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Perdixi E, Cotta Ramusino M, Costa A, Bernini S, Conti S, Jesuthasan N, Severgnini M, Prinelli F. Polypharmacy, drug-drug interactions, anticholinergic burden and cognitive outcomes: a snapshot from a community-dwelling sample of older men and women in northern Italy. Eur J Ageing 2024; 21:11. [PMID: 38551689 PMCID: PMC10980670 DOI: 10.1007/s10433-024-00806-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 04/01/2024] Open
Abstract
Polypharmacy (PP) use is very common in older people and may lead to drug-drug interactions (DDIs) and anticholinergic burden (ACB) that may affect cognitive function. We aimed to determine the occurrence of PP, potential DDIs and ACB and their role in cognitive outcomes in an older population. Cross-sectional data from 636 community-dwelling adults (73.2 ± 6.0 SD, 58.6% women) participating in the NutBrain study (2019-2023) were analyzed. Participants were asked about their medication use, and data on potential DDIs and ACB were extracted. The associations of PP (≥ 5 drugs/day), potential DDIs, and ACB with mild cognitive impairment (MCI) and specific cognitive domains were assessed using logistic regression adjusted for confounders. Sex-stratified analysis was performed. Overall, 27.2% of the participants were exposed to PP, 42.3% to potential DDIs and 19% to cumulative ACB. Women were less exposed to PP and more exposed to ACB than men. In multivariate analysis, the odds of having MCI (24%) were three times higher in those with severe ACB (≥ 3) (OR 3.34, 95%CI 1.35-8.25). ACB was positively associated with poor executive function (OR 4.45, 95%CI 1.72-11.49) and specifically with the Frontal Assessment Battery and neuropsychological tests of phonological and semantic fluency. In sex-stratified analysis, ACB was statistically significantly associated with MCI and executive function in women and with memory in men. PP, potential DDIs and anticholinergics use are very common in community-dwelling older people. ACB exposure is associated with MCI, particularly with poor executive function. Clinicians are encouraged to be vigilant when prescribing anticholinergics.Trial registration: Trial registration number NCT04461951, date of registration July 7, 2020 (retrospectively registered, ClinicalTrials.gov).
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Affiliation(s)
- Elena Perdixi
- Department of Neurology, IRCCS Humanitas Clinical and Research Center, Via Alessandro Manzoni, 56, 20089, Rozzano, MI, Italy
- Neuropsychology Lab/Center for Cognitive Disorders and Dementia IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Matteo Cotta Ramusino
- Clinical Neuroscience Unit of Dementia, Dementia Research Center, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
- Unit of Behavioral Neurology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Alfredo Costa
- Clinical Neuroscience Unit of Dementia, Dementia Research Center, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
- Unit of Behavioral Neurology, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Sara Bernini
- Neuropsychology Lab/Center for Cognitive Disorders and Dementia IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
- Clinical Neuroscience Unit of Dementia, Dementia Research Center, IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
| | - Silvia Conti
- Neuropsychology Lab/Center for Cognitive Disorders and Dementia IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy
- Institute of Biomedical Technologies - National Research Council, Via Fratelli Cervi 93, 20054, Segrate, MI, Italy
| | - Nithiya Jesuthasan
- Institute of Biomedical Technologies - National Research Council, Via Fratelli Cervi 93, 20054, Segrate, MI, Italy
| | - Marco Severgnini
- Institute of Biomedical Technologies - National Research Council, Via Fratelli Cervi 93, 20054, Segrate, MI, Italy
| | - Federica Prinelli
- Neuropsychology Lab/Center for Cognitive Disorders and Dementia IRCCS Mondino Foundation, Via Mondino 2, 27100, Pavia, Italy.
- Institute of Biomedical Technologies - National Research Council, Via Fratelli Cervi 93, 20054, Segrate, MI, Italy.
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Al Shuhaimi L, Henman M, McCallion P, McCarron M, O'Dwyer M. The adverse effects of long-term exposure to anticholinergics among people with intellectual disabilities: a scoping review. HRB Open Res 2022; 5:63. [PMID: 37396688 PMCID: PMC10308137 DOI: 10.12688/hrbopenres.13599.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 09/22/2024] Open
Abstract
Background: Older adults with intellectual disability are exposed to a higher anticholinergic burden compared to general older adults. This is due to a higher rate of both mental and neurological disorders among people with intellectual disability. The use of medications with a high anticholinergic burden is associated with adverse effects including daytime dozing, constipation and higher dependence level in the Barthel index for measuring activities of daily living. This scoping review aims to map and examine the existing research on physical and cognitive adverse effects associated with the long-term impact of anticholinergics among people with intellectual disabilities. Methods: The search was conducted in: PubMed, Cochrane library, EMBASE, Medline, Science Direct, CINAHL Complete and PsycINFO. Preliminary studies, grey literature, and conference papers were searched in related electronic databases. The search terms included terms related to 'anticholinergic', 'long-term exposure', 'intellectual disability' and 'adverse drug reaction' with Boolean operator 'and'. Studies with at least three months' exposure to anticholinergics were included. The search was restricted to research papers on people with intellectual disability aged 40 or over and publication in the English language only. Initially, it was conducted in May and June 2021 and covered the publication period between 1970 and 2021. It was re-run in October 2021. Results: The conducted search provided 509 records of publications and grey literature. Duplicates were removed using EndNote 20 and resulted in 432 remaining records. Then, 426 further records were excluded because they were deemed irrelevant, or non-longitudinal studies or conducted on different populations. Only six full articles were retrieved to assess their eligibility and all were excluded due to different study populations. This resulted in no studies meeting the stated inclusion criteria. Conclusions: Further research is urgently required to examine the long-term adverse effects associated with higher anticholinergic scores among older people with intellectual disability.
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Affiliation(s)
- Lamya Al Shuhaimi
- School of Pharmacy and Pharmaceutical Sciences and IDS-TILDA School of Nursing and Midwifery, Trinity College Dublin, Dublin, D02 PN40, Ireland
| | - Martin Henman
- School of Pharmacy and Pharmaceutical Sciences and IDS-TILDA School of Nursing and Midwifery, Trinity College Dublin, Dublin, D02 PN40, Ireland
| | - Philip McCallion
- School of Social Work, Temple University, Philadelphia, PA, 19122, USA
| | - Mary McCarron
- Trinity Centre for Ageing and Intellectual Disability, Trinity College Dublin, Dublin, D01 W596, Ireland
| | - Maire O'Dwyer
- School of Pharmacy and Pharmaceutical Sciences and IDS-TILDA School of Nursing and Midwifery, Trinity College Dublin, Dublin, D02 PN40, Ireland
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Lattanzio F, Corigliano V, Soraci L, Fumagalli A, Onder G, Volpato S, Cherubini A, Ruggiero C, Cozza A, Guarasci F, Corsonello A. Unveiling the Burden of Interactions Among Clinical Risk Factors for 1-Year Mortality in Hospitalized Older Patients. Front Med (Lausanne) 2021; 8:771115. [PMID: 34901086 PMCID: PMC8655869 DOI: 10.3389/fmed.2021.771115] [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: 09/05/2021] [Accepted: 10/26/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Hospitalized older patients are particularly exposed to adverse health outcomes. Objective: In this study, we aimed at investigating the prognostic interactions between disability in basic activities of daily living (BADL), cognitive impairment, low handgrip strength, anticholinergic cognitive burden (ACB), and depression on 1-year mortality. Setting and Subjects: Our series consisted of 503 older patients discharged from acute care hospitals. Methods: Disability in at least one BADL, ACB, depression, cognitive impairment, and low handgrip strength was considered in the analysis. One-year mortality was investigated by Cox regression analysis and prognostic interactions among study variables were assessed by survival tree analysis. Results: Basic activities of daily living disability, ACB, cognitive impairment, and low handgrip strength were significantly associated with 1-year mortality. Survival tree analysis showed that patients with BADL disability and high ACB carried the highest risk of poor survival [hazard ratio (HR): 16.48 (2.63–74.72)], followed by patients with BADL disability and low ACB (HR: 8.43, 95% CI: 1.85–38.87). Patients with cognitive impairment and no BADL disability were characterized by a lower but still significant risk of mortality (HR: 6.61, 95% CI: 1.51–28.97) and those with high ACB scores and good cognitive and functional performance (HR: 5.28, 95% CI: 1.13–24.55). Conclusion: Basic activities of daily living dependency, cognitive impairment, and ACB score were the three main predictors of 1-year mortality among patients discharged from acute care hospitals; the interaction between BADL dependency and ACB score was found to significantly affect survival. Early identification of such high-risk patients may help tailor targeted interventions to counteract their detrimental effects on prognosis.
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Affiliation(s)
- Fabrizia Lattanzio
- Scientific Direction, Istituto Di Ricovero e Cura a Carattere Scientifico Italian National Research Centers on Aging, Ancona, Italy
| | - Valentina Corigliano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Luca Soraci
- Unit of Geriatric Medicine, Istituto Di Ricovero e Cura a Carattere Scientifico Italian National Research Centers on Aging, Cosenza, Italy
| | - Alessia Fumagalli
- Respiratory Unit, Istituto Di Ricovero e Cura a Carattere Scientifico Italian National Research Centers on Aging, Casatenovo, Italy
| | - Graziano Onder
- Department of Cardiovascular, Endocrine-Metabolic Diseases and Aging, IstitutoSuperiore di Sanitá, Rome, Italy
| | - Stefano Volpato
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy.,Center for Clinical Epidemiology, School of Medicine, University of Ferrara, Ferrara, Italy
| | - Antonio Cherubini
- Geriatria, Accettazionegeriatrica e Centro di Ricerca per l'Invecchiamento, Istituto Di Ricovero e Cura a Carattere Scientifico Italian National Research Centers on Aging, Ancona, Italy
| | - Carmelinda Ruggiero
- Orthogeriatric and Geriatric Units, Gerontology and Geriatric Sections, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Annalisa Cozza
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, Istituto Di Ricovero e Cura a Carattere Scientifico Italian National Research Centers on Aging, Ancona, Italy
| | - Francesco Guarasci
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, Istituto Di Ricovero e Cura a Carattere Scientifico Italian National Research Centers on Aging, Ancona, Italy
| | - Andrea Corsonello
- Unit of Geriatric Medicine, Istituto Di Ricovero e Cura a Carattere Scientifico Italian National Research Centers on Aging, Cosenza, Italy.,Unit of Geriatric Pharmacoepidemiology and Biostatistics, Istituto Di Ricovero e Cura a Carattere Scientifico Italian National Research Centers on Aging, Ancona, Italy
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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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The Interplay between Anticholinergic Burden and Anemia in Relation to 1-Year Mortality among Older Patients Discharged from Acute Care Hospitals. J Clin Med 2021; 10:jcm10204650. [PMID: 34682773 PMCID: PMC8539729 DOI: 10.3390/jcm10204650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/26/2021] [Accepted: 10/08/2021] [Indexed: 01/15/2023] Open
Abstract
Anticholinergic burden (ACB) and anemia were found associated with an increased risk of death among older patients. Additionally, anticholinergic medications may contribute to the development of anemia. Therefore, we aimed at investigating the prognostic interplay of ACB and anemia among older patients discharged from hospital. Our series consisted of 783 patients enrolled in a multicenter observational study. The outcome of the study was 1 year mortality. ACB was assessed by an Anticholinergic Cognitive Burden score. Anemia was defined as hemoglobin < 13 g/dL in men and <12 g/dL in women. The association between study variables and mortality was investigated by Cox regression analysis. After adjusting for several potential confounders, ACB score = 2 or more was significantly associated with the outcome in anemic patients (HR = 1.93, 95%CI = 1.13–3.40), but not non anemic patients (HR = 1.51, 95%CI = 0.65–3.48). An additive prognostic interaction between ACB and anemia was observed (p = 0.02). Anemia may represent a relevant effect modifier in the association between ACB and mortality.
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Ward LM, Stanley B, Greenlaw N, Cooper SA, Pacitti C, Henderson A, Gibson J, Kinnear D. Risk of anticholinergic burden in adults with intellectual disabilities: a Scottish retrospective cohort study of n = 17 220. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2021; 65:813-830. [PMID: 34169610 DOI: 10.1111/jir.12861] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/25/2021] [Accepted: 05/26/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Several drugs have anticholinergic side effects that are associated with adverse health outcomes. Anticholinergic burden studies in adults with intellectual disabilities (ID) have focused exclusively on older adults. This study investigates anticholinergic burden and its associations in adults with ID of all ages (17-94 years). METHODS Adults with ID (n = 4 305), each with three general population age-sex-neighbourhood-matched controls (n = 12 915), were linked to their prescribed medications with anticholinergic effects between 2009 and 2017. Analyses were undertaken using logistic regression models. RESULTS Adults with ID were more likely to be prescribed any anticholinergic medicines, odds ratio (OR) = 1.49 (1.38-1.59), especially 'very strong' risk medicines, OR = 2.59 (2.39-2.81); 48.5% had very high total anticholinergic burden (3+) compared with 35.4% of the general population, OR = 1.77 (1.64-1.90). This group difference was greater for males, OR = 2.02 (1.84-2.22), than females, OR = 1.48 (1.33-1.65). Adults with ID had significantly higher odds of having very high total anticholinergic burden up to 75 years old, with the greatest group effect occurring in younger ages, 17-24-year-olds, OR = 3.05 (2.39-3.89), and the extent of the difference decreased as age increased. The main effect of neighbourhood deprivation showed greater group differences with increasing affluence of neighbourhood. Results examining only the ID group showed that very high total anticholinergic burden was greatest for females, OR = 1.21 (1.07-1.37), and those over age 55, and extent of neighbourhood deprivation was not significant. CONCLUSIONS Adults with ID are at higher risk of anticholinergic burden than the general population, especially young adults. Overall anticholinergic burden increased with age, but burden was high across all ages in the ID group. Very high total anticholinergic burden is prevalent across all types of neighbourhoods for the adults with ID, in contrast to the steeper gradient seen in the general population. Adults with ID have increased likelihood of unintended adverse effects, regardless of potential confounds, so clinicians undertaking medication reviews need to consider anticholinergic side effects and cumulative burden across concomitant medications, including in young adults with ID, not just older adults, and particularly women.
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Affiliation(s)
- L M Ward
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - B Stanley
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - N Greenlaw
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - S-A Cooper
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - C Pacitti
- NHS Greater Glasgow & Clyde, Leverndale Hospital, Glasgow, UK
| | - A Henderson
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
| | - J Gibson
- School of Medicine, Dentistry and Nursing, Glasgow Dental Hospital and School, Glasgow, UK
| | - D Kinnear
- Institute of Health and Wellbeing, University of Glasgow, Gartnavel Royal Hospital, Glasgow, UK
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Sørensen SR, Frederiksen JD, Anru PL, Masud T, Petrovic M, Rosholm JU, Ryg J. Use of Drugs with Anticholinergic Properties at Hospital Admission Associated with Mortality in Older Patients: A Danish Nationwide Register-Based Cohort Study. Drugs Real World Outcomes 2021; 9:129-140. [PMID: 34414558 PMCID: PMC8844340 DOI: 10.1007/s40801-021-00270-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Use of drugs with anticholinergic properties (DAP) has a negative impact on older people. OBJECTIVE Our aim was to examine the association between DAP at hospital admission and mortality in older patients. PATIENTS AND METHODS We performed a nationwide population-based cohort study including patients aged ≥ 65 years admitted to Danish geriatric medicine departments during 2005-2014. National health registers were used to link with individual-level data. Patients were followed to emigration, death, or study termination (31 December 2015). DAP was defined as medications included in the anticholinergic cognitive burden (ACB) scale, which assigns each DAP a score between 1 and 3. The individual ACB score was calculated and the number of DAP counted. We used Cox proportional-hazard regressions to estimate the crude and adjusted hazard ratios adjusting for age, activities of daily living, marital status, index admission period, BMI, and prior hospitalizations (model 1), and additionally Charlson Comorbidity Index (model 2). RESULTS We included 74,589 patients aged (median [IQR]) 83 (77-88) years. Use of one or more DAP (62.5%) was associated with increased mortality compared with those with no use (p < 0.001). In the fully adjusted model 2, compared with no use, higher mortality risks (HR [95% CI]) were seen with ACB score of 2 and number of DAP ≥ 5 for 30-day (1.46 [1.32-1.61] and 1.46 [1.09-1.95]), 1-year (1.34 [1.28-1.41] and 1.48 [1.29-1.70]), and overall mortality (1.27 [1.23-1.31] and 1.44 [1.31-1.59]), respectively. CONCLUSIONS Use of DAP at hospital admission is associated with short- and long-term mortality in geriatric patients. Deprescribing studies are warranted to study whether the impact on mortality can be attenuated.
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Affiliation(s)
- Søren Ramsdal Sørensen
- Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jeppe Dalskov Frederiksen
- Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Pavithra Laxsen Anru
- Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
| | - Tahir Masud
- Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Geriatric Department, Nottingham University Hospital, Nottingham, UK
| | - Mirko Petrovic
- Deaprtment of Geriatrics, Ghent University Hospital, Ghent, Belgium
| | - Jens-Ulrik Rosholm
- Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, J.B. Winsløws Vej 4, 5000, Odense C, Denmark.
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
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Reinold J, Braitmaier M, Riedel O, Haug U. Anticholinergic burden: First comprehensive analysis using claims data shows large variation by age and sex. PLoS One 2021; 16:e0253336. [PMID: 34191827 PMCID: PMC8244868 DOI: 10.1371/journal.pone.0253336] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 06/02/2021] [Indexed: 01/21/2023] Open
Abstract
Purpose The cumulative effect of medication inhibiting acetylcholine activity—also known as anticholinergic burden (AB)—can lead to functional and cognitive decline, falls, and death. Given that studies on the population prevalence of AB are rare, we aimed to describe it in a large and unselected population sample. Methods Using the German Pharmacoepidemiological Research Database (GePaRD) with claims data from ~20% of the German population we analyzed outpatient drug dispensations in 2016. Based on the Anticholinergic Cognitive Burden (ACB) scale, we classified persons into four categories and determined the cumulative AB as continuous variable. Results Among 16,470,946 persons (54% female), the prevalence of clinically relevant AB (ACB≥3) was 10% (women) and 7% (men). Below age 40 it was highest in persons ≤18 years (6% both sexes). At older ages (50–59 vs. 90–99 years), prevalence of ACB≥3 increased from 7% to 26% (men) and from 10% to 32% (women). Medication classes contributing to the cumulative AB differed by age: antihistamines, antibiotics, glucocorticoids (≤19 years), antidepressants (20–49 years), antidepressants, cardiovascular medication, antidiabetics (50–64 years), and additionally medication for urinary incontinence/overactive bladder (≥65 years). Medication dispensed by general physicians contributed most to the cumulative AB. Conclusion Although a clinically relevant AB is particularly common in older persons, prevalence in younger age groups was up to 7%. Given the risks associated with AB in older persons, targeted interventions at the prescriber level are needed. Furthermore, risks associated with AB in younger persons should be explored.
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Affiliation(s)
- Jonas Reinold
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology–BIPS, Bremen, Germany
- * E-mail:
| | - Malte Braitmaier
- Department of Biometry and Data Management, Leibniz Institute for Prevention Research and Epidemiology–BIPS, Bremen, Germany
| | - Oliver Riedel
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology–BIPS, Bremen, Germany
| | - Ulrike Haug
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology–BIPS, Bremen, Germany
- Faculty of Human and Health Sciences, University of Bremen, Bremen, Germany
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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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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: 45] [Impact Index Per Article: 11.3] [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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11
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Amoros-Reboredo P, Soy D, Hernandez-Hernandez M, Lens S, Mestres C. Anticholinergic Burden and Safety Outcomes in Older Patients with Chronic Hepatitis C: A Retrospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E3776. [PMID: 32466526 PMCID: PMC7311997 DOI: 10.3390/ijerph17113776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 05/15/2020] [Accepted: 05/21/2020] [Indexed: 11/16/2022]
Abstract
AIM Older patients with chronic hepatitis C infection starting direct-acting antivirals (DAAs) are frequently prescribed multiple medications that may be categorized as inappropriate. Anticholinergic burden has been shown to be a predictor of adverse health and functional outcomes. Different scales are available to calculate anticholinergic burden. The aim of this study was to determine the prevalence of anticholinergic medication among older patients treated with DAAs and the risk factors associated using the Anticholinergic Cognitive Burden (ACB) scale, the Anticholinergic Risk Scale (ARS) and the Anticholinergic Drug Scale (ADS) and analyze the resulting safety consequences. METHODS Observational, retrospective cohort study of consecutive patients ≥65 years old receiving DAAs and taking concomitant medication. This study was conducted in accordance with the Strengthening the Reporting of observational studies in Epidemiology Statement. RESULTS 236 patients were included. The average age was 71.7 years, 73.3% cirrhotic, and 47% patients took ≥5 medicines. According to the ACB, ARS and ADS scales, 35.2% (n = 83), 10.6% (n = 25) and 34.3% (n = 81) of the patients were treated with anticholinergic medication. Two hundred-and-six (86%) patients presented any adverse events (AEs) during therapy. ARS scale showed a significant relationship between presence of anticholinergic medication and AEs. A large number of patients suffered anticholinergic events, with more events per patient in patients taking anticholinergic drugs. CONCLUSIONS Older hepatitis C chronic patients are exposed to potentially inappropriate polypharmacy and anticholinergic risk, according to the ACB, ARS and ADS scales. The three scales showed different results. Only the ARS scale was associated with AEs, but the rate of anticholinergic effects per patient was significantly higher in patients with anticholinergic drugs, regardless of the scale used. Consider quality of pharmacotherapy when starting DAA with a multidisciplinary approach could improve health outcomes.
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Affiliation(s)
| | - Dolors Soy
- Pharmacy Service Division of Medicines Hospital Clínic de Barcelona, University of Barcelona, IDIBAPS, 08036 Barcelona, Spain;
| | | | - Sabela Lens
- Liver Unit Hospital Clínic de Barcelona, University of Barcelona, IDIBAPS, 08036 Barcelona, Spain;
- Centro de Investigación Biomédica Red de Enfermedades Hepáticas y Digestivas (CIBERehd), 28029 Madrid, Spain
| | - Conxita Mestres
- School of Health Sciences Blanquerna, University Ramon Llull, 08025 Barcelona, Spain;
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12
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D'Alia S, Guarasci F, Bartucci L, Caloiero R, Guerrieri ML, Soraci L, Colombo D, Crescibene L, Onder G, Volpato S, Cherubini A, Ruggiero C, Corsonello A, Lattanzio F, Fabbietti P. Hand Grip Strength May Affect the Association Between Anticholinergic Burden and Mortality Among Older Patients Discharged from Hospital. Drugs Aging 2020; 37:447-455. [PMID: 32415534 DOI: 10.1007/s40266-020-00766-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE The relationship between anticholinergic burden and mortality is unclear, and the impact of anticholinergic burden on prognosis may vary in the presence of other conditions common in old age. We aimed to investigate the role of hand grip strength as a potential effect modifier in the association between anticholinergic burden and 1-year mortality in older patients discharged from hospital. METHODS Our series consisted of 620 older patients consecutively admitted to seven geriatric and internal medicine acute care wards in the context of a prospective multicenter observational study. Overall anticholinergic burden was assessed by Anticholinergic Cognitive Burden (ACB) score. Hand grip strength was assessed by the use of a North Coast medical hand dynamometer and categorized by using sex-specific cut-offs (women < 15 kg, men < 20 kg). The study outcome was 1-year mortality. Statistical analysis was performed by Cox regression analysis. RESULTS After adjusting for potential confounders, the co-occurrence of an ACB score of 2 or more and low hand grip strength was significantly associated with mortality (hazard ratio [HR] = 2.30, 95% confidence interval [CI] 1.07-6.01). Stratified analysis confirmed that an ACB score of 2 or more was associated with mortality among patients with low (HR = 2.15, 95% CI 1.08-5.02), but not normal hand grip strength (HR = 0.88, 95% CI 0.13-3.52). The association was confirmed among patients with low hand grip strength after adjusting for the ACB score at the 3-month follow-up (HR = 2.20; 95% CI 1.09-4.87), as well as when considering the ACB score as a continuous variable (HR = 1.24, 95% CI 1.03-1.48). CONCLUSIONS The ACB score at discharge may predict mortality among older patients discharged from an acute care hospital with low hand grip strength. Hospital physicians should be aware that prescribing anticholinergic medications in such a vulnerable population may have negative prognostic implications.
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Affiliation(s)
- Sonia D'Alia
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, Scientific Research Institute-Italian National Research Center on Aging (IRCCS INRCA), Ancona and Cosenza, Italy
| | - Francesco Guarasci
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, Scientific Research Institute-Italian National Research Center on Aging (IRCCS INRCA), Ancona and Cosenza, Italy.
| | - Luca Bartucci
- Unit of Geriatric Medicine, Scientific Research Institute-Italian National Research Center on Aging (IRCCS INRCA), Ancona and Cosenza, Italy
| | - Ramona Caloiero
- Unit of Geriatric Medicine, Scientific Research Institute-Italian National Research Center on Aging (IRCCS INRCA), Ancona and Cosenza, Italy
| | - Maurizio Leonardo Guerrieri
- Unit of Geriatric Medicine, Scientific Research Institute-Italian National Research Center on Aging (IRCCS INRCA), Ancona and Cosenza, Italy
| | - Luca Soraci
- Department of Clinical and Experimental Medicine, University Hospital of Messina, Messina, Italy
| | - Daniele Colombo
- Unit of Rehabilitative Pneumology, Scientific Research Institute-Italian National Research Center on Aging (IRCCS INRCA), Casatenovo, Italy
| | - Lucia Crescibene
- Clinical Laboratory, Scientific Research Institute-Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
| | - Graziano Onder
- Department of Cardiovascular and Endocrine-Metabolic Diseases, and Aging, Istituto Superiore di Sanità, Rome, Italy
| | - Stefano Volpato
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Carmelinda Ruggiero
- Section of Gerontology and Geriatrics, Department of Medicine, University of Perugia, Perugia, Italy
| | - Andrea Corsonello
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, Scientific Research Institute-Italian National Research Center on Aging (IRCCS INRCA), Ancona and Cosenza, Italy.,Unit of Geriatric Medicine, Scientific Research Institute-Italian National Research Center on Aging (IRCCS INRCA), Ancona and Cosenza, Italy
| | - Fabrizia Lattanzio
- Scientific Direction, Scientific Research Institute-Italian National Research Center on Aging (IRCCS INRCA), Ancona, Italy
| | - Paolo Fabbietti
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, Scientific Research Institute-Italian National Research Center on Aging (IRCCS INRCA), Ancona and Cosenza, Italy
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13
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Bourrel C, Zacarin A, Rousseau V, Montastruc JL, Bagheri H. Are potentially inappropriate and anticholinergic medications being prescribed for institutionalized elderly subjects? Fundam Clin Pharmacol 2020; 34:743-748. [PMID: 32289182 DOI: 10.1111/fcp.12560] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/12/2020] [Accepted: 04/08/2020] [Indexed: 12/13/2022]
Abstract
The PAAPI project (Optimising Inappropriate Prescriptions in the Elderly) is a multi-disciplinary approach put in place by the Toulouse Pharmacovigilance Centre (CRPV) in order to improve drug prescribing practice in nursing homes. The aim of this study was to analyse the association between polypharmacy, frequency of prescriptions for potentially inappropriate medications (PIMs) and the anticholinergic burden of prescriptions in elderly patients from the PAAPI cohort. We carried out a retrospective study on residents of 24 nursing homes (EHPAD) participating in the PAAPI programme between 1er January 2017 and 31 December. Resident's Data were collected in a single review in a random day. Drug prescriptions were analysed quantitatively and qualitatively. PIMs and anticholinergic drugs were identified by the list EU(7)PIM and the Duran scale, respectively. The total anticholinergic burden was calculated by adding the anticholinergic scores of each drug. We classified the drugs into three categories: no anticholinergic burden (burden = 0), low anticholinergic burden (≥1 ≤ 3) or high anticholinergic burden (burden > 3). A total of 1191 residents living were included, and we analysed 8869 drug prescription lines. The average age of the residents was 87.0 ± 8.3 years, and the majority (71.5%) were female. Nearly half of the residents (49.6%, n = 67) having a prescription with a high anticholinergic burden were taking more than 9 drugs (Fisher exact test P < 0.05). All the prescriptions with more than 5 PIMs (n = 23) had an anticholinergic burden > 0, with the majority (65.2%, n = 15) having a high anticholinergic burden (Kruskal-Wallis test, P < 0.0001). In this cohort, 88% (n = 539) of prescriptions with a low anticholinergic burden and 100% (n = 135) of prescriptions with a high anticholinergic burden included at least one PIM. According to our study, the anticholinergic burden of prescriptions given to residents in the PAAPI cohort is associated with the prescription of PIMs and with polypharmacy. Optimizing the use of medicines remains essential in this population, given the harmful properties of these drugs. It would also be useful for the list of anticholinergic drugs to be updated as new medicines come onto the market.
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Affiliation(s)
- Claire Bourrel
- Department of Medical and Clinical Pharmacology, Centre for Pharmacovigilance, PharmacoEpidemiology and Information on Medications, Faculty of Medicine, INSERM UMR 1027, University Hospital and Faculty of Medicine, Toulouse, France
| | - Alice Zacarin
- Department of Medical and Clinical Pharmacology, Centre for Pharmacovigilance, PharmacoEpidemiology and Information on Medications, Faculty of Medicine, INSERM UMR 1027, University Hospital and Faculty of Medicine, Toulouse, France
| | - Vanessa Rousseau
- Department of Medical and Clinical Pharmacology, Centre for Pharmacovigilance, PharmacoEpidemiology and Information on Medications, Faculty of Medicine, INSERM UMR 1027, University Hospital and Faculty of Medicine, Toulouse, France
| | - Jean-Louis Montastruc
- Department of Medical and Clinical Pharmacology, Centre for Pharmacovigilance, PharmacoEpidemiology and Information on Medications, Faculty of Medicine, INSERM UMR 1027, University Hospital and Faculty of Medicine, Toulouse, France
| | - Haleh Bagheri
- Department of Medical and Clinical Pharmacology, Centre for Pharmacovigilance, PharmacoEpidemiology and Information on Medications, Faculty of Medicine, INSERM UMR 1027, University Hospital and Faculty of Medicine, Toulouse, France
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14
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Bennett F, Ferner R, Sofat R. Overprescribing and rational therapeutics: Barriers to change and opportunities to improve. Br J Clin Pharmacol 2020; 87:34-38. [PMID: 32216108 DOI: 10.1111/bcp.14291] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/21/2020] [Accepted: 03/06/2020] [Indexed: 02/03/2023] Open
Abstract
There is increasing national and international interest in overprescribing and polypharmacy, and the burden that the inappropriate use of multiple medicines can place on individual patients and on society as a whole. This paper explores the challenges faced by prescribers and pharmacists wishing to reduce polypharmacy, including the uncertainties about the risks and benefits of continuing or stopping individual drugs. We discuss the factors influencing us to prescribe-which may lead to overprescribing-including the increasing number of guidelines, perceived patient pressure and advertising. We offer a critical appraisal of the tools currently available to clinicians and pharmacists aiming to rationalise medicines, and finally a systems-wide approach to improving overprescribing and problematic polypharmacy.
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Affiliation(s)
- Frances Bennett
- Department of Clinical Pharmacology, University College London Hospital Foundation Trust, UK
| | - Robin Ferner
- School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK.,Institute of Cardiovascular Science, University College London, UK
| | - Reecha Sofat
- Department of Clinical Pharmacology, University College London Hospital Foundation Trust, UK.,Institute of Health Informatics, University College London, UK.,Centre of Clinical Pharmacology, Division of Medicine, University College London, UK
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15
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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: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/05/2019] [Indexed: 01/29/2023]
Abstract
PURPOSE The purpose of the study is to conduct a systematic review of studies examining the association between anticholinergic burden and mortality in older individuals. METHODS A literature search was performed to identify relevant studies, using MEDLINE, EMBASE, PsycINFO and CENTRAL, from January 1990 to December 2018. We included studies of patients with a mean age of 65 years or older where the anticholinergic burden was estimated using anticholinergic risk assessment tools, and associations between anticholinergic load and mortality were investigated. The primary outcome of interest was the association between anticholinergic burden and mortality. RESULTS Twenty-seven studies were included. These were three cross-sectional, one nested case-control and 23 prospective or retrospective cohort studies. Most studies were determined to be of good quality. A total of 15 studies reported a positive correlation between anticholinergic burden and mortality, while the remaining 10 studies did not report a significant association. Eighteen out of 27 studies (80%) had a short follow-up period of 1 year or less. Among the five high-quality studies that met all the domains of the quality assessment criteria, four showed a positive association. CONCLUSION The variation in results could relate to the quality of the studies, follow-up period, anticholinergic risk assessment tool used and the study setting. Sixty-three percent (n = 17) of all the included studies, but almost all of the high-quality studies with an extended follow-up, reported a positive correlation between anticholinergic burden and mortality. Further high-quality research, using standardized measures and with adequate follow-up periods, is required to confirm the relationship between anticholinergic burden and mortality.
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