Anticholinergic load and delirium in end-of-life patients

Anticholinergic Burden and Cognitive Impairment in Nursing Homes: A Comparison of Four Anticholinergic Scales

BACKGROUND

Medications with anticholinergic effects are commonly used in nursing homes, and their cumulative effect is of particular concern for the risk of adverse effects on cognition.

OBJECTIVE

The relation between cognitive function and anticholinergic burden measured with four scales, the Anticholinergic Cognitive Burden (ACB) Scale, the Anticholinergic Risk Scale, the German Anticholinergic Burden Scale, and the CRIDECO Anticholinergic Load Scale, is assessed according to the hypothesis that a higher anticholinergic burden is associated with reduced cognitive performance.

METHODS

This retrospective cross-sectional multicenter study was conducted in a sample of Italian long-term-care nursing homes (NH). Sociodemographic details, diagnosis, and drug treatments of each NH resident were collected using medical records four times during 2018 and 2019. Cognitive status was rated with the Mini-Mental State Examination (MMSE). The prevalence of anticholinergic use and its burden were calculated referring to the last time point for each patient. A longitudinal analysis was done on NH residents with at least two MMSE between 2018 and 2019 to assess the relation between the anticholinergic load and decline in MMSE. The relationship between drug-related anticholinergic burden and cognitive performance was analyzed using Poisson regression model theory. Multivariate analyses were adjusted according to the known risk factors of reduced cognitive performance available [age, sex, history of stroke or transient ischemic attack (TIA), and number of non-anticholinergic drugs] and for cholinesterase inhibitors. In view of the high number of subjects with an MMSE score = 0 among residents with dementia, for this group a zero-inflated Poisson regression model was used to give more consistent results. The association of anticholinergic burden with mortality was examined from each patient's last visit using a multivariate logistic model adjusted for age, sex, and Charlson Comorbidity Index (CCI).

RESULTS

Among 1412 residents recruited, a clear direct relationship was found between higher anticholinergic burden and cognitive impairment only for the Anticholinergic Cognitive Burden Scale. Residents taking an anticholinergic who scored 5 or more had 2.5 points more decline than those not taking them (p < 0.001). Among residents without dementia there was a trend toward direct relationship for the Anticholinergic Cognitive Burden Scale and the Anticholinergic Risk Scale. Residents with higher scores had about 2 points more decline than residents not taking anticholinergic drugs. No relation was found between anticholinergic burden and cognitive decline or mortality.

CONCLUSIONS

The cumulative effect of medications with modest antimuscarinic activity may influence the cognitive performance of NH residents. The anticholinergic burden measured with the ACB scale should help identify NH residents who may benefit from reducing the anticholinergic burden. A clear direct relationship between anticholinergic burden and cognitive impairment was found only for the ACB Scale.

Perspectives on deprescribing in palliative care

INTRODUCTION

Pharmacotherapy plays a critical role in the delivery of high-quality palliative care, but the intersection of palliative care and deprescribing has received little attention.

AREAS COVERED

We conducted a scoping review of English language articles using PubMed to identify relevant publications between 1 January 2000 to 31 July 2022 using search terms of deprescribing, palliative care, end of life, and hospice. We summarize current definitions and developments in palliative care and deprescribing from both clinical and research perspectives. We highlight key challenges and outline proposed solutions and needed research.

EXPERT OPINION

The future of deprescribing in palliative care requires the development and adoption of individualized approaches to medication management, including a reconsidered approach to communication about deprescribing. Evidence from high-quality clinical outcomes studies is lacking, and the field needs new approaches to coordination of care delivery. This review article will be of interest to both clinical and research-based pharmacists, physicians, and nurses interested in improving care for patients with serious illness.

Risk factors for delirium in advanced cancer patients: A systematic review and meta-analysis

PURPOSE

To systematically collect published research in order to identify and quantify risk factors for delirium in advanced cancer patients.

METHODS

The Cochrane Library, PubMed, Proquest, CINAHL, Web of Science, Ovid MEDLINE, Embase, Scopus, Chinese Wanfang Data, Chinese Periodical Full-text Database (VIP), Chinese Biomedical Literature Database (CBM), and Chinese National Knowledge Infrastructure (CNKI) were systematically searched for cohort or case-control studies reporting individual risk factors for delirium among advanced-stage cancer patients published prior to March 2022. The Newcastle-Ottawa Scale was used to assess the methodological quality of included studies. The pooled adjusted odds ratio (aOR) and its 95% confidence interval were calculated using the RevMan 5.4 software package.

RESULTS

A total of 15 studies with data from 3106 advanced cancer patients were included in our analysis. Nine studies were high-quality and six were of moderate quality. Pooled analyses revealed that 11 risk factors were statistically significant. High-intensity risk factors included sleep disturbance, infection, cachexia and the Palliative Prognostic Index; medium-intensity risk factors included male sex, renal failure, dehydration and drowsiness; low-intensity risk factors included age, total bilirubin and opioid use. Antibiotic use was found to have been a protective factor.

CONCLUSIONS

We identified 12 independent risk factors that were significantly associated with delirium in advanced cancer patients and provide an evidence-based foundation to implement appropriate preventive strategies.

Risk Factors for Delirium in the Palliative Care Population: A Systematic Review and Meta-Analysis

Objective: Delirium is common and highly distressing for the palliative care population. Until now, no study has systematically reviewed the risk factors of delirium in the palliative care population. Therefore, we performed a systematic review and meta-analysis to evaluate delirium risk factors among individuals receiving palliative care. Methods: We systematically searched PubMed, Medline, Embase, and Cochrane database to identify relevant observational studies from database inception to June 2021. The methodological quality of the eligible studies was assessed by the Newcastle Ottawa Scale. We estimated the pooled adjusted odds ratio (aOR) for individual risk factors using the inverse variance method. Results: Nine studies were included in the review (five prospective cohort studies, three retrospective case-control studies and one retrospective cross-section study). In pooled analyses, older age (aOR: 1.02, 95% CI: 1.01-1.04, I ² = 37%), male sex (aOR:1.80, 95% CI: 1.37-2.36, I ² = 7%), hypoxia (aOR: 0.87, 95% CI: 0.77-0.99, I ² = 0%), dehydration (aOR: 3.22, 95%CI: 1.75-5.94, I ² = 18%), cachexia (aOR:3.40, 95% CI: 1.69-6.85, I ² = 0%), opioid use (aOR: 2.49, 95%CI: 1.39-4.44, I ² = 0%), anticholinergic burden (aOR: 1.18, 95% CI: 1.07-1.30, I ² = 9%) and Eastern Cooperative Oncology Group Performance Status (aOR: 2.54, 95% CI: 1.56-4.14, I ² = 21%) were statistically significantly associated with delirium. Conclusion: The risk factors identified in our review can help to highlight the palliative care population at high risk of delirium. Appropriate strategies should be implemented to prevent delirium and improve the quality of palliative care services.