Use of Medications with Anticholinergic Properties and the Long-Term Risk of Hospitalization for Falls and Fractures in the EPIC-Norfolk Longitudinal Cohort Study

Changes in Anticholinergic Burden in Parkinson's Disease After Deep Brain Stimulation

OBJECTIVE

This study aimed to evaluate the effect of deep brain stimulation (DBS) on anticholinergic burden in Parkinson's disease (PD) and the association of anticholinergic burden with cognition.

MATERIALS AND METHODS

A retrospective chart review in patients with PD who underwent bilateral subthalamic nucleus (STN) or globus pallidus internus (GPi) DBS from 2010 to 2020 reviewed medications with anticholinergic burden at baseline, six months, and one year (N = 216) after surgery. The cumulative anticholinergic burden at each visit was calculated using the Anticholinergic Risk Scale (ARS).

RESULTS

ARS scores were significantly lower for patients six months and one year after surgery than at baseline (z = 6.58, p < 0.0001; z = 6.99, p < 0.0001). Change in ARS scores at both six months and one year were driven by down-titration of PD medications (z = 9.35, p < 0.0001; z = 8.61, p < 0.0001), rather than changes in pain, psychiatric, or urinary medications with anticholinergic effects. There was no significant difference in change in ARS scores at one year between targets (t = 0.41, p = 0.68). In addition, there was no significant association between anticholinergic burden and cognitive performance.

CONCLUSION

GPi and STN DBS are associated with decreased anticholinergic burden due to PD medications in the first year after surgery.

Anticholinergics and falls in older adults

INTRODUCTION

The use of medications with anticholinergic (ACh) properties is associated with numerous adverse effects especially in older adults. Emerging evidence suggests the presence of long-term effects with ACh use.

AREAS COVERED

Our article presents an overview of ACh effects and falls in older individuals including examination of emerging evidence on ACh use and cumulative exposure on short-term and long-term falls risk. The databases CINAHL, MEDLINE, EMBASE, and Web of Science were searched for articles published from January 2002 to December 2021.

EXPERT OPINION

Anticholinergic side effects include muscle weakness, blurred vision, and mental confusion which are likely to lead to increased falls risk. Many commonly used medications such as beta-blockers, calcium-channel blockers, and antihistamines are now known to have mild ACh properties. With polypharmacy now considered unavoidable in older patients, the cumulative effects of the use of multiple drugs with mild ACh properties may also lead to increased falls risk. The relationship between ACh drugs and falls may also be irreversible as ACh effects may extend beyond the period of drug use, due to cognitive and physical deconditioning following the initial exposure to ACh drugs. Future long-term studies with accurate quantification of cumulative ACh exposure and measurement of actual falls outcomes are urgently required.

The cognitive effect of anticholinergics for patients with overactive bladder

Overactive bladder (OAB) is often treated with medications that block the cholinergic receptors in the bladder (known as anticholinergics). The effect of this medication class on cognition and risk of dementia has been increasingly studied over the past 40 years after initial studies suggested that the anticholinergic medication class could affect memory. Short-term randomized clinical trials demonstrated that the administration of the anticholinergic oxybutynin leads to impaired memory and attention, and large, population-based studies showed associations between several different anticholinergic medications and dementia. However, trials involving anticholinergics other than oxybutynin have not shown such substantial effects on short-term cognitive function. This discordance in results between short-term cognitive safety of OAB anticholinergics and the long-term increased dementia risk could be explained by the high proportion of patients using oxybutynin in the OAB subgroups of the dementia studies, or a study duration that was too short in the prospective clinical trials on cognition with other OAB anticholinergics. Notably, all studies must be interpreted in the context of potential confounding factors, such as when prodromal urinary symptoms associated with the early stages of dementia lead to an increase in OAB medication use, rather than the use of OAB medication causing dementia. In patients with potential risk factors for cognitive impairment, the cautious use of selected OAB anticholinergic agents with favourable physicochemical and pharmacokinetic properties and clinical trial evidence of cognitive safety might be appropriate.

Anticholinergic burden measures and older people's falls risk: a systematic prognostic review

Introduction

Several adverse outcomes have been associated with anticholinergic burden (ACB), and these risks increase with age. Several approaches to measuring this burden are available but, to date, no comparison of their prognostic abilities has been conducted. This PROSPERO-registered systematic review (CRD42019115918) compared the evidence behind ACB measures in relation to their ability to predict risk of falling in older people.

Methods

Medline (OVID), EMBASE (OVID), CINAHL (EMBSCO) and PsycINFO (OVID) were searched using comprehensive search terms and a validated search filter for prognostic studies. Inclusion criteria included: participants aged 65 years and older, use of one or more ACB measure(s) as a prognostic factor, cohort or case-control in design, and reporting falls as an outcome. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool.

Results

Eight studies reporting temporal associations between ACB and falls were included. All studies were rated high risk of bias in ⩾1 QUIPS tool categories, with five rated high risk ⩾3 categories. All studies (274,647 participants) showed some degree of association between anticholinergic score and increased risk of falls. Findings were most significant with moderate to high levels of ACB. Most studies (6/8) utilised the anticholinergic cognitive burden scale. No studies directly compared two or more ACB measures and there was variation in how falls were measured for analysis.

Conclusion

The evidence supports an association between moderate to high ACB and risk of falling in older people, but no conclusion can be made regarding which ACB scale offers best prognostic value in older people.

Plain language summary

A review of published studies to explore which anticholinergic burden scale is best at predicting the risk of falls in older people Introduction: One third of older people will experience a fall. Falls have many consequences including fractures, a loss of independence and being unable to enjoy life. Many things can increase the chances of having a fall. This includes some medications. One type of medication, known as anticholinergic medication, may increase the risk of falls. These medications are used to treat common health issues including depression and bladder problems. Anticholinergic burden is the term used to describe the total effects from taking these medications. Some people may use more than one of these medications. This would increase their anticholinergic burden. It is possible that reducing the use of these medications could reduce the risk of falls. We need to carry out studies to see if this is possible. To do this, we need to be able to measure anticholinergic burden. There are several scales available, but we do not know which is best.Methods: We wanted to answer: 'Which anticholinergic scale is best at predicting the risk of falling in older people?'. We reviewed studies that could answer this. We did this in a systematic way to capture all published studies. We restricted the search in several ways. We only included studies relevant to our question.Results: We found eight studies. We learned that people who are moderate to high users of these medications (often people who will use more than one of these medications) had a higher risk of falling. It was less clear if people who have a lower burden (often people who only use one of these medications) had an increased risk of falling. The low number of studies prevented us from determining if one scale was better than another.Conclusion: These findings suggest that we should reduce use of these medications. This could reduce the number falls and improve the well-being of older people.

Anticholinergic burden in older adult inpatients: patterns from admission to discharge and associations with hospital outcomes

Background:

Anticholinergic medications are associated with adverse outcomes in older adults and should be prescribed cautiously. We describe the Anticholinergic Risk Scale (ARS) scores of older inpatients and associations with outcomes.

Methods:

We included all emergency, first admissions of adults ⩾65 years old admitted to one hospital over 4 years. Demographics, discharge specialty, dementia/history of cognitive concern, illness acuity and medications were retrieved from electronic records. ARS scores were calculated as the sum of anticholinergic potential for each medication (0 = limited/none; 1 = moderate; 2 = strong and 3 = very strong). We categorised patients based on admission ARS score [ARS = 0 (reference); ARS = 1; ARS = 2; ARS ⩾ 3] and change in ARS score from admission to discharge [admission and discharge ARS = 0 (reference); same; decreased; increased]. We described anticholinergic prescribing patterns by discharge specialty and explored multivariable associations between ARS score categories and mortality using logistic regression [odds ratios (ORs), 95% confidence intervals (CIs)].

Results:

From 33,360 patients, 10,183 (31%) were prescribed an anticholinergic medication on admission. Mean admission ARS scores were: Cardiology and Stroke = 0.56; General Medicine = 0.78; Geriatric Medicine = 0.83; Other medicine = 0.81; Trauma and Orthopaedics = 0.66; Other Surgery = 0.65. Mean ARS did not increase from admission to discharge in any specialty but reductions varied significantly, from 4.6% (Other Surgery) to 27.7% (Geriatric Medicine) (p < 0.001). The odds of both 30-day inpatient and 30-day post-discharge mortality increased with admission ARS = 1 (OR = 1.21, 95% CI 1.01–1.44 and OR = 1.44, 1.18–1.74) but not with ARS = 2 or ARS ⩾ 3. The odds of 30-day post-discharge mortality were higher in all ARS change categories, relative to no anticholinergic exposure (same: OR = 1.45, 1.21–1.74, decreased: OR = 1.27, 1.01–1.57, increased: OR = 2.48, 1.98–3.08).

Conclusion:

The inconsistent dose–response associations with mortality may be due to confounding and measurement error which may be addressed by a prospective trial. Definitive evidence for this prevalent modifiable risk factor is required to support clinician behaviour-change, thus reducing variation in anticholinergic deprescribing by inpatient speciality.

Plain language summary

We describe how commonly medicines which block the chemical acetylcholine are prescribed to older adults admitted to hospital as an emergency and explore links between these medicines and death during or soon after hospital admission

Backgroud: Medicines which block the chemical acetylcholine are commonly prescribed to treat symptoms such as itch and difficulty sleeping or to treat medical conditions such as depression. However, some studies in older adults have found potential links between these medicines and confusion and falls. Therefore, doctors are recommended to prescribe these drugs cautiously in adults aged 65 years and over.

Methods: In our paper we use data collected as part of routine medical care at one university hospital to describe how often these medicines are prescribed in a large sample of older adults admitted to hospital as an emergency. We look at the medicines patients are prescribed on admission to the hospital and also when they are later discharged.

Results: We find that these medicines are frequently prescribed. We also find that, in general, patients are prescribed fewer of these potentially harmful medicines on hospital discharge compared with hospital admission. This suggests that clinicians are aware of advice to prescribe acetylcholine blocking medicines cautiously and they are more often stopped in hospital than started. However, we find a lot of variation in practice depending on which hospital specialty was caring for the patient during their inpatient stay. We also find potential links with these medicines and death during the admission or soon after hospital discharge, but these potential links are not always consistent.

Conclusion: Further study is needed to fully understand links between medicines that block acetylcholine and late life health. This will be important to reduce variation in prescribing practices.

Smart homes for the older population: particularly important during the COVID-19 outbreak

Osteoporosis, one of the leading causes of disability in older adults, significantly reduces the quality of life and leads to loss of independence. Dynamic development of “smart” solutions based on artificial intelligence more and more commonly applied in older people’s houses may be an answer to the above issues.

The aim of this study is to present selected “smart home” solutions for the diagnosis and prevention of falls in the older population through a literature review. The conducted meta-analysis based on a review of the scientific literature available in English and Polish in the Medline/PubMed, Embase, Scopus, and GBL databases was undertaken from 01.01.2015 to 01.10.2020 with the string search method using key words.

According to the authors of this study, the development of new technology based on artificial intelligence allows older people to live independently, which contributes to a higher level of life satisfaction and quality.

Association between anticholinergic burden and anticholinergic adverse outcomes in the elderly: Pharmacological basis of their predictive value for adverse outcomes

The use of anticholinergic drugs and other drugs with anticholinergic activity is highly prevalent in older people. Cumulative anticholinergic effects, known as anticholinergic burden, are associated with important peripheral and central adverse effects and outcomes. Several methods have been developed to quantify anticholinergic burden and to estimate the risk of adverse anticholinergic effects. Serum anticholinergic activity (SAA) and anticholinergic burden scoring systems are the most commonly used methods to predict the occurrence of important negative outcomes. These tools could guide clinicians in making more rational prescriptions to enhance patient safety, especially in older people. However, the literature has reported conflicting results about the predictive ability of these tools. The majority of these instruments ignore relevant pharmacologic aspects such as the doses used, differential muscarinic receptor subtype affinities, and blood-brain barrier permeability. To increase the clinical relevance of these tools, mechanistic and clinical pharmacology should collaborate. This narrative review describes the rational and pharmacological basis of anticholinergic burden tools and provides insight about their predictive value for adverse outcomes.

Size of the associations between anticholinergic burden tool scores and adverse outcomes in older patients

Background Several anticholinergic scales and equations to evaluate the anticholinergic burden have been previously created. Association of these instruments with the anticholinergic outcomes are usually estimated by means of hypothesis contrast tests, which ignore the size of the association effect. Objective To evaluate the effect size of the associations between the scores on cumulative anticholinergic burden instruments with peripheral or central anticholinergic adverse outcomes in older patients. Setting Internal medicine ward of a Tertiary University Hospital. Methods A case-control study was conducted in patients over 65 years who were admitted to two internal medicine wards of a Portuguese university hospital. The Anticholinergic Drug Scale, Anticholinergic Risk Scale, Anticholinergic Cognitive Burden scale and Drug Burden Index were used to calculate the patients' anticholinergic burden. Peripheral (dry mouth-swab technique; dry eye-Schirmer test) and central (falls and cognitive impairment-Mini-Mental State Examination) anticholinergic adverse outcomes were investigated. The Barthel Index was used to assess overall physical functionality. The Mann-Whitney test was used to evaluate probabilistic differences in the anticholinergic scores between case and control individuals. To establish the effect size of the associations, the area under the curve of the receiver operating characteristics curve was calculated. Main outcome measure Anticholinergic adverse effects. Results A total of 250 patients (mean age 81.67 years, standard deviation 7.768; 50% females) were included. In total, 148 patients (59.2%) presented with dry mouth, 85 (34%) with dry eye, 141 (56.4%) with impaired functionality, 44 (17.6%) with a history of falls and 219 (87.6%) with cognitive impairment. Significant differences (p < 0.05) were obtained for the majority of the associations between Anticholinergic Drug Scale, Anticholinergic Risk Scale, Anticholinergic Cognitive Burden and Drug Burden Index and adverse effects. Conversely, the effect sizes of these associations ranged from "fail" (area under the curve 0.5 to 0.6) to "fair" (area under the curve 0.7 to 0.8). Conclusion Although significant differences in the scores of anticholinergic burden instruments and adverse outcomes may exist, the effect sizes of these associations ranged from 'fail' to 'fair', which limits their utility in preventing anticholinergic adverse outcomes with medication review interventions.