1
|
Ieong C, Chen T, Chen S, Gao X, Yan K, He W, Hong H, Gu Y, Chen X, Yuan G. Differences of anticholinergic drug burden between older hospitalized patients with and without delirium: a systematic review and meta-analysis based on prospective cohort studies. BMC Geriatr 2024; 24:599. [PMID: 38997670 PMCID: PMC11241997 DOI: 10.1186/s12877-024-05197-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 07/02/2024] [Indexed: 07/14/2024] Open
Abstract
OBJECTIVES This review aims to comprehensively summarize the differences in anticholinergic drug burden (ADB) scores between older hospitalized patients with and without delirium. METHODS We searched PubMed, Embase, Web of Science, Cochrane Library and CINAHL EBSCOhost databases to identify prospective cohort studies exploring the relationship between ADB and the occurrence of delirium in older hospitalized patients. The primary outcome of the review was the mean ADB scores for the delirium and non-delirium groups, and the secondary outcome was the scores for the subsyndromal and non-delirium groups. The standardized mean difference (SMD) and corresponding 95% confidence intervals (95% CI) were incorporated using a fixed-effect method. Moreover, we performed subgroup analysis according to the admission type, age, the ADB scale type and the ADB classification. RESULTS Nine prospective cohort studies involving 3791 older patients with a median age of 75.1 (71.6-83.9) were included. The ADB score was significantly higher in the delirium group than in the non-delirium group (SMD = 0.21, 95%CI 0.13-0.28). In subgroup analysis, the age subgroup was split into < 75 and ≥ 75 according to the median age of the older people. There were significant differences in ADB scores between older people with delirium and those without delirium in various subgroups: surgical (SMD = 0.20, 95%CI 0.12-0.28), internal medicine (SMD = 0.64, 95%CI 0.25-1.02), age < 75 (SMD = 0.17, 95%CI 0.08-0.26), age ≥ 75 (SMD = 0.27, 95%CI 0.15-0.39), ADS scale (SMD = 0.13, 95%CI 0.13-0.40), ARS scale (SMD = 0.15, 95%CI 0.03-0.26), ACB scale (SMD = 0.13, 95%CI 0.01-0.25), pre-admission ADB (SMD = 0.24, 95%CI 0.05-0.43) and ADB during hospitalization (SMD = 0.20, 95%CI 0.12-0.27). CONCLUSIONS We found a quantitative relationship between ADB and delirium in older patients admitted for internal medicine and surgery. And this relationship remained significant in different age, ADB scale type and ADB classification subgroups. However, the actual difference in ADB scores between patients with delirium and without delirium was small. More high-quality observational studies should be conducted to explore the impact of ADB on delirium and subsyndromal delirium. CLINICAL TRIAL REGISTRATION The protocol was published in the International Prospective Register of Systematic Reviews (PROSPERO) [Ref: CRD42022353649].
Collapse
Affiliation(s)
- Chifong Ieong
- Department of Geriatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Tingjia Chen
- Healthcare Center, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Sai Chen
- Department of Geriatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiang Gao
- Department of Geriatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Kemin Yan
- Department of Geriatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wen He
- Department of Geriatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hua Hong
- Department of Geriatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yong Gu
- Department of Geriatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiao Chen
- Department of Pharmacy, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Gang Yuan
- Department of Geriatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| |
Collapse
|
2
|
Coli KG, Yuksel JM, McCall KL, Guan J, Ulen KR, Noviasky J. Utilization of Lower-Dose Cyclobenzaprine in the Older Inpatient. Sr Care Pharm 2024; 39:249-258. [PMID: 38937891 DOI: 10.4140/tcp.n.2024.249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
Background In older inpatients, anticholinergic medications can increase the risk of complications that may increase length of stay (LOS). Cyclobenzaprine is an anticholinergic medication associated with mental status changes, falls, and injuries in older patients. Objective The purpose of this study is to determine whether use of a lower cyclobenzaprine dose (5 mg) compared with higher dosing (10 mg) will affect LOS, 30-day readmission rates, and need for injectable psychotropic agents in inpatients 65 years of age and older. Methods This was a retrospective cohort analysis comparing outcomes in patients 65 years of age and older who received either a 5 mg or 10 mg cyclobenzaprine dose during their inpatient admission over a 2.5-year period. The primary outcome was hospital LOS, adjusted using multivariate linear regression. Secondary outcomes included 30-day readmission rate adjusted using logistic regression and use of injectable antipsychotics or benzodiazepines. A sub-analysis evaluated the impact of the institution's implementation of a geriatric prescribing context (GEM-CON) on cyclobenzaprine dose selection. Results The adjusted LOS was 32.7% longer (95% CI 25.9%-39.9%) for patients exposed to higher-dose cyclobenzaprine. Use of injectable antipsychotics or benzodiazepines was also significantly greater in the higher-dose group (P < 0.001; P = 0.025). Cyclobenzaprine dose was not significantly associated with readmission on multivariate analysis (OR = 0.93, 95% CI 0.45-1.93). After GEM-CON implementation, there was a significant increase in use of the recommended lower cyclobenzaprine dose (P < 0.001). Conclusion Use of lower cyclobenzaprine dosing in older inpatients is associated with reduced hospital LOS and need for injectable antipsychotics and benzodiazepines.
Collapse
Affiliation(s)
- Katherine G Coli
- 1 Upstate University Hospital, Pharmacy Department, Syracuse, New York
| | - Jaylan M Yuksel
- 2 Upstate Community Hospital, Pharmacy Department, Syracuse, New York
| | - Kenneth L McCall
- 3 Binghamton University School of Pharmacy and Pharmaceutical Sciences, Department of Pharmacy Practice, Johnson City, New York
| | - Jiajie Guan
- 2 Upstate Community Hospital, Pharmacy Department, Syracuse, New York
| | - Kelly R Ulen
- 2 Upstate Community Hospital, Pharmacy Department, Syracuse, New York
| | - John Noviasky
- 2 Upstate Community Hospital, Pharmacy Department, Syracuse, New York
| |
Collapse
|
3
|
Rössler J, Abramczyk E, Paredes S, Anusic N, Pu X, Maheshwari K, Turan A, Ruetzler K. Association of Intravenous Neostigmine and Anticholinergics or Sugammadex with Postoperative Delirium: A Retrospective Cohort Study. Anesth Analg 2024:00000539-990000000-00778. [PMID: 38446705 DOI: 10.1213/ane.0000000000006939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
BACKGROUND Administration of cholinesterase inhibitors in combination with anticholinergic drugs for reversal of neuromuscular blocks may precipitate delirium through impairment of central cholinergic transmission, which could be avoided by using sugammadex. Therefore, we tested the primary hypothesis that postoperative delirium is less common when neuromuscular block is reversed with sugammadex than with neostigmine combined with glycopyrrolate or atropine. METHODS We conducted a single-center retrospective cohort study, analyzing all adult patients having general anesthesia for noncardiac surgery who received neostigmine or sugammadex from January 2016 to March 2022. Inverse propensity score weighting and propensity score calibration were used to adjust for appropriate confounders. Our primary outcome was presence of delirium within the first 4 days after surgery, defined as at least 1 positive brief Confusion Assessment Method (bCAM) screening. The secondary outcome was the presence of early delirium within 24 hours of surgery. RESULTS Among 49,468 cases in our analysis, 6881 received sugammadex and 42,587 received neostigmine. After propensity weighting, the incidence of delirium was 1.09% in the sugammadex group and 0.82% in the neostigmine group. The odds of postoperative delirium did not differ between the sugammadex and neostigmine groups, with an estimated odds ratio (95% confidence interval) of 1.33 (0.91-1.95), P = .147. A sensitivity analysis restricted to only include cases with at least 6 bCAM measurements over postoperative day (POD) 1 to 4 had consistent results, as sugammadex compared with neostigmine was associated with an estimated odds ratio for postoperative delirium of 1.20 (0.82-1.77), P = .346. Sugammadex was significantly associated with an increased incidence of early postoperative delirium, with an estimated odds ratio of 1.71 (1.07-2.72), P = .025. Further analysis showed no treatment-by-age interaction for either postoperative delirium (P = .637) or postoperative early delirium (P = .904). CONCLUSIONS Compared to neostigmine, use of sugammadex for reversal of neuromuscular block was not associated with an increased risk of postoperative delirium in this retrospective single-center study. Though sugammadex was associated with a statistically significant increased risk of postoperative early delirium, the difference was small and not clinically relevant, and may reflect the presence of unknown confounders.
Collapse
Affiliation(s)
| | | | - Stephania Paredes
- From the Department of Outcomes Research
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Xuan Pu
- From the Department of Outcomes Research
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Kamal Maheshwari
- From the Department of Outcomes Research
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alparslan Turan
- From the Department of Outcomes Research
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kurt Ruetzler
- From the Department of Outcomes Research
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
4
|
Ankravs MJ, McKenzie CA, Kenes MT. Precision-based approaches to delirium in critical illness: A narrative review. Pharmacotherapy 2023; 43:1139-1153. [PMID: 37133446 DOI: 10.1002/phar.2807] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/08/2023] [Accepted: 03/21/2023] [Indexed: 05/04/2023]
Abstract
Delirium occurs in critical illness and is associated with poor clinical outcomes, having a longstanding impact on survivors. Understanding the complexity of delirium in critical illness and its deleterious outcome has expanded since early reports. Delirium is a culmination of predisposing and precipitating risk factors that result in a transition to delirium. Known risks range from advanced age, frailty, medication exposure or withdrawal, sedation depth, and sepsis. Because of its multifactorial nature, different clinical phenotypes, and potential neurobiological causes, a precise approach to reducing delirium in critical illness requires a broad understanding of its complexity. Refinement in the categorization of delirium subtypes or phenotypes (i.e., psychomotor classifications) requires attention. Recent advances in the association of clinical phenotypes with clinical outcomes expand our understanding and highlight potentially modifiable targets. Several delirium biomarkers in critical care have been examined, with disrupted functional connectivity being precise in detecting delirium. Recent advances reinforce delirium as an acute, and partially modifiable, brain dysfunction, and place emphasis on the importance of mechanistic pathways including cholinergic activity and glucose metabolism. Pharmacologic agents have been assessed in randomized controlled prevention and treatment trials, with a disappointing lack of efficacy. Antipsychotics remain widely used after "negative" trials, yet may have a role in specific subtypes. However, antipsychotics do not appear to improve clinical outcomes. Alpha-2 agonists perhaps hold greater potential for current use and future investigation. The role of thiamine appears promising, yet requires evidence. Looking forward, clinical pharmacists should prioritize the mitigation of predisposing and precipitating risk factors as able. Future research is needed within individual delirium psychomotor subtypes and clinical phenotypes to identify modifiable targets that hold the potential to improve not only delirium duration and severity, but long-term outcomes including cognitive impairment.
Collapse
Affiliation(s)
- Melissa J Ankravs
- Pharmacy Department and Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Cathrine A McKenzie
- School of Medicine, Perioperative and Critical Care Theme, University of Southampton, National Institute of Health and Social Care Research (NIHR), Biomedical Research Centre, Southampton, UK
- NIHR Wessex Applied Research Collaborative (ARC), Southampton Science Park, Southampton, UK
- Pharmacy and Critical Care, University Hospital, Southampton, Southampton, UK
- School of Cancer and Pharmacy, Institute of Pharmaceutical Sciences, King's College London, London, UK
| | - Michael T Kenes
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pharmacy, Michigan Medicine Hospital, Ann Arbor, Michigan, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
5
|
Kotake K, Noritake Y, Kawakami Y. Association of silodosin, tamsulosin, and naftopidil with delirium: analysis of the pharmacovigilance database in Japan. Int J Clin Pharm 2023; 45:1252-1259. [PMID: 37713027 DOI: 10.1007/s11096-023-01639-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/17/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND An association between adrenergic alpha-1 receptor antagonists and delirium has been suggested, but the details are unclear. AIM This study investigated the association between adrenergic alpha-1 receptor antagonists and delirium in patients with benign prostatic hyperplasia using the Japanese Adverse Drug Event Report database. METHOD First, disproportionality analysis compared the frequency of delirium in the adrenergic alpha-1 receptor antagonists silodosin, tamsulosin, and naftopidil. Next, multivariate logistic analysis was performed to examine the association between delirium and adrenergic alpha-1 receptor antagonists where disproportionality was detected. RESULTS A disproportionality in delirium was observed in patients receiving tamsulosin (reporting odds ratio [ROR] 1.85, 95% confidence interval [CI] 1.38-2.44, P < 0.01) compared with those who did not, and also in patients receiving naftopidil (ROR 2.23, 95% CI 1.45-3.28, P < 0.01) compared with those who did not. Multivariate logistic analysis revealed that in addition to previously reported risk factors for delirium, delirium in patients receiving tamsulosin was significantly increased with concomitant use of anticholinergics (odds ratio 2.73, 95% CI 1.41-5.29, P < 0.01) and delirium in patients receiving naftopidil was significantly increased with concomitant use of beta3-adrenergic receptor agonists (odds ratio 4.19, 95% CI 1.66-10.6, P < 0.01). CONCLUSION Anticholinergics or beta3-adrenergic receptor agonists to treat overactive bladder in patients receiving tamsulosin and naftopidil was strongly associated with delirium. Confirming the medical history and concomitant medications of patients receiving tamsulosin or naftopidil may contribute to preventing delirium in patients with benign prostatic hyperplasia and to improving their outcomes.
Collapse
Affiliation(s)
- Kazumasa Kotake
- Department of Pharmacy, Okayama Saiseikai General Hospital, 2-25 Kokutaicho, Kita-ku, Okayama-shi, Okayama, 700-8511, Japan.
| | - Yumi Noritake
- Department of Pharmacy, Okayama Saiseikai General Hospital, 2-25 Kokutaicho, Kita-ku, Okayama-shi, Okayama, 700-8511, Japan
| | - Yasuhiro Kawakami
- Department of Pharmacy, Okayama Saiseikai General Hospital, 2-25 Kokutaicho, Kita-ku, Okayama-shi, Okayama, 700-8511, Japan
| |
Collapse
|
6
|
Havnes K, Svendsen K, Johansen JS, Granas AG, Garcia BH, Halvorsen KH. Is anticholinergic and sedative drug burden associated with postdischarge institutionalization in community-dwelling older patients acutely admitted to hospital? A Norwegian registry-based study. Pharmacoepidemiol Drug Saf 2022; 32:607-616. [PMID: 36585814 DOI: 10.1002/pds.5590] [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: 06/29/2022] [Revised: 11/03/2022] [Accepted: 12/22/2022] [Indexed: 01/01/2023]
Abstract
PURPOSE Investigate the association between anticholinergic (AC) and sedative (SED) drug burden before hospitalization and postdischarge institutionalization (PDI) in community-dwelling older patients acutely admitted to hospital. METHODS A cross-sectional study using data from the Norwegian Patient Registry and the Norwegian Prescription Database. We studied acutely hospitalized community-dwelling patients ≥70 years during 2013 (N = 86 509). Patients acutely admitted to geriatric wards underwent subgroup analyses (n = 1715). We calculated drug burden by the Drug Burden Index (DBI), use of AC/SED drugs, and the number of AC/SED drugs. Piecewise linearity of DBI versus PDI and a knot point (DBI = 2.45) was identified. Statistical analyses included an adjusted multivariable logistic regression model. RESULTS In the total population, 45.4% were exposed to at least one AC/SED drug, compared to 52.5% in the geriatric subgroup. AC/SED drugs were significantly associated with PDI. The DBI with odds ratios (ORs) of 1.11 (95% CI 1.07-1.15) for DBI < 2.45 and 1.08 (95% CI 1.04-1.13) for DBI ≥ 2.45. The number of AC/SED drugs with OR of 1.07 (95% CI 1.05-1.09). The AC component of DBI with OR 1.23 and the number of AC drugs with OR 1.13. In the subgroup, ORs were closer to 1 for AC drugs. CONCLUSIONS The use of AC/SED drugs was highly prevalent in older patients before acute hospital admissions, and significantly associated with PDI. The number, or just using AC/SED drugs, gave similar associations with PDI compared to applying the DBI. Using AC drugs showed higher sensitivity, indicating that to reduce the risk of PDI, a clinical approach could be to reduce the number of AC drugs.
Collapse
Affiliation(s)
- Kjerstin Havnes
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway.,Surgery, Cancer, and Women's Health Clinic, The University Hospital of North Norway, Tromsø, Norway
| | - Kristian Svendsen
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Jeanette Schultz Johansen
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Anne Gerd Granas
- Department of Pharmacy, The Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Beate Hennie Garcia
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| | - Kjell H Halvorsen
- Department of Pharmacy, Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsø, Norway
| |
Collapse
|
7
|
Lisibach A, Gallucci G, Benelli V, Kälin R, Schulthess S, Beeler PE, Csajka C, Lutters M. Evaluation of the association of anticholinergic burden and delirium in older hospitalised patients - A cohort study comparing 19 anticholinergic burden scales. Br J Clin Pharmacol 2022; 88:4915-4927. [PMID: 35675080 PMCID: PMC9796852 DOI: 10.1111/bcp.15432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 01/07/2023] Open
Abstract
AIMS A recent review identified 19 anticholinergic burden scales (ABSs) but no study has yet compared the impact of all 19 ABSs on delirium. We evaluated whether a high anticholinergic burden as classified by each ABS is associated with incident delirium. METHOD We performed a retrospective cohort study in a Swiss tertiary teaching hospital using data from 2015-2018. Included were patients aged ≥65, hospitalised ≥48 hours with no stay >24 hours in intensive care. Delirium was defined twofold: (i) ICD-10 or CAM and (ii) ICD-10 or CAM or DOSS. Patients' cumulative anticholinergic burden score, calculated within 24 hours after admission, was classified using a binary (<3: low, ≥3: high burden) and a categorical approach (0: no, 0.5-3: low, ≥3: high burden). Association was analysed using multivariable logistic regression. RESULTS Over 25 000 patients (mean age 77.9 ± 7.6 years) were included. Of these, (i) 864 (3.3%) and (ii) 2770 (11.0%) developed delirium. Depending on the evaluated ABS, 4-63% of the patients were exposed to at least one anticholinergic drug. Out of 19 ABSs, (i) 14 and (ii) 16 showed a significant association with the outcomes. A patient with a high anticholinergic burden score had odds ratios (ORs) of 1.21 (95% confidence interval [CI]: 1.03-1.42) to 2.63 (95% CI: 2.28-3.03) for incident delirium compared to those with low or no burden. CONCLUSION A high anticholinergic burden within 24 hours after admission was significantly associated with incident delirium. Although prospective studies need to confirm these results, discontinuing or substituting drugs with a score of ≥3 at admission might be a targeted intervention to reduce incident delirium.
Collapse
Affiliation(s)
- Angela Lisibach
- Clinical Pharmacy, Department Medical ServicesCantonal Hospital of BadenBadenSwitzerland,Center for Research and Innovation in Clinical Pharmaceutical SciencesUniversity Hospital and University of LausanneLausanneSwitzerland,School of Pharmaceutical SciencesUniversity of GenevaGenevaSwitzerland,Institute of Pharmaceutical Sciences of Western Switzerland, University of GenevaUniversity of LausanneSwitzerland
| | - Giulia Gallucci
- Clinical Pharmacy, Department Medical ServicesCantonal Hospital of BadenBadenSwitzerland
| | - Valérie Benelli
- Clinical Pharmacy, Department Medical ServicesCantonal Hospital of BadenBadenSwitzerland
| | - Ramona Kälin
- Clinical Pharmacy, Department Medical ServicesCantonal Hospital of BadenBadenSwitzerland
| | - Sven Schulthess
- Clinical Pharmacy, Department Medical ServicesCantonal Hospital of BadenBadenSwitzerland
| | - Patrick E. Beeler
- Division of Occupational and Environmental Medicine, Epidemiology, Biostatistics and Prevention InstituteUniversity of Zurich & University Hospital ZurichZurichSwitzerland
| | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical SciencesUniversity Hospital and University of LausanneLausanneSwitzerland,School of Pharmaceutical SciencesUniversity of GenevaGenevaSwitzerland,Institute of Pharmaceutical Sciences of Western Switzerland, University of GenevaUniversity of LausanneSwitzerland
| | - Monika Lutters
- Clinical Pharmacy, Department Medical ServicesCantonal Hospital of BadenBadenSwitzerland,Swiss Federal Institute of TechnologyZurichSwitzerland
| |
Collapse
|
8
|
Herrmann ML, Boden C, Maurer C, Kentischer F, Mennig E, Wagner S, Conzelmann LO, Förstner BR, Rapp MA, von Arnim CAF, Denkinger M, Eschweiler GW, Thomas C. Anticholinergic Drug Exposure Increases the Risk of Delirium in Older Patients Undergoing Elective Surgery. Front Med (Lausanne) 2022; 9:871229. [PMID: 35602472 PMCID: PMC9121116 DOI: 10.3389/fmed.2022.871229] [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] [Received: 03/05/2022] [Accepted: 03/29/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Postoperative delirium (POD) is a common and serious adverse event of surgery in older people. Because of its great impact on patients' safety and quality of life, identification of modifiable risk factors could be useful. Although preoperative medication intake is assumed to be an important modifiable risk factor, the impact of anticholinergic drugs on the occurrence of POD seems underestimated in elective surgery. The aim of this study was to investigate the association between preoperative anticholinergic burden and POD. We hypothesized that a high preoperative anticholinergic burden is an independent, potentially modifiable predisposing and precipitating factor of POD in older people. Methods Between November 2017 and April 2019, 1,470 patients of 70 years and older undergoing elective orthopedic, general, cardiac, or vascular surgery were recruited in the randomized, prospective, multicenter PAWEL trial. Anticholinergic burden of a sub-cohort of 899 patients, who did not receive a multimodal intervention for preventing POD, was assessed by two different tools at hospital admission: The established Anticholinergic Risk Scale (ARS) and the recently developed Anticholinergic Burden Score (ABS). POD was detected by confusion assessment method (CAM) and a validated post discharge medical record review. Logistic regression analyses were performed to evaluate the association between anticholinergic burden and POD. Results POD was observed in 210 of 899 patients (23.4%). Both ARS and ABS were independently associated with POD. The association persisted after adjustment for relevant confounding factors such as age, sex, comorbidities, preoperative cognitive and physical status, number of prescribed drugs, surgery time, type of surgery and anesthesia, usage of heart-lung-machine, and treatment in intensive care unit. If a patient was taking one of the 56 drugs listed in the ABS, risk for POD was 2.7-fold higher (OR = 2.74, 95% CI = 1.55–4.94) and 1.5-fold higher per additional point on the ARS (OR = 1.54, 95% CI = 1.15–2.02). Conclusion Preoperative anticholinergic drug exposure measured by ARS or ABS was independently associated with POD in older patients undergoing elective surgery. Therefore, identification, discontinuation or substitution of anticholinergic medication prior to surgery may be a promising approach to reduce the risk of POD in older patients.
Collapse
Affiliation(s)
- Matthias L. Herrmann
- Department of Neurology and Neurophysiology, Medical Center-University of Freiburg, Freiburg, Germany
- Geriatric Center and Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany
- *Correspondence: Matthias L. Herrmann
| | - Cindy Boden
- Geriatric Center and Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany
| | - Christoph Maurer
- Department of Neurology and Neurophysiology, Medical Center-University of Freiburg, Freiburg, Germany
- Center for Geriatrics and Gerontology, University Medical Center Freiburg, Freiburg, Germany
| | - Felix Kentischer
- Center for Geriatrics and Gerontology, University Medical Center Freiburg, Freiburg, Germany
| | - Eva Mennig
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
| | - Sören Wagner
- Department of Anesthesiology, Klinikum Stuttgart, Stuttgart, Germany
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | | | - Bernd R. Förstner
- Department of Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
| | - Michael A. Rapp
- Department of Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
| | - Christine A. F. von Arnim
- Department of Geriatrics, University Medical Center Göttingen, Georg August University, Göttingen, Germany
| | - Michael Denkinger
- Geriatric Center, Agaplesion Bethesda Clinic Ulm, Ulm, Germany
- Institute for Geriatric Research, Ulm University Medical Center, Ulm, Germany
| | - Gerhard W. Eschweiler
- Geriatric Center and Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany
| | - Christine Thomas
- Geriatric Center and Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
| |
Collapse
|
9
|
The role of the autonomic nervous system in cerebral blood flow regulation in dementia: A review. Auton Neurosci 2022; 240:102985. [DOI: 10.1016/j.autneu.2022.102985] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 02/28/2022] [Accepted: 04/28/2022] [Indexed: 11/19/2022]
|
10
|
Akgün Ö, Oudshoorn C, Mattace-Raso FUS, Egberts A. Anticholinergic Drug Use on Admission and the Risk of In-Hospital Falls in Older Hospitalized Patients. Clin Interv Aging 2022; 17:277-285. [PMID: 35313670 PMCID: PMC8934155 DOI: 10.2147/cia.s357818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/05/2022] [Indexed: 12/01/2022] Open
Abstract
Purpose In-hospital falls, especially among older patients, are a major and underestimated problem. Several studies have suggested a possible association between anticholinergic drug use and falls, but the results are inconclusive and studies focusing on in-hospital falls are scarce. The aim of the present study was to investigate whether anticholinergic drug exposure on admission is associated with in-hospital falls. Patients and Methods This retrospective chart review study was conducted in the Erasmus MC University Medical Center, Rotterdam, the Netherlands. Patients aged 65 years and older, who were acutely admitted to the geriatric ward between 2012 and 2015, were included. Anticholinergic drug exposure was determined with the Anticholinergic Risk Scale (ARS), the Anticholinergic Cognitive Burden scale (ACB) and the list of Chew. Logistic regression was used to investigate the possible association between anticholinergic drug exposure and in-hospital falls. Analyses were adjusted for age, sex, fall history, fall as reason for admission, number of drugs on admission, use of a mobility aid and delirium. Results A total of 905 patients were included, of which 94 patients experienced one or more in-hospital falls. Each additional anticholinergic drug in use, according to the ARS, was associated with an increased odd of experiencing a fall (OR = 1.49, 95% CI: 1.06–2.10). Other measures, ie anticholinergic drug use (yes/no) and different categories of anticholinergic drug burden, measured with the ARS, ACB and list of Chew, were all not associated with in-hospital falls. Conclusion Anticholinergic drug exposure on admission is possibly not a main risk factor for in-hospital falls among older patients.
Collapse
Affiliation(s)
- Özge Akgün
- Department of Internal Medicine, Section of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Christian Oudshoorn
- Department of Internal Medicine, Section of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Francesco U S Mattace-Raso
- Department of Internal Medicine, Section of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Angelique Egberts
- Department of Internal Medicine, Section of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Franciscus Gasthuis & Vlietland, Rotterdam & Schiedam, the Netherlands
- Correspondence: Angelique Egberts, Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Room Rg-527, PO Box 2040, Rotterdam, CA, 3000, the Netherlands, Tel +31 10 70 35979, Fax +31 10 70 34768, Email
| |
Collapse
|
11
|
Lisibach A, Gallucci G, Beeler PE, Csajka C, Lutters M. High anticholinergic burden at admission associated with in-hospital mortality in older patients: A comparison of 19 different anticholinergic burden scales. Basic Clin Pharmacol Toxicol 2021; 130:288-300. [PMID: 34837340 PMCID: PMC9299782 DOI: 10.1111/bcpt.13692] [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: 08/19/2021] [Revised: 11/10/2021] [Accepted: 11/18/2021] [Indexed: 01/16/2023]
Abstract
Although no gold standard exists to assess a patient's anticholinergic burden, a review identified 19 anticholinergic burden scales (ABSs). No study has yet evaluated whether a high anticholinergic burden measured with all 19 ABSs is associated with in‐hospital mortality and length of stay (LOS). We conducted a cohort study at a Swiss tertiary teaching hospital using patients' electronic health record data from 2015–2018. Included were patients aged ≥65 years, hospitalised ≥48 h without stays and >24 h in intensive care. Patients' cumulative anticholinergic burden score was classified using a binary (<3: low, ≥3: high) and categorical approach (0: no, 0.5–3: low, ≥3: high). In‐hospital mortality and LOS were analysed using multivariable logistic and linear regression, respectively. We included 27,092 patients (mean age 78.0 ± 7.5 years, median LOS 6 days). Of them, 913 died. Depending on the evaluated ABS, 1370 to 17,035 patients were exposed to anticholinergics. Patients with a high burden measured by all 19 ABSs were associated with a 1.32‐ to 3.03‐fold increase in in‐hospital mortality compared with those with no/low burden. We obtained similar results for LOS. To conclude, discontinuing drugs with anticholinergic properties (score ≥3) at admission might be a targeted intervention to decrease in‐hospital mortality and LOS.
Collapse
Affiliation(s)
- Angela Lisibach
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland.,Center for Research and Innovation in Clinical Pharmaceutical Sciences, University Hospital and University of Lausanne, Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Lausanne, Switzerland
| | - Giulia Gallucci
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
| | - Patrick E Beeler
- Division of Occupational and Environmental Medicine, Epidemiology, Biostatistics and Prevention Institute, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, University Hospital and University of Lausanne, Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Lausanne, Switzerland
| | - Monika Lutters
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland.,Swiss Federal Institute of Technology, Zurich, Switzerland
| |
Collapse
|
12
|
Wilczyński K, Gorczyca M, Gołębiowska J, Szewieczek J. Anticholinergic Burden of Geriatric Ward Inpatients. MEDICINA-LITHUANIA 2021; 57:medicina57101115. [PMID: 34684152 PMCID: PMC8540218 DOI: 10.3390/medicina57101115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/06/2021] [Accepted: 10/11/2021] [Indexed: 12/03/2022]
Abstract
Background and Objectives: Anticholinergic drug use in the pharmacotherapy of elderly persons is common despite the increased risk of side effects. We examined the prevalence of anticholinergic drug use and total anticholinergic drug burden among patients admitted to an acute care geriatric ward in Poland. Materials and Methods: Cross-sectional study of 329 subjects hospitalized at the geriatric ward. Patient condition was assessed with a comprehensive geriatric assessment. The Anticholinergic Cognitive Burden (ACB) scale was used to estimate the total anticholinergic load. Results: Mean patient age was 79.61 ± 6.82 years. 40.73% of them were burdened with at least one anticholinergic drug. The clinically significant anticholinergic burden was observed in 13.98% of subjects. Patients with dementia, risk of falls, and severe disability had significantly higher total ACB scores compared to other groups. The receiver operating characteristics (ROC) curve revealed that the total ACB score ≥ 1 was significantly associated with dementia and the risk of falls. Total ACB score ≥ 2 was significantly associated with severe disability. Conclusions: Patients admitted to an acute care geriatric ward had an anticholinergic cognitive burden score comparable to other patient populations. We found associations at both low and elevated levels of anticholinergic burden with dementia and risk of falls. At elevated anticholinergic burden levels, we found associations with severe disability. Despite recommendations against the use of anticholinergics in older adults these medications are still commonly prescribed. Further study is necessary to define the characteristics of anticholinergic medication most closely associated with negative outcomes in elderly populations.
Collapse
Affiliation(s)
- Krzysztof Wilczyński
- Department of Geriatrics, Faculty of Health Sciences in Katowice, Medical University of Silesia, Ziołowa 45/47, 40-635 Katowice, Poland;
- Correspondence: ; Tel.: +48-(32)-359-8239; Fax: +48-(32)-205-9483
| | - Marta Gorczyca
- Student Scientific Interest Group, Department of Geriatrics, Faculty of Medical Sciences, Medical University of Silesia, Ziołowa 45/47, 40-635 Katowice, Poland; (M.G.); (J.G.)
| | - Jagna Gołębiowska
- Student Scientific Interest Group, Department of Geriatrics, Faculty of Medical Sciences, Medical University of Silesia, Ziołowa 45/47, 40-635 Katowice, Poland; (M.G.); (J.G.)
| | - Jan Szewieczek
- Department of Geriatrics, Faculty of Health Sciences in Katowice, Medical University of Silesia, Ziołowa 45/47, 40-635 Katowice, Poland;
| |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
Igwe EO. A survey about postoperative delirium in older patients among nurses and anaesthetists: implications for future practice and policy. J Res Nurs 2021; 26:341-351. [PMID: 35251260 PMCID: PMC8894989 DOI: 10.1177/1744987120949893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Postoperative delirium is a major complication associated with anaesthesia and surgery, more commonly seen in older people. AIMS The aims of this study were to explore the knowledge and understanding of anaesthetists and nurses involved in anaesthesia through their responses to two case scenarios of postoperative delirium experienced by older people. METHODS A 30-item online survey was sent to 500 potential respondents. RESULTS Two hundred and twenty-six practitioners from Australia, New Zealand and Scotland responded. Most had no workplace protocols for anaesthesia planning in older people. There was substantial variability in practice in relation to postoperative delirium screening, detection, prevention and management. CONCLUSIONS Improvements in education and awareness, together with a more coherent approach, for example, as recommended in the European Society of Anaesthesiology Guidelines, could help to reduce the impact of postoperative delirium in older people. This should be combined with ongoing research into perioperative optimisation of detection, prevention and management of postoperative delirium.
Collapse
Affiliation(s)
- Ezinne O Igwe
- Ezinne O Igwe, School of Medicine, Faculty of Science Medicine and Health, University of Wollongong, NSW 2522, Australia.
| |
Collapse
|
15
|
|
16
|
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.
Collapse
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
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Egberts A, Alan H, Ziere G, Mattace-Raso FUS. Antipsychotics and Lorazepam During Delirium: Are We Harming Older Patients? A Real-Life Data Study. Drugs Aging 2021; 38:53-62. [PMID: 33164161 PMCID: PMC7838136 DOI: 10.1007/s40266-020-00813-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Delirium affects approximately one out of three older hospitalized patients and is associated with poor clinical outcomes. Approaches used to manage delirium consist of non-pharmacological and pharmacological interventions. Antipsychotics and lorazepam are commonly used to treat symptoms of delirium, but conflicting data exist on the effect of these drugs on the outcomes of delirium. OBJECTIVE The aim of this study was to investigate whether the use of antipsychotics, with or without lorazepam, increases the risk of prolonged hospital stay, post-discharge institutionalization, and in-hospital mortality in older patients with delirium. METHODS In this retrospective chart review study, we included acutely ill patients aged ≥ 65 years who were admitted to a geriatric ward and diagnosed with delirium. Patients were stratified into three groups based on whether or not they received antipsychotics and lorazepam to manage delirium: (0) no antipsychotics; (1) antipsychotics only; and (2) antipsychotics plus lorazepam. Length of hospital stay (LOS) and frequencies of post-discharge institutionalization and in-hospital mortality were compared. RESULTS In total, 212 patients with delirium were included (mean age 81.9 ± 5.6 years); 40 did not receive antipsychotics (18.9%), 123 received antipsychotics only (58.0%) and 49 received antipsychotics and lorazepam (23.1%). There was a trend to a longer LOS in patients who received both antipsychotics and lorazepam (median LOS group 0 = 8.0 days, group 1 = 10.0 days, and group 2 = 12.0 days). Furthermore, trends to a higher incidence of post-discharge institutionalization and in-hospital mortality were observed in patients who received both treatments (institutionalization group 0 = 45.0%, group 1 = 59.3%, group 2 = 81.6%; and in-hospital mortality group 0 = 7.5%, group 1 = 10.6%, group 2 = 16.3%). CONCLUSION The use of antipsychotics, with or without lorazepam, during delirium is associated with increased risks of poor outcomes. These findings suggest that clinicians should be cautious about routine prescribing of these drugs to older patients with delirium. Further investigation is needed to clarify this association.
Collapse
Affiliation(s)
- Angelique Egberts
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Room Rg-527, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
- Department of Hospital Pharmacy, Franciscus Gasthuis and Vlietland, Rotterdam and Schiedam, The Netherlands.
| | - Hava Alan
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Room Rg-527, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Gijsbertus Ziere
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Room Rg-527, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Francesco U S Mattace-Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Room Rg-527, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| |
Collapse
|
19
|
Abstract
Delirium is an acute confusional state that is common and costly and is associated with significant functional decline and distress. It is the manifestation of acute encephalopathy and is variably called acute brain failure, acute brain dysfunction, or altered mental status. All patients are at risk for delirium, although those with more vulnerabilities (such as advanced age, exposures to other stressors like infection, and certain medications) are at higher risk. The pathophysiologic cause of delirium is not well understood. It is important to recognize patients at risk for and those with delirium and to immediately identify and treat factors contributing to it. There is no single intervention or medication to treat delirium, making it challenging to manage. Therefore, risk mitigation and prompt treatment rely on a sophisticated strategy to address the contributing factors. Delirium may be prevented or attenuated when multimodal strategies are used, thereby improving patient outcomes.
Collapse
Affiliation(s)
- Melissa L P Mattison
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (M.L.M.)
| |
Collapse
|
20
|
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: 42] [Impact Index Per Article: 10.5] [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.
Collapse
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
| |
Collapse
|
21
|
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.
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Measuring Central Cholinergic Inhibition As a Risk Factor for Delirium Remains a Challenge. Pediatr Crit Care Med 2020; 21:590-591. [PMID: 32483024 DOI: 10.1097/pcc.0000000000002252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
24
|
Graves-Morris K, Stewart C, Soiza RL, Taylor-Rowan M, Quinn TJ, Loke YK, Myint PK. The Prognostic Value of Anticholinergic Burden Measures in Relation to Mortality in Older Individuals: A Systematic Review and Meta-Analysis. Front Pharmacol 2020; 11:570. [PMID: 32411001 PMCID: PMC7201087 DOI: 10.3389/fphar.2020.00570] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/15/2020] [Indexed: 11/13/2022] Open
Abstract
Background Greater anticholinergic burden (ACB) increases the risk of mortality in older individuals, yet the strength of this association varies between studies. One possible explanation for this variance is the use of different approaches to quantify ACB. This systematic review (PROSPERO number CRD42019115918) assessed the prognostic utility of ACB-specific measures on mortality in older individuals. Methods Multiple cross-disciplinary databases were searched from 2006-2018. Observational studies assessing the association between ACB and mortality utilizing ≥1 ACB measure, involving persons aged ≥65 years were included. Screening and data extraction were performed by two independent reviewers, with disagreements resolved by a third independent reviewer. Risk of bias and quality of evidence were assessed using Quality in Prognosis Studies (QUIPS) and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria. Meta-analysis was conducted where appropriate. Results Of 19,224 titles, 20 articles describing 18 cohort studies involving 498,056 older individuals were eligible. Eight anticholinergic-specific measures were identified; the Anticholinergic Cognitive Burden Scale (ACBS, n=9) and Anticholinergic Risk scale (ARS, n=8) were most frequently reported. The evidence base was of poor quality, with moderate to high risk of bias. Meta-analysis showed increased mortality risk. Conclusions There was a modest association between some ACB measures and mortality, with most evidence derived from the ACBS. Studies comparing different measures within the same population were lacking. Analysis was limited by poor generalizability between studies, specifically regarding heterogeneity in methodology and reporting, as well as high risk of bias for most studies in the evidence base.
Collapse
Affiliation(s)
- Katherine Graves-Morris
- Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Carrie Stewart
- Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Roy L Soiza
- Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.,Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, United Kingdom
| | - Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Phyo Kyaw Myint
- Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.,Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, United Kingdom
| |
Collapse
|
25
|
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.
Collapse
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
| |
Collapse
|
26
|
Association between anticholinergic drug burden and mortality in older people: a systematic review. Eur J Clin Pharmacol 2019; 76:319-335. [PMID: 31832732 DOI: 10.1007/s00228-019-02795-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/05/2019] [Indexed: 01/29/2023]
Abstract
PURPOSE The purpose of the study is to conduct a systematic review of studies examining the association between anticholinergic burden and mortality in older individuals. METHODS A literature search was performed to identify relevant studies, using MEDLINE, EMBASE, PsycINFO and CENTRAL, from January 1990 to December 2018. We included studies of patients with a mean age of 65 years or older where the anticholinergic burden was estimated using anticholinergic risk assessment tools, and associations between anticholinergic load and mortality were investigated. The primary outcome of interest was the association between anticholinergic burden and mortality. RESULTS Twenty-seven studies were included. These were three cross-sectional, one nested case-control and 23 prospective or retrospective cohort studies. Most studies were determined to be of good quality. A total of 15 studies reported a positive correlation between anticholinergic burden and mortality, while the remaining 10 studies did not report a significant association. Eighteen out of 27 studies (80%) had a short follow-up period of 1 year or less. Among the five high-quality studies that met all the domains of the quality assessment criteria, four showed a positive association. CONCLUSION The variation in results could relate to the quality of the studies, follow-up period, anticholinergic risk assessment tool used and the study setting. Sixty-three percent (n = 17) of all the included studies, but almost all of the high-quality studies with an extended follow-up, reported a positive correlation between anticholinergic burden and mortality. Further high-quality research, using standardized measures and with adequate follow-up periods, is required to confirm the relationship between anticholinergic burden and mortality.
Collapse
|
27
|
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: 58] [Impact Index Per Article: 11.6] [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.
Collapse
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
| |
Collapse
|
28
|
Nguyen TX, Nguyen TN, Nguyen AT, Nguyen HTT, Nguyen TTH, Nguyen TN, Pham T, Vu HTT. Polypharmacy at discharge in older hospitalised patients in Vietnam and its association with frailty. Australas J Ageing 2019; 39:230-236. [PMID: 31677221 DOI: 10.1111/ajag.12722] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 08/20/2019] [Accepted: 08/21/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate the prevalence of polypharmacy and the common drugs prescribed at discharge in frail and non-frail older inpatients, and to examine whether frailty is significantly associated with polypharmacy. METHODS Cross-sectional analysis from data of a study about the prevalence of frailty in older inpatients in Vietnam in 2015. Polypharmacy was defined as using ≥5 medications. Frailty was defined by Fried's frailty criteria. RESULTS There were 382 participants, mean age 76.4, 56.5% female and 35.9% frail. At discharge, 59.2% had polypharmacy (62.8% in the frail and 57.1% in the non-frail). Vitamin/supplements were the most common drugs prescribed, followed by antiplatelets. Frailty was not significantly associated with polypharmacy (adjusted OR 1.45, 95% CI 0.89-2.34). CONCLUSIONS The prevalence of polypharmacy at discharge was high in both frail and non-frail participants. The association between frailty and polypharmacy needs to be investigated further in multicentre studies with larger sample sizes in Vietnam.
Collapse
Affiliation(s)
- Thanh Xuan Nguyen
- Scientific Research Department, National Geriatric Hospital, Hanoi, Vietnam.,Department of Geriatrics, Hanoi Medical University, Hanoi, Vietnam
| | - Tu N Nguyen
- Scientific Research Department, National Geriatric Hospital, Hanoi, Vietnam.,Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Anh Trung Nguyen
- Scientific Research Department, National Geriatric Hospital, Hanoi, Vietnam.,Department of Geriatrics, Hanoi Medical University, Hanoi, Vietnam
| | - Huong Thi Thu Nguyen
- Scientific Research Department, National Geriatric Hospital, Hanoi, Vietnam.,Department of Geriatrics, Hanoi Medical University, Hanoi, Vietnam
| | - Thu Thi Hoai Nguyen
- Scientific Research Department, National Geriatric Hospital, Hanoi, Vietnam.,Department of Geriatrics, Hanoi Medical University, Hanoi, Vietnam.,Dinh Tien Hoang Institute of Medicine, Hanoi, Vietnam
| | - Tam Ngoc Nguyen
- Scientific Research Department, National Geriatric Hospital, Hanoi, Vietnam.,Department of Geriatrics, Hanoi Medical University, Hanoi, Vietnam
| | - Thang Pham
- Scientific Research Department, National Geriatric Hospital, Hanoi, Vietnam.,Department of Geriatrics, Hanoi Medical University, Hanoi, Vietnam
| | - Huyen Thi Thanh Vu
- Scientific Research Department, National Geriatric Hospital, Hanoi, Vietnam.,Department of Geriatrics, Hanoi Medical University, Hanoi, Vietnam
| |
Collapse
|
29
|
Kassie GM, Kalisch Ellett LM, Nguyen TA, Roughead EE. Use of medicines that may precipitate delirium prior to hospitalisation in older Australians with delirium: An observational study. Australas J Ageing 2019; 38:124-131. [DOI: 10.1111/ajag.12608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 11/26/2018] [Accepted: 12/05/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Gizat M. Kassie
- Quality Use of Medicines and Pharmacy Research CentreSchool of Pharmacy and Medical SciencesUniversity of South Australia Adelaide South Australia Australia
| | - Lisa M. Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research CentreSchool of Pharmacy and Medical SciencesUniversity of South Australia Adelaide South Australia Australia
| | - Tuan A. Nguyen
- Quality Use of Medicines and Pharmacy Research CentreSchool of Pharmacy and Medical SciencesUniversity of South Australia Adelaide South Australia Australia
| | - Elizabeth E. Roughead
- Quality Use of Medicines and Pharmacy Research CentreSchool of Pharmacy and Medical SciencesUniversity of South Australia Adelaide South Australia Australia
| |
Collapse
|
30
|
De Vreese LP, Mantesso U, De Bastiani E, Marangoni A, Weger E, Gomiero T. Anticholinergic burden in adult and elderly people with intellectual disabilities: Results from an Italian multicenter cross-sectional study. PLoS One 2018; 13:e0205897. [PMID: 30379948 PMCID: PMC6209221 DOI: 10.1371/journal.pone.0205897] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 10/03/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Adults and older people with intellectual disabilities (ID) frequently receive anti-cholinergic drugs in chronic use, but no studies in Italy to date have investigated cumulative anticholinergic exposure and factors associated with high anticholinergic burden in this frail population. AIM To probe the cumulative exposure to anticholinergics and the demographic, social and clinical factors associated with high exposure. METHODS The 2012 updated version of the Anticholinergic Burden Score (ACB) was calculated for a multicentre sample of 276 adult and older people over 40 years with ID and associations with factors assessed. RESULTS Overall, antipsychotics, antiepileptics, anxiolytics, and antidepressants were the most frequent classes contributing to the total ACB score. People living in residential care were more likely exposed to high anticholinergic burden (an ACB score of 3+): both community housing (odds ratio [OR] 4.63, 95%CI 1.08-19.95) and nursing home facility ([OR] 9.99, 95%CI 2.32-43.04). There was also a significant association between an ACB score of 3+ and reporting mental health conditions ([OR] 25.56, 95% CI 8.08-80.89) or a neurological disease ([OR] 4.14, 95%CI 1.32-12.94). Neither demographic characteristics (age and gender) nor other clinical conditions (somatic comorbidity, levels and typology of ID) were associated with higher anticholinergic load. A high burden of anticholinergic was significantly more frequent in laxative users (22.6% ACB3+ vs. 5.1% ACB 0) (p = 0.003). CONCLUSIONS Psychotropics drugs were the highest contributors to the anticholinergic burden in adult and old age ID, especially in those people living in institutional settings with mental health and/or neurological conditions. High anticholinergic load has shown to be associated with the use of laxatives.
Collapse
Affiliation(s)
- Luc Pieter De Vreese
- Geriatric Center, Luigi Boni Foundation, Suzzara, Italy
- Project DAD (Down Alzheimer Dementia) ANFFAS Trentino Onlus, Trento, Italy
| | - Ulrico Mantesso
- Project DAD (Down Alzheimer Dementia) ANFFAS Trentino Onlus, Trento, Italy
| | - Elisa De Bastiani
- Project DAD (Down Alzheimer Dementia) ANFFAS Trentino Onlus, Trento, Italy
| | | | - Elisabeth Weger
- Project DAD (Down Alzheimer Dementia) ANFFAS Trentino Onlus, Trento, Italy
| | - Tiziano Gomiero
- Project DAD (Down Alzheimer Dementia) ANFFAS Trentino Onlus, Trento, Italy
- * E-mail:
| |
Collapse
|
31
|
Hentzen C, Haddad R, Sheikh Ismaël S, Chesnel C, Robain G, Amarenco G. Efficacy of posterior tibial nerve stimulation (PTNS) on overactive bladder in older adults. Eur Geriatr Med 2018; 9:249-253. [PMID: 34654250 DOI: 10.1007/s41999-017-0013-3] [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] [Received: 11/03/2017] [Accepted: 11/28/2017] [Indexed: 12/18/2022]
Abstract
INTRODUCTION The main objective of this retrospective study is to determine the efficacy of transcutaneous posterior tibial nerve stimulation (TPTNS) in older patients with overactive bladder (OAB) syndrome. The secondary objective is to look for predictive factors of efficacy of this treatment. METHODS All patients aged over 65 years with OAB syndrome for which TPTNS was introduced between 2010 and 2016 in two neuro-urology centers were included. Age, gender, etiology of OAB, urinary symptoms and detrusor overactivity (DO) were retrospectively collected. The main outcome was efficacy of TPTNS (i.e., purchase of the device between 3 and 6 months). RESULTS A total of 264 patients were included (mean age 74.1 ± 6.5 years; 63.3% of women), of whom 53% had neurogenic OAB. Urinary incontinence was reported by 83.7% of patients and DO was found on urodynamic studies in 154 patients. The overall efficacy of TPTNS was 45.1%. None of the tested factors were significantly predictive of efficacy, especially age (≥ 75 years, p = 0.62), associated stress urinary incontinence (p = 0.69) and presence of DO (p = 0.60), whether neurogenic or not. CONCLUSION TPTNS is an effective treatment in older patients with OAB syndrome. No predictive factors of efficacy were found, especially age and DO. This treatment seems to be a good alternative to antimuscarinics against overactive bladder in older adults.
Collapse
Affiliation(s)
- C Hentzen
- Department of Neuro-urology, Tenon Hospital, AP-HP, 4 Rue de la Chine, 75020, Paris, France. .,Clinical Research Group of Perineal Dysfunctions in Older Adults, GRAPPPA, Paris, France.
| | - R Haddad
- Department of Physical Medicine and Rehabilitation, Rothschild Hospital, AP-HP, Paris, France.,Clinical Research Group of Perineal Dysfunctions in Older Adults, GRAPPPA, Paris, France
| | - S Sheikh Ismaël
- Department of Neuro-urology, Tenon Hospital, AP-HP, 4 Rue de la Chine, 75020, Paris, France.,Clinical Research Group of Perineal Dysfunctions in Older Adults, GRAPPPA, Paris, France
| | - C Chesnel
- Department of Neuro-urology, Tenon Hospital, AP-HP, 4 Rue de la Chine, 75020, Paris, France.,Clinical Research Group of Perineal Dysfunctions in Older Adults, GRAPPPA, Paris, France
| | - G Robain
- Department of Physical Medicine and Rehabilitation, Rothschild Hospital, AP-HP, Paris, France.,Clinical Research Group of Perineal Dysfunctions in Older Adults, GRAPPPA, Paris, France
| | - G Amarenco
- Department of Neuro-urology, Tenon Hospital, AP-HP, 4 Rue de la Chine, 75020, Paris, France.,Clinical Research Group of Perineal Dysfunctions in Older Adults, GRAPPPA, Paris, France
| | | |
Collapse
|
32
|
Egberts A, Mattace-Raso FU. Increased neutrophil-lymphocyte ratio in delirium: a pilot study. Clin Interv Aging 2017; 12:1115-1121. [PMID: 28769556 PMCID: PMC5529095 DOI: 10.2147/cia.s137182] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Aim Delirium is a common and severe complication among older hospitalized patients. The pathophysiology is poorly understood, but it has been suggested that inflammation and oxidative stress may play a role. The aim of this pilot study was to investigate levels of the neutrophil–lymphocyte ratio (NLR) – a marker of systemic inflammation and oxidative stress – in patients with and without delirium. Methods This pilot study was performed within a retrospective chart review study that included acutely ill patients, 65 years and older, who were admitted to the ward of geriatrics of the Erasmus University Medical Center. All patients in whom the differential white blood cell (WBC) counts as well as the C-reactive protein (CRP) level were determined within 24 h after admission were included in the present study. Differences in NLR between patients with and without delirium were investigated using univariate analysis of variance, with adjustments for age, sex, comorbidities, CRP level, and total WBC count. Results Eighty-six patients were included. Thirteen patients were diagnosed with delirium. In adjusted models, higher mean NLR values were found in patients with, than in those without, delirium (9.10 vs 5.18, P=0.003). Conclusion In this pilot study, we found increased NLR levels in patients with delirium. This finding might suggest that an inadequate response of the immune system and oxidative stress may play a role in the pathogenesis of delirium. Further studies are needed to confirm the association between NLR and delirium.
Collapse
Affiliation(s)
- Angelique Egberts
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Francesco Us Mattace-Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| |
Collapse
|
33
|
Egberts A, van der Craats ST, van Wijk MD, Alkilabe S, van den Bemt PMLA, Mattace-Raso FUS. Anticholinergic drug exposure is associated with delirium and postdischarge institutionalization in acutely ill hospitalized older patients. Pharmacol Res Perspect 2017; 5:e00310. [PMID: 28603629 PMCID: PMC5464339 DOI: 10.1002/prp2.310] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 03/20/2017] [Indexed: 01/17/2023] Open
Abstract
Several studies investigated the possible association between anticholinergic drugs and diverse clinical outcomes in older persons, but the results are inconsistent. The aim of this study was to investigate whether anticholinergic drug exposure is associated with delirium on admission, length of hospital stay, postdischarge institutionalization and in-hospital mortality in acutely ill hospitalized older patients. In this observational chart review study, we included acutely ill patients aged 65 and older who were admitted to the geriatric ward of the Erasmus University Medical Center, Rotterdam, The Netherlands, between 2012 and 2015 (n = 905). Anticholinergic drug exposure on admission was defined as the use of anticholinergic drugs, total number of anticholinergic drugs and anticholinergic drug burden score (ADB), quantified with the Anticholinergic Risk Scale (ARS), the Anticholinergic Cognitive Burden scale (ACB) and the list of Chew et al. (Chew). Logistic regression analyses were performed to investigate possible associations between anticholinergic drug exposure and the aforementioned outcomes. Analyses were adjusted for age, sex, comorbidities, non-anticholinergic drugs and delirium, where appropriate. Moderate and high ADB measured with the ARS were associated with delirium on admission with odds ratios (OR) of 1.70 (95% confidence interval (CI) = 1.16-2.49) and 1.83 (95% CI = 1.06-3.15), respectively. High ADB measured with the ARS was also associated with postdischarge institutionalization (OR = 2.43, 95% CI = 1.24-4.75). No associations were found using the ACB and Chew. Future studies are warranted to investigate the clinical usefulness of the ARS in reducing complications in older persons.
Collapse
Affiliation(s)
- Angelique Egberts
- Section of Geriatric Medicine Department of Internal Medicine Erasmus University Medical Center Rotterdam The Netherlands
| | - Saskia T van der Craats
- Section of Geriatric Medicine Department of Internal Medicine Erasmus University Medical Center Rotterdam The Netherlands
| | - Melissa D van Wijk
- Section of Geriatric Medicine Department of Internal Medicine Erasmus University Medical Center Rotterdam The Netherlands
| | - Shams Alkilabe
- Section of Geriatric Medicine Department of Internal Medicine Erasmus University Medical Center Rotterdam The Netherlands
| | | | - Francesco U S Mattace-Raso
- Section of Geriatric Medicine Department of Internal Medicine Erasmus University Medical Center Rotterdam The Netherlands
| |
Collapse
|