute unexpected changes of physical or psychological condition or the need for surgical
procedures were excluded. The primary outcome was recovery of activities of daily living
as measured by the motor and cognitive subscores of the Functional Independence Measure.
The secondary outcome was recovery of physical function as assessed by the 10-m walk
test and the Berg balance scale. Multiple Cox proportional hazard regression analyses
were conducted to calculate hazard ratios with 95% confidence intervals for the outcome
measures. Results: Of 122 patients included in the study, 81 (66%) were exposed to anticholinergics and
sedatives. Patients’ age, body mass index, and average daily drug burden during
hospitalization were independently associated with achieving the cutoff Functional
Independence Measure–motor subscore. Patients’ age and average daily drug burden during
hospitalization were independently associated with achieving the Berg balance scale
cut-off score. Conclusions: Our study of Japanese patients who were transferred from acute stroke care hospitals
to a rehabilitation facility identified the drug burden of anticholinergics and
sedatives as an independent factor associated with the time to recovery of activities of
daily living and postural balance.
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Affiliation(s)
- Yukari Ogawa
- Department of Pharmacy, Faculty of Pharmacy, Musashino University, Tokyo, Japan
| | - Futoshi Nibe
- Convalescent Rehabilitation Center, Nerima Ken-ikukai Hospital, Tokyo, Japan
| | - Ryuichi Ogawa
- Department of Pharmacotherapy, Meiji Pharmaceutical University, Tokyo, Japan
| | - Masaharu Sakoh
- Convalescent Rehabilitation Center, Nerima Ken-ikukai Hospital, Tokyo, Japan
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The Swedish SPinal Cord Injury Study on Cardiopulmonary and Autonomic Impairment: Methodology, Cohort Demographics, and Initial Results. Am J Phys Med Rehabil 2020; 99:522-531. [PMID: 32167960 DOI: 10.1097/phm.0000000000001365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to present the methodology, cohort demographics, and initial results of the Swedish SPinal Cord Injury Study on Cardiopulmonary and Autonomic Impairment (SPICA). DESIGN The SPICA is based on the Swedish CArdioPulmonary BioImage Study, a study on cardiopulmonary diseases in a cohort of 30,000 people. The assessments in the SPICA cover the structure and function of the cardiopulmonary and autonomic systems using bioimaging and functional analyses, together with a study-specific questionnaire and generic and spinal cord injury-specific assessment tools. The inclusion criteria were as follows: age 50-65 yrs, traumatic spinal cord injury of 5 yrs or more, and injury levels C1-T6, American Spinal Injury Association Impairment Scale A-C. RESULTS Of 38 potential participants, 25 comprised the final sample (20% women, mean age 58 yrs, mean time since injury 28 yrs). Eight percent had sustained a cardiovascular event, and 72% were classified as a high risk for cardiovascular disease. Asthma was previously diagnosed in only 8%, and none had chronic obstructive pulmonary disease. CONCLUSIONS The risk for cardiovascular disease in people with severe high-level spinal cord injury is a major clinical concern. Forthcoming studies in the SPICA will provide new knowledge of cardiopulmonary health in this cohort, which can guide future research and be used to develop long-term management.
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Dykewicz MS, Wallace DV, Amrol DJ, Baroody FM, Bernstein JA, Craig TJ, Dinakar C, Ellis AK, Finegold I, Golden DBK, Greenhawt MJ, Hagan JB, Horner CC, Khan DA, Lang DM, Larenas-Linnemann DES, Lieberman JA, Meltzer EO, Oppenheimer JJ, Rank MA, Shaker MS, Shaw JL, Steven GC, Stukus DR, Wang J, Dykewicz MS, Wallace DV, Dinakar C, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Khan DA, Lang DM, Lieberman JA, Oppenheimer JJ, Rank MA, Shaker MS, Stukus DR, Wang J, Dykewicz MS, Wallace DV, Amrol DJ, Baroody FM, Bernstein JA, Craig TJ, Finegold I, Hagan JB, Larenas-Linnemann DES, Meltzer EO, Shaw JL, Steven GC. Rhinitis 2020: A practice parameter update. J Allergy Clin Immunol 2020; 146:721-767. [PMID: 32707227 DOI: 10.1016/j.jaci.2020.07.007] [Citation(s) in RCA: 138] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 06/22/2020] [Accepted: 07/01/2020] [Indexed: 12/12/2022]
Abstract
This comprehensive practice parameter for allergic rhinitis (AR) and nonallergic rhinitis (NAR) provides updated guidance on diagnosis, assessment, selection of monotherapy and combination pharmacologic options, and allergen immunotherapy for AR. Newer information about local AR is reviewed. Cough is emphasized as a common symptom in both AR and NAR. Food allergy testing is not recommended in the routine evaluation of rhinitis. Intranasal corticosteroids (INCS) remain the preferred monotherapy for persistent AR, but additional studies support the additive benefit of combination treatment with INCS and intranasal antihistamines in both AR and NAR. Either intranasal antihistamines or INCS may be offered as first-line monotherapy for NAR. Montelukast should only be used for AR if there has been an inadequate response or intolerance to alternative therapies. Depot parenteral corticosteroids are not recommended for treatment of AR due to potential risks. While intranasal decongestants generally should be limited to short-term use to prevent rebound congestion, in limited circumstances, patients receiving regimens that include an INCS may be offered, in addition, an intranasal decongestant for up to 4 weeks. Neither acupuncture nor herbal products have adequate studies to support their use for AR. Oral decongestants should be avoided during the first trimester of pregnancy. Recommendations for use of subcutaneous and sublingual tablet allergen immunotherapy in AR are provided. Algorithms based on a combination of evidence and expert opinion are provided to guide in the selection of pharmacologic options for intermittent and persistent AR and NAR.
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Affiliation(s)
- Mark S Dykewicz
- Section of Allergy and Immunology, Division of Infectious Diseases, Allergy and Immunology, Department of Internal Medicine, School of Medicine, Saint Louis University, St Louis, Mo.
| | - Dana V Wallace
- Department of Medicine, Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - David J Amrol
- Department of Internal Medicine, School of Medicine, University of South Carolina, Columbia, SC
| | - Fuad M Baroody
- Department of Otolaryngology-Head and Neck Surgery, Pritzker School of Medicine, University of Chicago, Chicago, Ill
| | - Jonathan A Bernstein
- Allergy Section, Division of Immunology, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Timothy J Craig
- Departments of Medicine and Pediatrics, Penn State University, Hershey, Pa
| | - Chitra Dinakar
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, School of Medicine, Stanford University, Stanford, Calif
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ira Finegold
- Division of Allergy and Immunology, Department of Medicine, Mount Sinai West, New York, NY
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Department of Medicine, School of Medicine, John Hopkins University, Baltimore, Md
| | - Matthew J Greenhawt
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, School of Medicine, University of Colorado, Aurora, Colo
| | - John B Hagan
- Division of Allergic Diseases, Mayo Clinic, Rochester, Minn
| | - Caroline C Horner
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, School of Medicine, Washington University, St Louis, Mo
| | - David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Tex
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio
| | | | - Jay A Lieberman
- Division of Pulmonology Allergy and Immunology, Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tenn
| | - Eli O Meltzer
- Division of Allergy and Immunology, Department of Pediatrics, School of Medicine, University of California, San Diego, Calif; Allergy and Asthma Medical Group and Research Center, San Diego, Calif
| | - John J Oppenheimer
- Division of Pulmonary & Critical Care Medicine and Allergic & Immunologic Diseases, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, New Brunswick, NJ; Pulmonary and Allergy Associates, Morristown, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | | | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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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: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [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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Albertson TE, Pugashetti JV, Chau-Etchepare F, Chenoweth JA, Murin S. Pharmacotherapeutic management of asthma in the elderly patient. Expert Opin Pharmacother 2020; 21:1991-2010. [PMID: 32686969 DOI: 10.1080/14656566.2020.1795131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Asthma is a heterogeneous syndrome with variable phenotypes. Reversible airway obstruction and airway hyper-responsiveness often with an atopic or eosinophilic component is common in the elderly asthmatic. Asthma chronic obstructive pulmonary disease overlap syndrome (ACOS), a combination of atopy-mediated airway hyper-responsiveness and a history of smoking or other environmental noxious exposures, can lead to some fixed airway obstruction and is also common in elderly patients. Little specific data exist for the treating the elderly asthmatic, thus requiring the clinician to extrapolate from general adult data and asthma treatment guidelines. AREAS COVERED A stepwise approach to pharmacotherapy of the elderly patient with asthma and ACOS is offered and the literature supporting the use of each class of drugs reviewed. EXPERT OPINION Inhaled, long-acting bronchodilators in combination with inhaled corticosteroids represent the backbone of treatment for the elderly patient with asthma or ACOS . Beyond these medications used as direct bronchodilators and topical anti-inflammatory agents, a stepwise approach to escalation of therapy includes multiple options such as oral leukotriene receptor antagonist or 5-lipoxygense inhibitor therapy, oral phosphodiesterase inhibitors, systemic corticosteroids, oral macrolide antibiotics and if evidence of eosinophilic/atopic component disease exists then modifying monoclonal antibody therapies.
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Affiliation(s)
- Timothy E Albertson
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Emergency Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Janelle V Pugashetti
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Florence Chau-Etchepare
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - James A Chenoweth
- Department of Emergency Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
| | - Susan Murin
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, School of Medicine, U. C. Davis , Sacramento, CA, USA.,Department of Medicine, Veterans Administration Northern California Health Care System , Mather, CA, USA
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Naharci MI, Tasci I. Frailty status and increased risk for falls: The role of anticholinergic burden. Arch Gerontol Geriatr 2020; 90:104136. [PMID: 32563737 DOI: 10.1016/j.archger.2020.104136] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/19/2020] [Accepted: 06/02/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE OF THE STUDY Frailty leads to serious adverse outcomes including falls. The relationship between frailty and falls has not been evaluated in the context of the side effects of drugs with anticholinergic properties. The aim of this study was to examine the potential association of anticholinergic burden (ACB) with the risk of falls among frail older adults. DESIGN AND METHODS Community-dwelling older adults were consecutively selected from the geriatrics outpatient clinic. Based on a fall history in the last 12 months, the participants were grouped as fallers and non-fallers. Frailty status was assessed by Fried's phenotype method. Exposure to anticholinergic medications was estimated using the ACB scale, and the participants were classified into ACB_0 (none), ACB_1 (possible) and ACB_2+ (definite). RESULTS The study included 520 older adults (mean age 77.7 years, 62.7 % female), with a fall prevalence of 25.8 % 12 months past. The proportions of frailty and pre-frailty were 33.1 % and 57.4 %, respectively. After adjustment for study confounders, receiving at least 1 drug with either possible or definite anticholinergic properties was independently associated to falls in frail [OR = 3.84 (1.48-9.93), p = 0.006] and pre-frail participants [OR = 2.71 (1.25-5.89); p = 0.012], but not in robust subjects. Moreover, ACB was significantly associated with the frailty components on adjusted analysis (p's<0.05). IMPLICATIONS Current study showed that the use of any drugs with possible or definite anticholinergic properties was associated with an increased risk of falls in frail older adults. The results emphasize the importance of medication management with respect to fall prevention in these patients.
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Affiliation(s)
- Mehmet Ilkin Naharci
- University of Health Sciences, Gulhane Faculty of Medicine & Gulhane Training and Research Hospital, Division of Geriatrics, Ankara, 06010, Turkey.
| | - Ilker Tasci
- University of Health Sciences, Gulhane Faculty of Medicine & Gulhane Training and Research Hospital, Department of Internal Medicine, Ankara, Turkey
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82
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Zerah L, Bihan K, Kohler S, Mariani LL. Iatrogenesis and neurological manifestations in the elderly. Rev Neurol (Paris) 2020; 176:710-723. [PMID: 32389421 DOI: 10.1016/j.neurol.2019.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/22/2019] [Accepted: 11/26/2019] [Indexed: 12/20/2022]
Abstract
Older people are often exposed to polypharmacy in a multimorbidity context. Inappropriate polypharmacy is often harmful, increasing the risk of inappropriate prescriptions and therefore adverse drug events (ADEs). Five to 20% of all hospital admissions are related to ADE in older people, among which 40 to 70% could be prevented. However, identifying ADEs and drug-related admissions in the elderly is challenging because ADEs often present as common geriatric problems such as falls, delirium, which might be due to the aging process, underlying diseases, and/or medications. In the pharmacovigilance database of the World Health Organization, drug-related neurological manifestations are the third reported cause of ADEs in the elderly, and neurological drugs are the third leading class of medications involved in ADEs. We must therefore be particularly vigilant, both in our prescriptions but also in our diagnoses to avoid prescribing inappropriate treatments and detect ADEs. Even though multiple pharmacologic changes occur in the elderly (absorption, distribution, drug metabolism and excretion), most of medications are still often prescribed at the same daily dosage as in young adults. When prescribing any drug for old patients, we should remember that daily intake should be adapted to these specificities, keeping in mind the old well-known aphorism "start low, go slow". In this review, we describe the main drug-related neurological manifestations (drug-induced movement disorders, falls, seizures, delirium, hypoglycemia, stroke, hyponatremia, peripheral neuropathy and myopathy, and serotonin syndrome) and the main drugs associated with neurological manifestations (dopamine receptor blocking agents, antithrombotics, anticholinergics, beta-lactams, antidepressants, benzodiazepines, mood stabilizers).
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Affiliation(s)
- L Zerah
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpitaux Universitaires Pitié-Salpêtrière-Charles Foix, Département de gériatrie, 75013 Paris, France
| | - K Bihan
- Sorbonne Université, Assistance Publique Hôpitaux de Paris, Regional Pharmacovigilance Center, Department of Pharmacology, Pitié-Salpêtrière Hospital, Paris, France
| | - S Kohler
- Hôpital Bretonneau, Service de Gériatrie à Orientation Psychiatrique - DMU INVICTUS - Paris nord Université - Assistance Publique-Hôpitaux de Paris, Paris, France
| | - L-L Mariani
- Sorbonne University, Assistance Publique-Hôpitaux de Paris, Brain and Spine Institute, ICM, Inserm U 1127, CNRS UMR 7225, Department of Neurology, Pitié-Salpêtrière Hospital, 75013 Paris, France.
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83
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Tan MP, Tan GJ, Mat S, Luben RN, Wareham NJ, Khaw KT, Myint PK. Use of Medications with Anticholinergic Properties and the Long-Term Risk of Hospitalization for Falls and Fractures in the EPIC-Norfolk Longitudinal Cohort Study. Drugs Aging 2020; 37:105-114. [PMID: 31808140 DOI: 10.1007/s40266-019-00731-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The consumption of medications with anticholinergic activity has been suggested to result in the adverse effects of mental confusion, visual disturbance, and muscle weakness, which may lead to falls. Existing published evidence linking anticholinergic drugs with falls, however, remains weak. This study was conducted to evaluate the relationship between anticholinergic cognitive burden (ACB) and the long-term risk of hospitalization with falls and fractures in a large population study. The dataset comprised information from 25,639 men and women (aged 40-79 years) recruited from 1993 to 1997 from Norfolk, United Kingdom into the European Prospective Investigation into Cancer (EPIC)-Norfolk study. The time to first hospital admission with a fall with or without fracture was obtained from the National Health Service hospital information system. Cox-proportional hazards analyses were conducted to adjust for confounders and competing risks. The fall hospitalization rate was 5.8% over a median follow-up of ~ 19.4 years. The unadjusted incidence rate ratio for the use of any drugs with anticholinergic properties was 1.79 (95% CI 1.66-1.93). The hazard ratios (95% CI) for ACB scores of 1, 2-3, and ≥ 4 compared with ACB = 0 for fall hospitalization were 1.20 (1.09-1.33), 1.42 (1.25-1.60), and 1.39 (1.21-1.60) after adjustment for age, gender, medical conditions, physical activity, and blood pressure. Medications with anticholinergic activity are associated with an increased risk of subsequent hospitalization with a fall over a 19-year follow-up period. The biological mechanisms underlying the long-term risk of hospitalization with a fall or fracture following baseline ACB exposure remains unclear and requires further evaluation.
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Affiliation(s)
- Maw Pin Tan
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia.
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
- Department of Medical Sciences, Faculty of Healthcare and Medical Sciences, Sunway University, Bandar Sunway, Malaysia.
| | - Guo Jeng Tan
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Sumaiyah Mat
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Robert N Luben
- Clinical Gerontology Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Kay-Tee Khaw
- Clinical Gerontology Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Phyo Kyaw Myint
- Clinical Gerontology Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
- Ageing Clinical and Experimental Research (ACER) Team, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK.
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84
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Mueller A, Spies CD, Eckardt R, Weiss B, Pohrt A, Wernecke KD, Schmidt M. Anticholinergic burden of long-term medication is an independent risk factor for the development of postoperative delirium: A clinical trial. J Clin Anesth 2020; 61:109632. [DOI: 10.1016/j.jclinane.2019.109632] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 09/16/2019] [Accepted: 09/27/2019] [Indexed: 01/23/2023]
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Arain MA, Graham L, Ahmad A, Cole M. Pilot implementation of elder-friendly care practices in acute care setting: a mixed methods study. BMC Health Serv Res 2020; 20:347. [PMID: 32331521 PMCID: PMC7181575 DOI: 10.1186/s12913-020-05091-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 03/09/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Frail older patients are at risk of experiencing a decline in physical and cognitive function unrelated to the reason for admission. The Elder-Friendly Care (EFC) program was designed to improve the care, experiences, and outcomes of frail older adults. The project supported 8 Early Adoption Sites (EAS) in a large Canadian healthcare organization by providing multiple strategies, educational opportunities, and resources. The purpose of this study was to assess the usefulness of EFC educational materials and resources, staff practice changes and perceptions in pilot sites, and readiness for scale and spread. METHODS The study was conducted from May 2017 to June 2018 using a mixed-methods approach incorporating the Kirkpatrick Model of Training/Evaluation. A total of 76 Direct Care Staff participated in the staff survey, which assessed their awareness of, satisfaction with, and utilization of EFC principles, resources, and practices. Additionally, 12 interviews were conducted with staff who were directly involved in site implementation of EFC. RESULTS Most survey participants were aware (86%, n = 63) of the EFC program, and 85% (n = 41) indicated they or their site/unit had implemented EFC. Out of these 41 participants, the most common practice changes identified were: incorporating alternatives to restraint (81%, n = 33), decreased use of pharmacological restraint (78%, n = 32), and patient and family care planning (76%, n = 31). Participants that attended all 3 EFC Learning Workshops (LWs) were significantly more likely to recommend the EFC Toolkit to others (87% versus 40%; χ2 = 8.82, p < 0.01) compared to participants attending less than 3 EFC LWs. Interview participants indicated that the program was well structured and flexible as sites/units could adopt changes that suited their individual sites, needs, contexts, and challenges. CONCLUSIONS The educational materials and resources used for the EFC project are useful and appreciated by the Direct Care Staff. Further, participants perceive the EFC intervention as effective in creating positive practice change and useful in reducing hospital-related complications for older patients. Future implementation will investigate the impact of EFC on system-level outcomes in acute care.
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Affiliation(s)
- Mubashir Aslam Arain
- Alberta Health Services, Health Systems Evaluation and Evidence, Provincial Clinical Excellence, 10301 Southport Lane SW, Calgary, AB, T2W 1S7, Canada.
| | - Laura Graham
- Alberta Health Services, Health Systems Evaluation and Evidence, Provincial Clinical Excellence, 10301 Southport Lane SW, Calgary, AB, T2W 1S7, Canada
| | - Armghan Ahmad
- Alberta Health Services, Health Systems Evaluation and Evidence, Provincial Clinical Excellence, 10301 Southport Lane SW, Calgary, AB, T2W 1S7, Canada
| | - Mollie Cole
- Alberta Health Services, Seniors Health Strategic Clinical Networks, Calgary, AB, Canada
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Brueckle MS, Thomas ET, Seide SE, Pilz M, Gonzalez-Gonzalez AI, Nguyen TS, Harder S, Glasziou PP, Gerlach FM, Muth C. Adverse drug reactions associated with amitriptyline - protocol for a systematic multiple-indication review and meta-analysis. Syst Rev 2020; 9:59. [PMID: 32183872 PMCID: PMC7079360 DOI: 10.1186/s13643-020-01296-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 02/16/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Unwanted anticholinergic effects are both underestimated and frequently overlooked. Failure to identify adverse drug reactions (ADRs) can lead to prescribing cascades and the unnecessary use of over-the-counter products. The objective of this systematic review and meta-analysis is to explore and quantify the frequency and severity of ADRs associated with amitriptyline vs. placebo in randomized controlled trials (RCTs) involving adults with any indication, as well as healthy individuals. METHODS A systematic search in six electronic databases, forward/backward searches, manual searches, and searches for Food and Drug Administration (FDA) and European Medicines Agency (EMA) approval studies, will be performed. Placebo-controlled RCTs evaluating amitriptyline in any dosage, regardless of indication and without restrictions on the time and language of publication, will be included, as will healthy individuals. Studies of topical amitriptyline, combination therapies, or including < 100 participants, will be excluded. Two investigators will screen the studies independently, assess methodological quality, and extract data on design, population, intervention, and outcomes ((non-)anticholinergic ADRs, e.g., symptoms, test results, and adverse drug events (ADEs) such as falls). The primary outcome will be the frequency of anticholinergic ADRs as a binary outcome (absolute number of patients with/without anticholinergic ADRs) in amitriptyline vs. placebo groups. Anticholinergic ADRs will be defined by an experienced clinical pharmacologist, based on literature and data from Martindale: The Complete Drug Reference. Secondary outcomes will be frequency and severity of (non-)anticholinergic ADRs and ADEs. The information will be synthesized in meta-analyses and narratives. We intend to assess heterogeneity using meta-regression (for indication, outcome, and time points) and I2 statistics. Binary outcomes will be expressed as odds ratios, and continuous outcomes as standardized mean differences. Effect measures will be provided using 95% confidence intervals. We plan sensitivity analyses to assess methodological quality, outcome reporting etc., and subgroup analyses on age, dosage, and duration of treatment. DISCUSSION We will quantify the frequency of anticholinergic and other ADRs/ADEs in adults taking amitriptyline for any indication by comparing rates for amitriptyline vs. placebo, hence, preventing bias from disease symptoms and nocebo effects. As no standardized instrument exists to measure it, our overall estimate of anticholinergic ADRs may have limitations. SYSTEMATIC REVIEW REGISTRATION Submitted to PROSPERO; assignment is in progress.
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Affiliation(s)
- Maria-Sophie Brueckle
- Institute of General Practice, |Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany
| | - Elizabeth T. Thomas
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Svenja E. Seide
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Maximilian Pilz
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Ana Isabel Gonzalez-Gonzalez
- Institute of General Practice, |Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany
| | - Truc Sophia Nguyen
- Institute of General Practice, |Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany
| | - Sebastian Harder
- Goethe University, Institute of Clinical Pharmacology, Frankfurt, Germany
| | - Paul P. Glasziou
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Ferdinand M. Gerlach
- Institute of General Practice, |Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany
| | - Christiane Muth
- Institute of General Practice, |Johann Wolfgang Goethe University, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany
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Valladales-Restrepo LF, Duran-Lengua M, Castro-Osorio EE, Machado-Alba JE. Consistency between anticholinergic burden scales in the elderly with fractures. PLoS One 2020; 15:e0228532. [PMID: 32092055 PMCID: PMC7039428 DOI: 10.1371/journal.pone.0228532] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 12/30/2019] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE Falls and bone fractures are important causes of morbidity and mortality in the elderly. The objective of this study was to identify the degree of consistency between the anticholinergic scales used for patients diagnosed with fractures. METHODS This was an analytical agreement study conducted in patients diagnosed with vertebral and nonvertebral fractures in Colombia. The quadratic-weighted kappa coefficient was used to identify the consistency between the Anticholinergic Drug Scale-ADS, Anticholinergic Cognitive Burden Scale-ACB and Anticholinergic Risk Scale-ARS in assessing the prescriptions of fracture patients during the month prior to the fracture, during their stay as an inpatient and at discharge, according to Landis criteria. RESULTS 220 patients with fractures were included, with a mean age of 75.3±10.3 years, and 68.2% were women. The ACB scale identified the highest anticholinergic burden (26.8%) in prescriptions made the month before the fracture, and the highest agreement was between ACB and ADS (0.717); during hospitalization and at discharge, the cholinergic antagonists were best identified with ADS (77.7% and 72.1%, respectively), with the best agreement between ACB and ARS (0.613 and 0.568, respectively). The prescription of tramadol was found in 64.1% of hospitalized patients and in 61.4% of patients at the time of discharge. CONCLUSIONS The scales evaluated show marked discrepancies between them, with highly variable frequencies of anticholinergic drugs identified at the different prescription times, and with low agreement among them, which is why the scales are not interchangeable in patients with bone fractures.
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Affiliation(s)
- Luis Fernando Valladales-Restrepo
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Risaralda, Colombia
- Grupo Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia
| | | | - Edgar Eduardo Castro-Osorio
- Internal Medicine, Geriatrics, Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Hospital Universitario de Caldas, Manizales, Colombia
| | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Risaralda, Colombia
- * E-mail:
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The Relationship Between Anticholinergic Exposure and Falls, Fractures, and Mortality in Patients with Overactive Bladder. Drugs Aging 2020; 36:957-967. [PMID: 31359329 DOI: 10.1007/s40266-019-00694-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [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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Rigor J, Rueff Rato I, Ferreira PM, Pereira R, Ribeiro C, Teixeira D, Mesquita Oliveira P, Silva AM, Pereira S, Costa I, Ferreira P, Sequeira M, Monteiro-Soares M, Martins-Mendes D. Prehospital Anticholinergic Burden Is Associated With Delirium but Not With Mortality in a Population of Acutely Ill Medical Patients. J Am Med Dir Assoc 2020; 21:481-485. [PMID: 31983551 DOI: 10.1016/j.jamda.2019.12.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/13/2019] [Accepted: 12/17/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Anticholinergic drugs have several side effects, and they have been associated with adverse outcomes, particularly in older patients. The aim of this study was to analyze anticholinergic burden and its relationship to delirium and mortality in older acutely ill medical patients. DESIGN Cohort study. SETTING AND PARTICIPANTS Patients 65 years of age and older who were admitted to an Internal Medicine ward between August 1 and December 31, 2016. METHODS Anticholinergic drug use, outpatient and inpatient, was assessed using the Anticholinergic Cognitive Burden Scale (ACB). Prevalent delirium was diagnosed by the Short Confusion Assessment Method (Short-CAM). RESULTS Of the 198 patients, 28.3% developed delirium. Mortality rate was 13.6% in-hospital and 45.6% at 12 months. In multivariate analysis, outpatient ACB was associated with delirium, with an odds ratio (OR) of 1.65 [95% confidence interval (CI) 1.09-2.51]. Those with delirium had longer hospital stays (median 13 vs 8 days; P = .01), received more drugs (median 18 vs 15; P = .02), and presented a higher inpatient ACB (mean 3.9 vs 3.1; P = .034). No increased risk was found for in-hospital or 12-month mortality with drug use, ACB, or delirium. DISCUSSION In the population studied, we found an association between anticholinergic burden as measured by the ACB and the presence of delirium, but not with mortality at 12 months. A very high 12-month mortality rate might have been an obstacle for association recognition. CONCLUSIONS AND IMPLICATIONS Clinician awareness of possible drug side effects, especially in older populations, is crucial. As part of medication reconciliation at the time of hospitalization, ACB of prehospitalization medications should be routinely calculated by inpatient pharmacy services and made available to medical teams.
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Affiliation(s)
- Joana Rigor
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal.
| | - Inês Rueff Rato
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Paula Marques Ferreira
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Rita Pereira
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Catarina Ribeiro
- Nephrology Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Diogo Teixeira
- Dermatology Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Pedro Mesquita Oliveira
- Intensive Care Unit, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Ana Mafalda Silva
- Internal Medicine Department, Entre Douro e Vouga Hospital Center, E.P.E., Santa Maria da Feira, Portugal
| | - Sofia Pereira
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Ingride Costa
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Paula Ferreira
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Manuela Sequeira
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Matilde Monteiro-Soares
- MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine of the University of Porto, Porto, Portugal; CINTESIS-Center for Health Technology and Services Research, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Daniela Martins-Mendes
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal; Biomedicine Department, Faculty of Medicine of the University of Porto, Porto, Portugal; i3S-Instituto de Investigação e Inovação em Saúde da Universidade do Porto, Porto, Portugal
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90
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López-Álvarez J, Sevilla-Llewellyn-Jones J, Agüera-Ortiz L. Anticholinergic Drugs in Geriatric Psychopharmacology. Front Neurosci 2019; 13:1309. [PMID: 31866817 PMCID: PMC6908498 DOI: 10.3389/fnins.2019.01309] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/22/2019] [Indexed: 12/31/2022] Open
Abstract
Drugs with anticholinergic action are widely prescribed in the elderly population due to their potential clinical benefits. However, these benefits are limited by adverse effects which may be serious in particular circumstances. This review presents different aspects of the use of anticholinergics in old age with a focus in psychogeriatric patients. We critically review published data on benefits and disadvantages of anticholinergics, which are often controversial. Prevalence, pathophysiology and measurement methods of the anticholinergic action of drugs are discussed. We also present the most important drawbacks resulting from its use, including effects on cognition in healthy and cognitively impaired people, in aged schizophrenia patients, emergence of delirium and psychiatric symptoms, influence in functionality, hospitalization, institutionalization and mortality, and the potential benefits and limitations of their discontinuation. Finally, we suggest practical recommendations for the safe use of anticholinergics in clinical conditions affecting elderly patients, such as dementia, schizophrenia and acute hallucinatory episodes, depression, anxiety, Parkinson's disease, cardiovascular conditions and urinary incontinence.
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Affiliation(s)
- Jorge López-Álvarez
- Servicio de Psiquiatría, Hospital 12 de Octubre (imas12), Madrid, Spain.,Instituto de Investigación, Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Julia Sevilla-Llewellyn-Jones
- Instituto de Psiquiatría y Salud Mental, Hospital Clínico San Carlos, Madrid, Spain.,Instituto de Investigación (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| | - Luis Agüera-Ortiz
- Servicio de Psiquiatría, Hospital 12 de Octubre (imas12), Madrid, Spain.,Instituto de Investigación, Hospital 12 de Octubre (imas12), Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental, Ministry of Science and Innovation, Madrid, Spain.,Departamento de Medicina Legal, Psiquiatría y Patología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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91
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Potentially inappropriate prescriptions of anticholinergic medications in patients with closed-angle glaucoma. Int Ophthalmol 2019; 40:803-809. [PMID: 31792854 DOI: 10.1007/s10792-019-01241-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 11/21/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Glaucoma is the leading cause for blindness after cataracts worldwide. The aim was to identify anticholinergic drugs prescribed to patients diagnosed with closed-angle glaucoma in Colombia. METHODS This cross-sectional study identified the prescribing patterns of cholinergic antagonists related to the increased intraocular pressure in patients diagnosed with closed-angle glaucoma from a Colombian database. The Anticholinergic Drug Scale was used to quantify the anticholinergic burden. RESULTS We identified 1958 patients with closed-angle glaucoma, with a mean age of 70.5 ± 10.3 years, 72.9% of whom were women. Cholinergic antagonists were prescribed in at least 32.4% of cases. An age range between 75 and 84 years (odds ratio (OR) 2.35, 95% confidence interval (CI) 1.366-4.059) and being aged 85 years or older (OR 3.40, 95% CI 1.809-6.425) were associated with a greater probability of receiving an anticholinergic burden between 1 and 2 points. Females (OR 1.54, 95% CI 1.096-2.181) had a higher probability of receiving an anticholinergic burden ≥ 3 points. Interactions between antiglaucoma medications and anticholinergic treatments were identified in 32.1% of the patients. CONCLUSIONS Most patients were prescribed multiple antiglaucoma medications, reflecting a large number of potentially inappropriate prescriptions, with anticholinergic drugs, related to the increased intraocular pressure.
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92
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Ferner R, Aronson J. Susceptibility to adverse drug reactions. Br J Clin Pharmacol 2019; 85:2205-2212. [PMID: 31169324 PMCID: PMC6783620 DOI: 10.1111/bcp.14015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 12/19/2022] Open
Abstract
The pharmacological effects of a drug depend on its concentration at the site of action, and therefore on the concentration in blood and on the dose. The relationship between the concentration or dose and the corresponding effect can usually be represented mathematically as a rectangular hyperbola; when effect is plotted against log concentration or log dose, the curve is sigmoidal. Inevitably, the effect size and the doses causing benefit and harm will differ among individuals, since they are biological phenomena: some individuals are more likely than others to suffer harm at any given dose. Some harmful effects can occur at much lower doses than those used in therapeutics; that is, the log dose-response curve for harm lies far to the left of the log dose-response curve for benefit. Those who suffer such reactions are hypersusceptible. When the dose-response curves for harm and therapeutic effect are in the same range, dose cannot separate the harmful effects from the therapeutic effects, and adverse reactions are collateral. Toxic effects occur when harmful doses are above the doses needed for benefit. In this review we consider factors that influence a subject's susceptibility to adverse drug reactions. Determinants of susceptibility include Immunological, Genetic, demographic (Age and Sex), Physiological and Exogenous factors (drug-drug interactions, for example), and Diseases and disorders such as renal failure, giving the mnemonic I GASPED. Some susceptibility factors are discrete (for example, all-or-none) and some are continuous; susceptibility can therefore be discrete or continuous; and the factors can interact to determine a person's overall susceptibility to harm.
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Affiliation(s)
- Robin Ferner
- West Midlands Centre for Adverse Drug Reactions, City HospitalBirminghamUK
- Institute of Clinical SciencesUniversity of BirminghamUK
| | - Jeffrey Aronson
- West Midlands Centre for Adverse Drug Reactions, City HospitalBirminghamUK
- Nuffield Department of Primary Care Health SciencesCentre for Evidence Based MedicineOxfordUK
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93
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[Geriatric intensive care : Consensus paper of DGIIN, DIVI, DGAI, DGGG, ÖGGG, ÖGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG]. Z Gerontol Geriatr 2019; 52:440-456. [PMID: 31278486 DOI: 10.1007/s00391-019-01584-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.
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94
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Reinold J, Schäfer W, Christianson L, Barone-Adesi F, Riedel O, Pisa FE. Anticholinergic burden and fractures: a protocol for a methodological systematic review and meta-analysis. BMJ Open 2019; 9:e030205. [PMID: 31439607 PMCID: PMC6707654 DOI: 10.1136/bmjopen-2019-030205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 07/19/2019] [Accepted: 08/02/2019] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Medications with anticholinergic activity are used in the treatment of many diseases common in old age, including depression, psychosis, Parkinson's disease, allergies, pain and urinary incontinence. A high anticholinergic burden (ACB) is considered a major risk factor for fractures in older adults but recent studies reported inconsistent results. These inconsistencies may partly be due to differences in methodological aspects. However, no systematic review so far has addressed this association and considered study methods. Thus, we aim to conduct a systematic review and meta-analysis of observational studies addressing the association of ACB with fractures and to provide a methodological appraisal of the included studies. METHODS AND ANALYSIS We will search MEDLINE, EMBASE, the Science Citation Index, CENTRAL and grey literature using a strategy that combines the terms anticholinergic and fractures. We will hand search reference lists of articles. Two reviewers will independently screen all identified abstracts for eligibility and evaluate the risk of bias of the included studies using the Newcastle-Ottawa Quality Assessment Scale and RTI item bank. Discrepancies will be resolved by consensus or consultation with a third researcher. We will conduct a meta-analysis, either for the overall population or for specific and more homogeneous subgroups, if the number of studies retrieved and their heterogeneity allows it. ETHICS AND DISSEMINATION No ethics approval will be sought, as no original data will be collected for this review. Findings will be disseminated through peer-reviewed publication and conference presentations. PROSPERO REGISTRATION NUMBER CRD42018116737.
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Affiliation(s)
- Jonas Reinold
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Wiebke Schäfer
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Lara Christianson
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | | | - Oliver Riedel
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Federica Edith Pisa
- Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
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95
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Valladales‐Restrepo LF, Duran‐Lengua M, Machado‐Alba JE. Potentially inappropriate prescriptions of anticholinergics drugs in Alzheimer's disease patients. Geriatr Gerontol Int 2019; 19:913-917. [DOI: 10.1111/ggi.13748] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 06/04/2019] [Accepted: 07/02/2019] [Indexed: 01/20/2023]
Affiliation(s)
- Luis Fernando Valladales‐Restrepo
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnologica de Pereira‐Audifarma S.A Pereira Colombia
- Grupo de Biomedicina, Fundación Universitaria Autónoma de las Américas Pereira Colombia
| | | | - Jorge Enrique Machado‐Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnologica de Pereira‐Audifarma S.A Pereira Colombia
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96
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Valladales-Restrepo LF, Machado-Alba JE. Potentially inappropriate anticholinergic drug prescriptions for patients with Sjögren's syndrome. J Transl Autoimmun 2019; 2:100007. [PMID: 32743497 PMCID: PMC7388360 DOI: 10.1016/j.jtauto.2019.100007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 06/19/2019] [Indexed: 10/27/2022] Open
Abstract
Sjögren's syndrome is characterized by the involvement of exocrine glands, manifesting with xerostomia and xerophthalmia. The objective was to determine the treatment received and identify potentially inappropriate prescriptions by estimating the anticholinergic burden generated by medications in patients with Sjögren's syndrome in Colombia. This cross-sectional study was based on a population database that identified patients with Sjögren's syndrome, comorbidities, pharmacological treatment, and medications with anticholinergic properties. The anticholinergic burden was estimated using the Anticholinergic Drug Scale. A total of 4945 patients with Sjögren's syndrome were identified, with a mean age of 64.6 ± 14.04 years and 75.7% women. A total of 79.0% received a topical lubricant, with hyaluronate being the most prescribed (26.8%), while oral pilocarpine was prescribed for 7.4%. The use of biological disease-modifying antirheumatic drugs was identified in 1.3% of cases. A total of 39.1% (n = 1932) of all patients received cholinergic antagonists, especially codeine (6.5%), prednisolone (5.7%), and furosemide (5.3%). The mean anticholinergic burden was 0.91 ± 1.57 (range: 0-24), 17.2% (n = 850) had a score of 1, 7.7% (n = 381) had a score of 2, and 14.2% (n = 701) ≥3 points. Multiple comorbidities were associated with the risk of having cholinergic antagonist medication prescribed. Most patients with Sjögren's syndrome were women whose symptomatic management mainly included ocular lubricants with low use of oral pilocarpine. A large proportion of patients had at least one cholinergic antagonist drug prescribed, increasing its use risk after 40 years of age.
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Affiliation(s)
- Luis Fernando Valladales-Restrepo
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Calle 105 No. 14-140, Pereira, Risaralda, Colombia Pereira, Risaralda, Colombia.,Grupo de Investigación Biomedicina, Fundación Universitaria Autónoma de las Américas, Ave Las Américas, # 98-56, Pereira, Colombia
| | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Calle 105 No. 14-140, Pereira, Risaralda, Colombia Pereira, Risaralda, Colombia
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97
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Tamblyn R, Bates DW, Buckeridge DL, Dixon W, Forster AJ, Girard N, Haas J, Habib B, Kurteva S, Li J, Sheppard T. Multinational comparison of new antidepressant use in older adults: a cohort study. BMJ Open 2019; 9:e027663. [PMID: 31092665 PMCID: PMC6530307 DOI: 10.1136/bmjopen-2018-027663] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES We used an international pharmacosurveillance network to estimate the rate and characteristics of antidepressant use in older adults in countries with more conservative (UK) and liberal depression guidelines (Canada, USA). SETTING Electronic health records and population-based administrative data from six jurisdictions in four countries (UK, Taiwan, USA and Canada). PARTICIPANTS A historical cohort of older adults (≥65 years) who had a new episode of antidepressant use between 2009 and 2014. OUTCOME MEASURES The age and sex-standardised cumulative incidence of new episodes of antidepressant use in older adults was measured. Descriptive statistics were used to compare the proportion of new users by the antidepressant prescribed, therapeutic class, potential treatment indication and country, as well as the characteristics of the first treatment episode (standardised daily doses, duration and changes). RESULTS The incidence of antidepressant use between 2009 and 2014 varied from 4.7% (Montreal and Quebec City) to 18.6% (Taiwan). Tricyclic antidepressants (TCAs) were the most commonly used class in the UK (48.8%) and Taiwan (52.4%) compared with selective serotonin reuptake inhibitors (SSRIs) in North American jurisdictions (42.3%-53.3%). Chronic pain was the most common potential treatment indication (41.2%-68.2%). Among users with chronic pain, TCAs were used most frequently in the UK and Taiwan (55.2%-60.4%), whereas SSRIs were used most frequently in North America (33.5%-46.4%). Treatment was longer (252-525 vs 169-437 days), standardised doses were higher (0.7-1.3 vs 0.5-1.0) and treatment was more likely to be changed (31%-46% vs 21%-34%) among patients with depression (9.1%-43%) than those with chronic pain. CONCLUSION Antidepressant use in older adults varied 24-fold by country, with the UK, which has the most conservative treatment guidelines, being among the lowest. Chronic pain was the most common potential treatment indication. Evaluation of real-world risks of TCAs is a priority for future research, given high rates of use and the potential for increased toxicity in older adults because of potent anticholinergic effects.
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Affiliation(s)
- Robyn Tamblyn
- Department of Medicine and Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
| | | | - David L Buckeridge
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
- Direction de santé publique, Agence de la Santé et des services Sociaux de Montréal, Montreal, Quebec, Canada
| | - Will Dixon
- Arthritis Research UK Centre for Epidemiology, University of Manchester, Manchester, UK
| | - Alan J Forster
- Internal Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Nadyne Girard
- Clinical and Health Informatics Research Group, McGill University, Montreal, Quebec, Canada
| | - Jennifer Haas
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Bettina Habib
- Clinical and Health Informatics Research Group, McGill University, Montreal, Quebec, Canada
| | - Siyana Kurteva
- Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Jack Li
- Graduate Institute of Biomedical Informatics, Taipei Medical University, Taipei, Taiwan
| | - Therese Sheppard
- Department of Medicine, University of Manchester, Manchester, UK
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98
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Szabo SM, Gooch K, Schermer C, Walker D, Lozano-Ortega G, Rogula B, Deighton A, Vonesh E, Campbell N. Association between cumulative anticholinergic burden and falls and fractures in patients with overactive bladder: US-based retrospective cohort study. BMJ Open 2019; 9:e026391. [PMID: 31061036 PMCID: PMC6502005 DOI: 10.1136/bmjopen-2018-026391] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To estimate the association between cumulative anticholinergic burden and falls and fractures in patients with overactive bladder (OAB). DESIGN A retrospective claims-based study (2007-2015) of patients with OAB; outcomes from a subset were contrasted to a non-OAB comparison. SETTING United States, commercially and Medicare-insured population. PARTICIPANTS 154 432 adults with OAB and 86 966 adults without OAB, mean age of 56 years, and 67.9% women. MAIN OUTCOME MEASURES Cumulative anticholinergic burden, a unitless value representing exposure over time, was estimated over the 12 months pre-index ('at baseline') and every 6 months post index. Burden was categorised as no burden (0), low burden (1-89), medium burden (90-499) or high burden (500+). Unadjusted rates of falls or fractures were estimated, and the increased risk associated with anticholinergic burden (measured at the closest 6-month interval prior to a fall or fracture) was assessed using a Cox proportional hazards model and a marginal structural model. RESULTS Median (IQR) baseline anticholinergic burden was 30 (0.0-314.0) and higher among older (≥65 years, 183 [3.0-713.0]) versus younger (<65 years, 13 [0.0-200.0]) adults. The unadjusted rate of falls or fractures over the period was 5.0 per 100 patient-years, ranging from 3.1 (95% CI 3.0-3.2) for those with no burden, to 7.4 (95% CI 7.1-7.6) for those with high burden at baseline. The adjusted risk of falls and fractures was greater with higher anticholinergic burden in the previous 6 months, with an HR of 1.2 (95% CI 1.2 to 1.3) for low burden versus no burden, to 1.4 (95% CI 1.3 to 1.4) for high versus no burden. Estimates from marginal structural models adjusting for time-varying covariates were lower but remained significantly higher with a higher anticholinergic burden. Rates of falls and fractures were approximately 40% higher among those with OAB (vs those without). CONCLUSION Higher levels of anticholinergic burden are associated with higher rates of falls and fractures, highlighting the importance of considering anticholinergic burden when treating patients with OAB.
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Affiliation(s)
- Shelagh M Szabo
- Broadstreet Health Economics & Outcomes Research, Vancouver, British Columbia, Canada
| | - Katherine Gooch
- Medical Affairs, Astellas Pharma Global Development Inc, Northbrook, Illinois, USA
| | - Carol Schermer
- Medical Affairs, Astellas Pharma Global Development Inc, Northbrook, Illinois, USA
| | - David Walker
- Medical Affairs, Astellas Pharma Global Development Inc, Northbrook, Illinois, USA
| | - G Lozano-Ortega
- Broadstreet Health Economics & Outcomes Research, Vancouver, British Columbia, Canada
| | - Basia Rogula
- Broadstreet Health Economics & Outcomes Research, Vancouver, British Columbia, Canada
| | - Alison Deighton
- Broadstreet Health Economics & Outcomes Research, Vancouver, British Columbia, Canada
| | - Edward Vonesh
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Noll Campbell
- Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana, USA
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99
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Joung KI, Kim S, Cho YH, Cho SI. Association of Anticholinergic Use with Incidence of Alzheimer's Disease: Population-based Cohort Study. Sci Rep 2019; 9:6802. [PMID: 31043628 PMCID: PMC6494800 DOI: 10.1038/s41598-019-43066-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 04/10/2019] [Indexed: 11/09/2022] Open
Abstract
Drugs with strong anticholinergic properties are used under a variety of conditions; however, they can cause various adverse effects including a negative impact on cognitive functions, with older adults being more susceptible to these effects. We explored whether the use of anticholinergic agents (ACs) affects the risk of Alzheimer's disease (AD) in terms of incidence by using National Health Insurance Service elderly cohort database (2002-2013). As a result, AD risk was higher in subjects with an increased amount of prescriptions for strong ACs over a long period of time (9-12 years) than that in the least-exposed reference group (0-9 dose/year) [hazard ratio (HR) (95% confidence interval (95% CI)) 0.99 (0.95-1.03), 1.19 (1.12-1.26), 1.39 (1.30-1.50); in the 10-49 doses/year, 50-119 doses/year, and ≥120 doses/year groups]. Hazard ratios were particularly high in the young-old subgroup (60-64 years old in 2002) [HR (95% CI) 1.11 (1.04-1.22), 1.43 (1.25-1.65), 1.83 (1.56-2.14); in the 10-49 doses/year, 50-119 doses/year, and ≥120 doses/year groups]. Use of strong ACs dose-dependently increased the risk of AD in terms of incidence when exposure was followed up for 9 years or more, and the association was greater in the young-old subgroup.
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Affiliation(s)
- Kyung-In Joung
- Division of Epidemiology, Department of Public Health Science, Graduate School of Public Health, Seoul National University, 08826, Seoul, Republic of Korea
| | - Sukil Kim
- Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, 06591, Seoul, Republic of Korea
| | - Yoon Hee Cho
- Department of Biomedical & Pharmaceutical Sciences, The University of Montana, 59812, Missoula, USA
| | - Sung-Il Cho
- Department of Public Health Science, Graduate School of Public Health and Institute of Health and Environment, Seoul National University, 08826, Seoul, Republic of Korea.
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100
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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.
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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
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