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Bhatkhande G, Choudhry NK, Mahesri M, Haff N, Lauffenburger JC. Disentangling drug contributions: anticholinergic burden in older adults linked to individual medications: a cross-sectional population-based study. BMC Geriatr 2024; 24:44. [PMID: 38200457 PMCID: PMC10782746 DOI: 10.1186/s12877-023-04640-4] [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: 10/06/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Medications with potent anticholinergic properties have well-documented adverse effects. A high cumulative anticholinergic burden may arise from the concurrent use of multiple medications with weaker anticholinergic effects. We sought to identify patterns of high anticholinergic burden and associated patient characteristics. METHODS We identified patients aged ≥ 65 who filled ≥ 1 medication with anticholinergic adverse effects in 2019 and had a cumulative Anticholinergic Burden score (ACB) ≥ 4 (i.e., high anticholinergic burden) in a large US health insurer. We classified patients based on how they attained high burden, as follows: 1) only filling strong or moderate anticholinergic medications (i.e., ACB = 2 or 3, "moderate/strong"), 2) only filling lightly anticholinergic medications (i.e., ACB = 1, "light/possible"), and 3) filling any combination ("mix"). We used multinomial logistic regression to assess the association between measured patient characteristics and membership in the three anticholinergic burden classifications, using the moderate/strong group as the referent. RESULTS In total, 83,286 eligible patients with high anticholinergic burden were identified (mean age: 74.3 years (SD:7.1), 72.9% female). Of these, 4.5% filled only strong/moderate anticholinergics, 4.3% filled only light/possible anticholinergics, and the rest filled a mix (91.2%). Within patients in the mixed group, 64.3% of medication fills were for light/possible anticholinergics, while 35.7% were for moderate/strong anticholinergics. Compared with patients in the moderate/strong anticholinergics group, patients filling only light/possible anticholinergics were more likely to be older (adjusted Odds Ratio [aOR] per 1-unit of age: 1.06, 95%CI: 1.05-1.07), less likely to be female (aOR: 0.56, 95%CI: 0.50-0.62 vs. male), more likely to have comorbidities (e.g., heart failure aOR: 3.18, 95%CI: 2.70-3.74 or depression aOR: 1.20, 95%CI: 1.09-1.33 vs. no comorbidity), and visited fewer physicians (aOR per 1-unit of change: 0.98, 95%CI: 0.97-0.98). Patients in the mixed group were older (aOR per 1-unit of age: 1.02, 95%CI: 1.02-1.03) and less likely to be female (aOR: 0.89, 95%CI: 0.82-0.97 vs. male) compared with those filling moderate/strong anticholinergics. CONCLUSION Most older adults accumulated high anticholinergic burden through a combination of light/possible and moderate/strong anticholinergics rather than moderate/strong anticholinergics, with light/possible anticholinergics being the major drivers of overall anticholinergic burden. These insights may inform interventions to improve prescribing in older adults.
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Affiliation(s)
- Gauri Bhatkhande
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Niteesh K Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Mufaddal Mahesri
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
| | - Nancy Haff
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Julie C Lauffenburger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA.
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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2
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Hirdes JP, Morris JN, Perlman CM, Saari M, Betini GS, Franco-Martin MA, van Hout H, Stewart SL, Ferris J. Mood Disturbances Across the Continuum of Care Based on Self-Report and Clinician Rated Measures in the interRAI Suite of Assessment Instruments. Front Psychiatry 2022; 13:787463. [PMID: 35586405 PMCID: PMC9108209 DOI: 10.3389/fpsyt.2022.787463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 03/25/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Mood disturbance is a pervasive problem affecting persons of all ages in the general population and the subset of those receiving services from different health care providers. interRAI assessment instruments comprise an integrated health information system providing a common approach to comprehensive assessment of the strengths, preferences and needs of persons with complex needs across the continuum of care. OBJECTIVE Our objective was to create new mood scales for use with the full suite of interRAI assessments including a composite version with both clinician-rated and self-reported items as well as a self-report only version. METHODS We completed a cross-sectional analysis of 511,641 interRAI assessments of Canadian adults aged 18+ in community mental health, home care, community support services, nursing homes, palliative care, acute hospital, and general population surveys to develop, test, and refine new measures of mood disturbance that combined clinician and self-rated items. We examined validity and internal consistency across diverse care settings and populations. RESULTS The composite scale combining both clinician and self-report ratings and the self-report only variant showed different distributions across populations and settings with most severe signs of disturbed mood in community mental health settings and lowest severity in the general population prior to the COVID-19 pandemic. The self-report and composite measures were strongly correlated with each other but differed most in populations with high rates of missing values for self-report due to cognitive impairment (e.g., nursing homes). Evidence of reliability was strong across care settings, as was convergent validity with respect to depression/mood disorder diagnoses, sleep disturbance, and self-harm indicators. In a general population survey, the correlation of the self-reported mood scale with Kessler-10 was 0.73. CONCLUSIONS The new interRAI mood scales provide reliable and valid mental health measures that can be applied across diverse populations and care settings. Incorporating a person-centered approach to assessment, the composite scale considers the person's perspective and clinician views to provide a sensitive and robust measure that considers mood disturbances related to dysphoria, anxiety, and anhedonia.
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Affiliation(s)
- John P Hirdes
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | | | | | - Margaret Saari
- SE Research Centre, SE Health and Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Gustavo S Betini
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | | | - Hein van Hout
- Department of General Practice and Medicine for Older Persons, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Shannon L Stewart
- Faculty of Education, Western University (Canada), London, ON, Canada
| | - Jason Ferris
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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3
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Sanchez S, Chrusciel J, Ndiongue BM, Blochet C, Forget JF, Letty A, Hay PE, Novella JL. Risk Indicators Improve the Prescription Quality of Drugs with Anticholinergic Properties in Nursing Homes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:ijerph19010423. [PMID: 35010682 PMCID: PMC8744764 DOI: 10.3390/ijerph19010423] [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: 10/29/2021] [Revised: 12/24/2021] [Accepted: 12/28/2021] [Indexed: 11/16/2022]
Abstract
AIM The objective of this study was to assess the impact of a collaborative therapeutic optimization program on the rate of potentially inappropriate prescription of drugs with anticholinergic properties in nursing homes. METHODS Quasi-experimental study in 37 nursing homes in France. The intervention included the use of quality indicators for prescriptions combined with educational sessions and dedicated materials for nursing home staff (unlimited access to study material for staff, including nurses, general practitioners, pharmacists). Indicators were calculated based on routine data collected from an electronic pill dispenser system. The primary outcome was the presence of at least one prescription containing ≥1 drug from a list of 12 drugs with anticholinergic properties. A difference-in-differences analysis was conducted at 18 months as well as propensity score weighting to minimize any potential indication bias. A generalized estimating equation model estimated the probability of being prescribed at least one target drug at any time during a 9-month period for each resident. RESULTS In total, 33 nursing homes (intervention group: n = 10; control group: n = 23) were included, totalling 8137 residents. There was a decrease in the use of drugs with anticholinergic properties over time in both groups, as well as a decline in the intervention group compared to the control group (Odds Ratio: 0.685, 95% CI: 0.533, 0.880; p < 0.01) that was attributable to the intervention. An estimated 49 anticholinergic properties drug prescriptions were avoided by the intervention. CONCLUSION This study found that an intervention based on indicators derived from routine prescription data was effective in reducing use of drugs with anticholinergic properties prescriptions in nursing homes.
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Affiliation(s)
- Stéphane Sanchez
- Pole Territorial Santé Publique et Performance, Hôpitaux Champagne Sud, 10003 Troyes, France;
- Fondation Korian Pour le Bien Vieillir, 75008 Paris, France; (B.M.N.); (A.L.); (P.E.H.)
- EA 3797, Santé Publique, Vieillissement, Qualité de vie et Réadaptation des Sujets Fragiles, Université Reims Champagne Ardennes, 51100 Reims, France;
- Correspondence: ; Tel.: +33-25-49-75-61
| | - Jan Chrusciel
- Pole Territorial Santé Publique et Performance, Hôpitaux Champagne Sud, 10003 Troyes, France;
| | - Biné Mariam Ndiongue
- Fondation Korian Pour le Bien Vieillir, 75008 Paris, France; (B.M.N.); (A.L.); (P.E.H.)
| | | | | | - Aude Letty
- Fondation Korian Pour le Bien Vieillir, 75008 Paris, France; (B.M.N.); (A.L.); (P.E.H.)
| | - Paul Emile Hay
- Fondation Korian Pour le Bien Vieillir, 75008 Paris, France; (B.M.N.); (A.L.); (P.E.H.)
| | - Jean Luc Novella
- EA 3797, Santé Publique, Vieillissement, Qualité de vie et Réadaptation des Sujets Fragiles, Université Reims Champagne Ardennes, 51100 Reims, France;
- Pole Autonomie Santé, Centre Hospitalier Universitaire de Reims, 92130 Issy les Moulineaux, France
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4
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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.
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Affiliation(s)
- Angela Lisibach
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland.,Center for Research and Innovation in Clinical Pharmaceutical Sciences, 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
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5
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Anticholinergics and clinical outcomes amongst people with pre-existing dementia: A systematic review. Maturitas 2021; 151:1-14. [PMID: 34446273 DOI: 10.1016/j.maturitas.2021.06.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/10/2021] [Accepted: 06/14/2021] [Indexed: 12/23/2022]
Abstract
Many medicines have anticholinergic properties, which have previously been correlated with a range of adverse effects, including cognitive impairment, hallucinations and delirium. These effects are potentially of concern for people with dementia. This systematic review investigated the effect of anticholinergic medicines on the health outcomes of people with pre-existing dementia. Embase, Medline and the Cochrane Library were searched from January 2000 to January 2021. Studies were included if they matched the following criteria: (1) the intervention involved anticholinergic medications; (2) the study was conducted in people with pre-existing dementia; (3) there was at least one comparator group; and (4) the outcome of interest was clinically measurable. A total of 14 studies met the inclusion criteria. Most studies used an anticholinergic burden scale to measure anticholinergic exposure. Five high-quality studies consistently identified a strong association between anticholinergic medications and all-cause mortality. Anticholinergics were also found to be associated with longer hospital length of stay in three studies. Inconsistent findings were reported for cognitive function (in 4 studies) and neuropsychiatric functions (in 2 studies). In single studies, anticholinergic medications were associated with the composite outcome of stroke and mortality, pneumonia, delirium, poor physical performance, reduced health-related quality of life and treatment modifications due to reduced treatment response or symptom exacerbation. While the evidence suggests that anticholinergic medication use for people with dementia has a strong association with all-cause mortality, the association with cognitive and other clinical outcomes remains uncertain. Hence, further studies are needed to substantiate the evidence for other outcomes.
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6
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Spinewine A, Evrard P, Hughes C. Interventions to optimize medication use in nursing homes: a narrative review. Eur Geriatr Med 2021; 12:551-567. [PMID: 33751478 PMCID: PMC8149362 DOI: 10.1007/s41999-021-00477-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/25/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE Polypharmacy, medication errors and adverse drug events are frequent among nursing home residents. Errors can occur at any step of the medication use process. We aimed to review interventions aiming at optimization of any step of medication use in nursing homes. METHODS We narratively reviewed quantitative as well as qualitative studies, observational and experimental studies that described interventions, their effects as well as barriers and enablers to implementation. We prioritized recent studies with relevant findings for the European setting. RESULTS Many interventions led to improvements in medication use. However, because of outcome heterogeneity, comparison between interventions was difficult. Prescribing was the most studied aspect of medication use. At the micro-level, medication review, multidisciplinary work, and more recently, patient-centered care components dominated. At the macro-level, guidelines and legislation, mainly for specific medication classes (e.g., antipsychotics) were employed. Utilization of technology also helped improve medication administration. Several barriers and enablers were reported, at individual, organizational, and system levels. CONCLUSION Overall, existing interventions are effective in optimizing medication use. However there is a need for further European well-designed and large-scale evaluations of under-researched intervention components (e.g., health information technology, patient-centered approaches), specific medication classes (e.g., antithrombotic agents), and interventions targeting medication use aspects other than prescribing (e.g., monitoring). Further development and uptake of core outcome sets is required. Finally, qualitative studies on barriers and enablers for intervention implementation would enable theory-driven intervention design.
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Affiliation(s)
- Anne Spinewine
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Avenue Mounier 72/B1.72.02, Woluwe-Saint-Lambert, 1200, Brussels, Belgium.
- Pharmacy Department, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium.
| | - Perrine Evrard
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Avenue Mounier 72/B1.72.02, Woluwe-Saint-Lambert, 1200, Brussels, Belgium
| | - Carmel Hughes
- School of Pharmacy, Queen's University Belfast, Belfast, UK
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Kachru N, Holmes HM, Johnson ML, Chen H, Aparasu RR. Comparative risk of adverse outcomes associated with nonselective and selective antimuscarinic medications in older adults with dementia and overactive bladder. Int J Geriatr Psychiatry 2021; 36:684-696. [PMID: 33169433 PMCID: PMC9290172 DOI: 10.1002/gps.5467] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 11/01/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The differential muscarinic receptor selectivity could cause selective antimuscarinics to offer advantages over nonselective agents with respect to adverse effects. The objective was to examine the comparative risk of falls/fractures and all-cause hospitalizations among older adults with dementia and overactive bladder (OAB) using nonselective and selective antimuscarinics METHODS/DESIGN: A retrospective cohort study design was conducted among older patients with dementia and OAB using incident antimuscarinics. The primary exposure was classified as nonselective (oxybutynin, tolterodine, trospium, and fesoterodine) and selective (solifenacin and darifenacin). Cox proportional-hazards regression using inverse probability of treatment weighting (IPTW) evaluated the risk of falls/fractures and all-cause hospitalizations within 6 months of nonselective and selective antimuscarinic use. RESULTS The study cohort consisted of 13,896 (76.9%) nonselective and 4,179 (23.1%) selective antimuscarinic incident users. The unadjusted falls/fractures rate was 27.14% (3,772) for nonselective and 24.55% (1,026) for selective users (p-value< 0.01). The unadjusted all-cause hospitalizations rate was 24.14% (3,354) for nonselective and 21.58% (902) for selective users (p-value <0.01). The IPTW models did not find a significant difference in the risk of falls/fractures (Hazard Ratio [HR] 1.03; 95% Confidence Interval [CI] 0.99-1.07) and risk of all-cause hospitalizations (HR 1.04; 95% CI 0.99-1.08) between nonselective and selective antimuscarinics. Several sensitivity analyses corroborated the main findings. CONCLUSIONS The study did not find a differential risk of falls/fractures and all-cause hospitalizations in older adults with dementia and OAB using nonselective and selective antimuscarinics. More research is needed to understand the role of pharmacodynamics and pharmacokinetics in the safety profile of antimuscarinics in dementia.
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Affiliation(s)
- Nandita Kachru
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX
| | - Holly M. Holmes
- Division of Geriatric and Palliative Medicine, McGovern Medical School at UTHealth, Houston, TX
| | - Michael L. Johnson
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX
| | - Rajender R. Aparasu
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX
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8
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Lisibach A, Benelli V, Ceppi MG, Waldner-Knogler K, Csajka C, Lutters M. Quality of anticholinergic burden scales and their impact on clinical outcomes: a systematic review. Eur J Clin Pharmacol 2021; 77:147-162. [PMID: 33011824 DOI: 10.1007/s00228-020-0299x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 09/10/2020] [Indexed: 05/23/2023]
Abstract
PURPOSE Older people are at risk of anticholinergic side effects due to changes affecting drug elimination and higher sensitivity to drug's side effects. Anticholinergic burden scales (ABS) were developed to quantify the anticholinergic drug burden (ADB). We aim to identify all published ABS, to compare them systematically and to evaluate their associations with clinical outcomes. METHODS We conducted a literature search in MEDLINE and EMBASE to identify all published ABS and a Web of Science citation (WoS) analysis to track validation studies implying clinical outcomes. Quality of the ABS was assessed using an adapted AGREE II tool. For the validation studies, we used the Newcastle-Ottawa Scale and the Cochrane tool Rob2.0. The validation studies were categorized into six evidence levels based on the propositions of the Oxford Center for Evidence-Based Medicine with respect to their quality. At least two researchers independently performed screening and quality assessments. RESULTS Out of 1297 records, we identified 19 ABS and 104 validations studies. Despite differences in quality, all ABS were recommended for use. The anticholinergic cognitive burden (ACB) scale and the German anticholinergic burden scale (GABS) achieved the highest percentage in quality. Most ABS are validated, yet validation studies for newer scales are lacking. Only two studies compared eight ABS simultaneously. The four most investigated clinical outcomes delirium, cognition, mortality and falls showed contradicting results. CONCLUSION There is need for good quality validation studies comparing multiple scales to define the best scale and to conduct a meta-analysis for the assessment of their clinical impact.
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Affiliation(s)
- Angela Lisibach
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland.
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University Hospital and University of Lausanne, Lausanne, Switzerland.
- School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, University of Geneva, Geneva, Switzerland.
| | - Valérie Benelli
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
| | - Marco Giacomo Ceppi
- Department of Neurorehabilitation, RehaClinic, Bad Zurzach, Switzerland
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | | | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University Hospital and University of Lausanne, Lausanne, Switzerland.
- School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, University of Geneva, Geneva, Switzerland.
| | - Monika Lutters
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
- Swiss Federal Institute of Technology, Zurich, Switzerland
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9
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Lisibach A, Benelli V, Ceppi MG, Waldner-Knogler K, Csajka C, Lutters M. Quality of anticholinergic burden scales and their impact on clinical outcomes: a systematic review. Eur J Clin Pharmacol 2020; 77:147-162. [PMID: 33011824 PMCID: PMC7803697 DOI: 10.1007/s00228-020-02994-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 09/10/2020] [Indexed: 12/13/2022]
Abstract
Purpose Older people are at risk of anticholinergic side effects due to changes affecting drug elimination and higher sensitivity to drug’s side effects. Anticholinergic burden scales (ABS) were developed to quantify the anticholinergic drug burden (ADB). We aim to identify all published ABS, to compare them systematically and to evaluate their associations with clinical outcomes. Methods We conducted a literature search in MEDLINE and EMBASE to identify all published ABS and a Web of Science citation (WoS) analysis to track validation studies implying clinical outcomes. Quality of the ABS was assessed using an adapted AGREE II tool. For the validation studies, we used the Newcastle-Ottawa Scale and the Cochrane tool Rob2.0. The validation studies were categorized into six evidence levels based on the propositions of the Oxford Center for Evidence-Based Medicine with respect to their quality. At least two researchers independently performed screening and quality assessments. Results Out of 1297 records, we identified 19 ABS and 104 validations studies. Despite differences in quality, all ABS were recommended for use. The anticholinergic cognitive burden (ACB) scale and the German anticholinergic burden scale (GABS) achieved the highest percentage in quality. Most ABS are validated, yet validation studies for newer scales are lacking. Only two studies compared eight ABS simultaneously. The four most investigated clinical outcomes delirium, cognition, mortality and falls showed contradicting results. Conclusion There is need for good quality validation studies comparing multiple scales to define the best scale and to conduct a meta-analysis for the assessment of their clinical impact. Electronic supplementary material The online version of this article (10.1007/s00228-020-02994-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Angela Lisibach
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland. .,Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University Hospital and University of Lausanne, Lausanne, Switzerland. .,School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, University of Geneva, Geneva, Switzerland.
| | - Valérie Benelli
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
| | - Marco Giacomo Ceppi
- Department of Neurorehabilitation, RehaClinic, Bad Zurzach, Switzerland.,Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | | | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University Hospital and University of Lausanne, Lausanne, Switzerland. .,School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, University of Geneva, Geneva, Switzerland.
| | - Monika Lutters
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland.,Swiss Federal Institute of Technology, Zurich, Switzerland
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10
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Risk of Mortality Associated with Non-selective Antimuscarinic medications in Older Adults with Dementia: a Retrospective Study. J Gen Intern Med 2020; 35:2084-2093. [PMID: 32026255 PMCID: PMC7351941 DOI: 10.1007/s11606-020-05634-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/23/2019] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Selective antimuscarinics may offer a favorable safety profile over non-selective antimuscarinics for the management of overactive bladder (OAB) in patients with dementia. OBJECTIVE To test the hypothesis that non-selective antimuscarinics are associated with increased risk of mortality compared to selective antimuscarinics in older adults with dementia and OAB. DESIGN Propensity score-matched retrospective new-user cohort design among Medicare beneficiaries in community settings. PATIENTS Older adults with dementia and OAB with incident antimuscarinic use. MAIN MEASURES The primary exposure was antimuscarinic medications classified as non-selective (oxybutynin, tolterodine, trospium, fesoterodine) and selective (solifenacin, darifenacin) agents. All-cause mortality within 180 days of incident antimuscarinic use formed the outcome measure. New users of non-selective and selective antimuscarinics were matched on propensity scores using the Greedy 5 → 1 matching technique. Cox proportional-hazards model stratified on matched pairs was used to evaluate the risk of mortality associated with the use of non-selective versus selective antimuscarinics in the sample. KEY RESULTS The study identified 16,955 (77.6%) non-selective antimuscarinic users and 4893 (22.4%) selective antimuscarinic users. Propensity score matching yielded 4862 patients in each group. The unadjusted mortality rate at 180 days was 2.6% (126) for non-selective and 1.6% (78) for selective antimuscarinic users in the matched cohort (p value < 0.01). The Cox model stratified on matched pairs found 50% higher risk of 180-day mortality with non-selective antimuscarinics as compared to selective ones (hazard ratio (HR) 1.50; 95% confidence interval (CI) 1.04-2.16). The study findings remained consistent across multiple sensitivity analyses. CONCLUSIONS Use of non-selective antimuscarinics was associated with a 50% increase in mortality risk among older adults with dementia and OAB. Given the safety concerns regarding non-selective antimuscarinic agents, there is a significant need to optimize their use in the management of OAB for older patients with dementia.
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11
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Omissions of Care in Nursing Home Settings: A Narrative Review. J Am Med Dir Assoc 2020; 21:604-614.e6. [DOI: 10.1016/j.jamda.2020.02.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/11/2020] [Accepted: 02/19/2020] [Indexed: 02/06/2023]
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12
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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.
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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
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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: 24] [Impact Index Per Article: 4.8] [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.
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Porter B, Arthur A, Savva GM. How do potentially inappropriate medications and polypharmacy affect mortality in frail and non-frail cognitively impaired older adults? A cohort study. BMJ Open 2019; 9:e026171. [PMID: 31092652 PMCID: PMC6530304 DOI: 10.1136/bmjopen-2018-026171] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To test whether the use of potentially inappropriate central nervous system acting medications, proton pump inhibitors (PPIs) or polypharmacy are associated with mortality in cognitively impaired older adults and whether frailer people are at greater risk of harm. SETTING A cohort study nested within the Cognitive Function and Ageing Study II, a population representative cohort study of the older population in Cambridgeshire, Nottingham and Newcastle, UK. PARTICIPANTS A total of 1154 cognitively impaired participants, aged 65 years or older. EXPOSURES Any use of antipsychotics, antidepressants, other anticholinergic medication, benzodiazepines or PPIs, polypharmacy (5-9) and hyperpolypharmacy (≥10 reported medications) were ascertained at baseline. Frailty was assessed using the Fried criteria. PRIMARY OUTCOME Mortality up to 8 years follow-up. HRs associated with potentially inappropriate medication (PIM), frailty and their interaction were estimated adjusting for covariates. RESULTS Within the sample, 44% were taking one or more PIM. Apart from antipsychotics (adjusted HR=3.24, 95% CI 1.83 to 5.73), use of specific PIM was not associated with greater subsequent mortality. Polypharmacy (HR=1.17, 95% CI 0.95 to 1.45) and hyperpolypharmacy were associated with mortality (HR=1.60, 95% CI 1.16 to 2.22). Being frail (HR=1.90, 95% CI 1.32 to 2.72) or prefrail (HR=1.56, 95% CI 1.10 to 2.20) was associated with increased mortality. There was some evidence that the HR for polypharmacy on mortality was lower among frailer individuals, but the overall polypharmacy by frailty interaction was not statistically significant (p=0.102). CONCLUSIONS For those with cognitive impairment, greater concern should be afforded to the number of medications than the prescription of specific classes. Frailer individuals may have a lower relative risk of mortality associated with polypharmacy than less frail individuals.
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Affiliation(s)
- Bryony Porter
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Antony Arthur
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - George M Savva
- School of Health Sciences, University of East Anglia, Norwich, UK
- Quadram Institute Bioscience, Norwich, UK
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Yoon S, Kim J, Jung J, Ahn S, Song Y, Bae N. Factors associated with potentially harmful drug–drug interactions in older Korean people: A population‐based study. Geriatr Gerontol Int 2019; 19:463-464. [DOI: 10.1111/ggi.13640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Seok‐Joon Yoon
- Department of Family MedicineChungnam National University Hospital Daejeon Korea
| | - Jong‐Sung Kim
- Department of Family MedicineChungnam National University Hospital Daejeon Korea
| | - Jin‐Gyu Jung
- Department of Family MedicineChungnam National University Hospital Daejeon Korea
| | - Soon‐Ki Ahn
- Public Health and Medical Services OfficeChungnam National University Hospital Daejeon Korea
| | - Young‐Su Song
- Korean National Health Insurance Review & Assessment Service Daejeon Korea
| | - Nam‐Kyou Bae
- Korean National Health Insurance Review & Assessment Service Daejeon Korea
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16
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de Germay S, Rueter M, Montastruc F, Rousseau V, Lapeyre-Mestre M, Montastruc JL. Trends of atropinic (anticholinergic) exposure in the elderly: a 10-year analysis in the French EGB database. Fundam Clin Pharmacol 2019; 33:471-478. [PMID: 30687946 DOI: 10.1111/fcp.12450] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 01/17/2019] [Accepted: 01/23/2019] [Indexed: 11/28/2022]
Abstract
Atropinic drugs are known to potentially induce physical and/or mental impairments in the elderly. The aim of this study was to investigate trends of atropinic exposure in patients ≥65 years in France between 2006 and 2015. A repeated cross-sectional study was performed quarterly from January 1, 2006 to December 31, 2015, in the 'Echantillon Généraliste des Bénéficiaires (EGB)', a representative sample of the French population. Exposed patients were identified using the Anticholinergic Durán's list. Outcomes were rate of patients exposed to at least one atropinic drug (atropinic prevalence rate) and atropinic burden per patient (sum of atropinic burden scores). Interrupted time series were used to analyze the impact of market withdrawal of some drugs with atropinic properties during the period of the study. The number of patients ≥65 years registered in the EGB ranged from 75 611 in 2006 to 95 389 in 2015. Atropinic prevalence rate decreased significantly from 45.6% in 2006 to 33.2% in 2015 (-12.4%, slope significance P < 0.05). Subjects aged ≥85 years were the most exposed. Total atropinic burden decreased significantly between 2006 and 2015 (2.2 ± 1.7 in 2006; 2.0 ± 1.5 in 2015; slope significance P < 0.05), especially in patients ≥85 years. Market withdrawals for safety reasons of some atropinic drugs were significantly associated with a decrease in the atropinic prevalence rate (P < 0.05) and atropinic burden per patient (P < 0.05). In conclusion, atropinic drug exposure in the elderly significantly decreased in France between 2006 and 2015. This decrease can be partly explained by regulatory measures against some atropinic drugs.
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Affiliation(s)
- Sibylle de Germay
- Service de Pharmacologie Médicale et Clinique, Centre Hospitalier Universitaire et Faculté de Médecine, 37 allées Jules Guesde, 31000, Toulouse, France.,UMR INSERM 1027, Faculté de Médecine, Université Paul-Sabatier, 37 allées Jules Guesde, 31000, Toulouse, France.,Centre de PharmacoVigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Centre Hospitalier Universitaire Toulouse, 37 allées Jules Guesde, 31000, Toulouse, France
| | - Manuela Rueter
- Service de Pharmacologie Médicale et Clinique, Centre Hospitalier Universitaire et Faculté de Médecine, 37 allées Jules Guesde, 31000, Toulouse, France.,UMR INSERM 1027, Faculté de Médecine, Université Paul-Sabatier, 37 allées Jules Guesde, 31000, Toulouse, France.,CIC INSERM 1436, Université et Centre Hospitalier Universitaire, 37 allées Jules Guesde, 31000, Toulouse, France
| | - François Montastruc
- Service de Pharmacologie Médicale et Clinique, Centre Hospitalier Universitaire et Faculté de Médecine, 37 allées Jules Guesde, 31000, Toulouse, France.,UMR INSERM 1027, Faculté de Médecine, Université Paul-Sabatier, 37 allées Jules Guesde, 31000, Toulouse, France.,Centre de PharmacoVigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Centre Hospitalier Universitaire Toulouse, 37 allées Jules Guesde, 31000, Toulouse, France.,CIC INSERM 1436, Université et Centre Hospitalier Universitaire, 37 allées Jules Guesde, 31000, Toulouse, France
| | - Vanessa Rousseau
- Service de Pharmacologie Médicale et Clinique, Centre Hospitalier Universitaire et Faculté de Médecine, 37 allées Jules Guesde, 31000, Toulouse, France.,UMR INSERM 1027, Faculté de Médecine, Université Paul-Sabatier, 37 allées Jules Guesde, 31000, Toulouse, France.,Centre de PharmacoVigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Centre Hospitalier Universitaire Toulouse, 37 allées Jules Guesde, 31000, Toulouse, France.,CIC INSERM 1436, Université et Centre Hospitalier Universitaire, 37 allées Jules Guesde, 31000, Toulouse, France
| | - Maryse Lapeyre-Mestre
- Service de Pharmacologie Médicale et Clinique, Centre Hospitalier Universitaire et Faculté de Médecine, 37 allées Jules Guesde, 31000, Toulouse, France.,UMR INSERM 1027, Faculté de Médecine, Université Paul-Sabatier, 37 allées Jules Guesde, 31000, Toulouse, France.,CIC INSERM 1436, Université et Centre Hospitalier Universitaire, 37 allées Jules Guesde, 31000, Toulouse, France.,Centre d'Evaluation et d'Information sur la PharmacoDépendance et d'AddictoVigilance (CEIP-A), 37 allées Jules Guesde, 31000, Toulouse, France
| | - Jean-Louis Montastruc
- Service de Pharmacologie Médicale et Clinique, Centre Hospitalier Universitaire et Faculté de Médecine, 37 allées Jules Guesde, 31000, Toulouse, France.,UMR INSERM 1027, Faculté de Médecine, Université Paul-Sabatier, 37 allées Jules Guesde, 31000, Toulouse, France.,Centre de PharmacoVigilance, de Pharmacoépidémiologie et d'Informations sur le Médicament, Centre Hospitalier Universitaire Toulouse, 37 allées Jules Guesde, 31000, Toulouse, France.,CIC INSERM 1436, Université et Centre Hospitalier Universitaire, 37 allées Jules Guesde, 31000, Toulouse, France
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Yoon SJ, Kim JS, Jung JG, Ahn SK, Song YS, Bae NK, Seon JY, Kim JH. Factors associated with potentially harmful drug-drug interactions in older Korean people: A population-based study. Geriatr Gerontol Int 2018; 18:1378-1382. [PMID: 30094910 DOI: 10.1111/ggi.13495] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/07/2018] [Accepted: 06/26/2018] [Indexed: 12/11/2022]
Abstract
AIM The present study investigated the status of potentially harmful drug-drug interactions (PHDI) in older adults, to obtain insight into factors that influence the risk of PHDI. METHODS The present study included Korean people aged ≥65 years who were prescribed one or more drugs included in the list of PHDI under the Beers Criteria 2015 from January to December, 2016 (n = 1 257 317). PHDI were defined based on the Beers Criteria 2015. Among 10 PHDI, a prevalence of >5% was taken to be clinically significant, and the relationships between multiple variables and PHDI were examined. RESULTS The most frequent PHDI was corticosteroids and non-steroidal anti-inflammatory drugs (n = 259 499, 20.64%), followed by a combination of two or more anticholinergic drugs (n = 139 622, 11.1%), and three or more drugs acting on the central nervous system (n = 86 023, 6.84%). These three types of PHDI were more frequent in women (OR 1.066-1.141) and medical aid beneficiaries (OR 1.095-1.510). The risk of PHDI increased in proportion to the number of healthcare institutions used by the participants and their outpatient visits during the year (OR 1.043-1.079, 1.008-1.010, respectively). The risk of PHDI was low when patients took no more than five medications in a single prescription (OR 0.017-0.791). CONCLUSIONS The findings of the present study highlight the three most frequent PHDI in Korea according to the Beers Criteria 2015. Healthcare providers should take PHDI into account when treating female patients, medical aid beneficiaries, patients using multiple healthcare institutions, frequent outpatient visitors and patients prescribed more than six medications in a single prescription. Geriatr Gerontol Int 2018; 18: 1378-1382.
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Affiliation(s)
- Seok-Joon Yoon
- Department of Family Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Jong-Sung Kim
- Department of Family Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Jin-Gyu Jung
- Department of Family Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Soon-Ki Ahn
- Public Health and Medical Service Office, Chungnam National University Hospital, Daejeon, Korea
| | - Young-Su Song
- Department of Long-term Care Service for Elderly, Korean National Health Insurance Review & Assessment Service, Daejeon, Korea
| | - Nam-Kyou Bae
- Department of Long-term Care Service for Elderly, Korean National Health Insurance Review & Assessment Service, Daejeon, Korea
| | - Jeong-Yeon Seon
- Department of Long-term Care Service for Elderly, Korean National Health Insurance Review & Assessment Service, Daejeon, Korea
| | - Jeong-Hyun Kim
- Department of Family Medicine, Chungnam National University Hospital, Daejeon, Korea
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Green AR, Reifler LM, Boyd CM, Weffald LA, Bayliss EA. Medication Profiles of Patients with Cognitive Impairment and High Anticholinergic Burden. Drugs Aging 2018; 35:223-232. [PMID: 29404965 DOI: 10.1007/s40266-018-0522-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Drugs with anticholinergic properties are considered potentially inappropriate in patients with cognitive impairment because harms-including delirium, falls, and fractures-may outweigh benefits. OBJECTIVE To highlight opportunities to improve clinical decision making and care for patients with cognitive impairment and multiple chronic conditions, we identified distinct subgroups of patients with mild cognitive impairment (MCI) and dementia who had high cumulative anticholinergic burden and specific patterns of anticholinergic use. PATIENTS AND METHODS We conducted a retrospective cohort study in a not-for-profit, integrated delivery system. Participants included community-dwelling adults aged 65 years and older (n = 13,627) with MCI or dementia and at least two other chronic diseases. We calculated the Anticholinergic Cognitive Burden (ACB) score for each participant from pharmacy and electronic health record (EHR) data. Among individuals with a mean 12-month ACB score ≥ 2, we used agglomerative hierarchical clustering to identify groups or clusters of individuals with similar anticholinergic prescription patterns. RESULTS Twenty-four percent (3257 participants) had high anticholinergic burden, defined as an ACB score ≥ 2. Clinically meaningful clusters based upon anchoring medications or drug classes included a cluster of cardiovascular medications (n = 1497; 46%); two clusters of antidepressant medications (n = 633; 20%); and a cluster based on use of bladder antimuscarinics (n = 431; 13%). Several clusters comprised multiple central nervous system (CNS)-active drugs. CONCLUSIONS Cardiovascular and CNS-active medications comprise a substantial portion of anticholinergic burden in people with cognitive impairment and multiple chronic conditions. Antidepressants were highly prevalent. Clinical profiles elucidated by these clusters of anticholinergic medications can inform targeted approaches to care.
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th Floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA.
| | - Liza M Reifler
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Ave. Suite 300, Denver, CO, 80207, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th Floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Linda A Weffald
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Ave. Suite 300, Denver, CO, 80207, USA
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Ave. Suite 300, Denver, CO, 80207, USA.
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
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de Germay S, Lapeyre-Mestre M, Montastruc JL, Montastruc F. [Atropinic burden and anticholinergic drugs: Interest and application in clinical practice in the elderly]. Therapie 2018; 76:665-673. [PMID: 29625707 DOI: 10.1016/j.therap.2018.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 01/26/2018] [Accepted: 02/20/2018] [Indexed: 11/18/2022]
Abstract
Anticholinergic drugs (also called antimuscarinics or atropinics) increase the risk of falls, cognitive impairment and/or mortality in older patients. These drugs belong to the lists of potentially inappropriate medications in the elderly. The aim of this review was to present and discuss the different tools available to measure the atropinic risk in drug exposure of older patients. Several scales, developed from biological and/or clinical criteria, allow to classify anticholinergic drugs according to their atropinic potency and to assign to them an atropinic burden. Total atropinic burden of patient drug exposure can be calculated as the sum of atropinic score of each drug. Other tools include drug daily doses to better estimate the atropinic risk. These different methods are a precious help to decrease atropinic exposure in the elderly. Nevertheless, they have to be considered as upgradable and it is necessary to adapt them regularly according to the introduction of new drugs in clinical practice.
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Affiliation(s)
- Sibylle de Germay
- Service de pharmacologie médicale et clinique, centre hospitalier universitaire et faculté de médecine de Toulouse, 37, allées Jules-Guesde, 31000 Toulouse, France; UMR Inserm 1027, faculté de médecine, université de Toulouse, 31000 Toulouse, France.
| | - Maryse Lapeyre-Mestre
- Service de pharmacologie médicale et clinique, centre hospitalier universitaire et faculté de médecine de Toulouse, 37, allées Jules-Guesde, 31000 Toulouse, France; UMR Inserm 1027, faculté de médecine, université de Toulouse, 31000 Toulouse, France; Centre Midi-Pyrénées d'évaluation et d'information sur la pharmacodépendance et d'addictovigilance (CEIP-A), centre hospitalier universitaire de Toulouse, 31000 Toulouse, France
| | - Jean-Louis Montastruc
- Service de pharmacologie médicale et clinique, centre hospitalier universitaire et faculté de médecine de Toulouse, 37, allées Jules-Guesde, 31000 Toulouse, France; UMR Inserm 1027, faculté de médecine, université de Toulouse, 31000 Toulouse, France; Centre Midi-Pyrénées de pharmacovigilance, de pharmacoépidémiologie et d'informations sur le médicament et pharmacopôle Midi-Pyrénées, 31000 Toulouse, France
| | - François Montastruc
- Service de pharmacologie médicale et clinique, centre hospitalier universitaire et faculté de médecine de Toulouse, 37, allées Jules-Guesde, 31000 Toulouse, France; UMR Inserm 1027, faculté de médecine, université de Toulouse, 31000 Toulouse, France; Centre Midi-Pyrénées de pharmacovigilance, de pharmacoépidémiologie et d'informations sur le médicament et pharmacopôle Midi-Pyrénées, 31000 Toulouse, France
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Niznik J, Zhao X, Jiang T, Hanlon JT, Aspinall SL, Thorpe J, Thorpe C. Anticholinergic Prescribing in Medicare Part D Beneficiaries Residing in Nursing Homes: Results from a Retrospective Cross-Sectional Analysis of Medicare Data. Drugs Aging 2018; 34:925-939. [PMID: 29214512 DOI: 10.1007/s40266-017-0502-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Prescribing of medications with anticholinergic properties in older nursing home residents is relatively common, despite an association with an increased risk for falls, delirium, and other outcomes. Few studies have investigated what factors influence different levels of prescribing of these agents. OBJECTIVES The primary objective was to identify factors associated with low- and high-level anticholinergic burden in nursing home residents. A secondary objective was to examine in detail the contribution of different medications to low versus high burden to aid in determining which drugs to target in interventions. METHODS This was a retrospective, cross-sectional analysis of a national sample of 2009-2010 Medicare Part A and B claims, Part D prescription drug events, and Minimum Data Set (MDS) v2.0 assessments. The cohort included 4730 Medicare beneficiaries aged ≥ 65 years with continuous Medicare Parts A, B, and D enrollment, admitted for non-skilled stays of ≥ 14 days between 1 January 2010 and 30 September 2010. Anticholinergic burden was defined using the Anticholinergic Cognitive Burden (ACB) scale. Medication scores were summed at the patient level and categorized as high (score ≥ 3), low (score 1-2), or none. Baseline predisposing factors (age, sex, race/ethnicity), enabling factors (prior year hospitalization, emergency department, primary care, specialist visits; region; Medicaid/low-income subsidy), and medical need factors (dementia severity, anti-dementia medication, Charlson co-morbidity index [CCI], select comorbidities) were evaluated for association with anticholinergic burden using multinomial logistic regression. RESULTS Overall, 29.6% of subjects had a high anticholinergic burden and 35.2% had a low burden. High burden was most often (72%) due to one highly anticholinergic medication rather than a cumulative effect. In adjusted analyses, factors associated with increased risk of both low and high anticholinergic burden included comorbidity, antidementia medication, depression, hypertension, and prior year hospitalization. Older age was associated with decreased odds of high anticholinergic burden. Urinary incontinence and prior year specialist visit were associated with increased odds of high anticholinergic burden. Severe and nonsevere dementia were associated with decreased odds of low burden but increased odds of high burden. CONCLUSION Almost two-thirds of nursing home patients have some degree of anticholinergic burden. Several medical need variables are significantly associated with increased risk for low and high anticholinergic burden. Interventions should be developed to optimize prescribing for residents at increased risk of receiving medications with anticholinergic properties. Future study is needed to evaluate the difference in the risk of adverse outcomes associated with various levels of anticholinergic burden.
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Affiliation(s)
- Joshua Niznik
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA. .,VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA. .,Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, USA.
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.,University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, USA
| | - Tao Jiang
- University of Pittsburgh, Pittsburgh, USA
| | - Joseph T Hanlon
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.,Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, USA.,Geriatric Research Education and Clinical Center, Pittsburgh, USA
| | - Sherrie L Aspinall
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.,VA Center for Medication Safety, Pittsburgh, USA.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, USA
| | - Joshua Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, USA
| | - Carolyn Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, USA
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Holden RJ, Srinivas P, Campbell NL, Clark DO, Bodke KS, Hong Y, Boustani MA, Ferguson D, Callahan CM. Understanding older adults' medication decision making and behavior: A study on over-the-counter (OTC) anticholinergic medications. Res Social Adm Pharm 2018; 15:53-60. [PMID: 29559218 DOI: 10.1016/j.sapharm.2018.03.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/29/2018] [Accepted: 03/05/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Older adults purchase and use over-the-counter (OTC) medications with potentially significant adverse effects. Some OTC medications, such as those with anticholinergic effects, are relatively contraindicated for use by older adults due to evidence of impaired cognition and other adverse effects. OBJECTIVE To inform the design of future OTC medication safety interventions for older adults, this study investigated consumers' decision making and behavior related to OTC medication purchasing and use, with a focus on OTC anticholinergic medications. METHODS The study had a cross-sectional design with multiple methods. A total of 84 adults participated in qualitative research interviews (n = 24), in-store shopper observations (n = 39), and laboratory-based simulated OTC shopping tasks (n = 21). Simulated shopping participants also rank-ordered eight factors on their importance for OTC decision making. RESULTS Findings revealed that many participants had concerns about medication adverse effects, generally, but were not aware of age-related risk associated with the use of anticholinergic medications. Analyses produced a map of the workflow of OTC-related behavior and decision making as well as related barriers such as difficulty locating medications or comparing them to an alternative. Participants reported effectiveness, adverse effects or health risks, and price as most important to their OTC medication purchase and use decisions. A persona analysis identified two types of consumers: the habit follower, who frequently purchased OTC medications and considered them safe; and the deliberator, who was more likely to weigh their options and consider alternatives to OTC medications. CONCLUSION A conceptual model of OTC medication purchase and use is presented. Drawing on study findings and behavioral theories, the model depicts dual processes for OTC medication decision making - habit-based and deliberation-based - as well as the antecedents and consequences of decision making. This model suggests several design directions for consumer-oriented interventions to promote OTC medication safety.
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Affiliation(s)
- Richard J Holden
- Department of BioHealth Informatics, Indiana University School of Informatics and Computing - Indianapolis, IN, USA; Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA.
| | - Preethi Srinivas
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA
| | - Noll L Campbell
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA; Purdue University College of Pharmacy - Lafayette, IN, USA
| | - Daniel O Clark
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA; Indiana University School of Medicine - Indianapolis, IN, USA
| | - Kunal S Bodke
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA
| | - Youngbok Hong
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA; Indiana University Herron School of Art and Design - Indianapolis, IN, USA
| | - Malaz A Boustani
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA; Indiana University School of Medicine - Indianapolis, IN, USA; Indiana University Center for Health Innovation and Implementation Science, Indiana CTSI - Indianapolis, IN, USA
| | - Denisha Ferguson
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA
| | - Christopher M Callahan
- Indiana University Center for Aging Research (IUCAR), Regenstrief Institute, Inc. - Indianapolis, IN, USA; Indiana University School of Medicine - Indianapolis, IN, USA
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