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Talwar A, Chatterjee S, Sherer J, Abughosh S, Johnson M, Aparasu RR. Cumulative Anticholinergic Burden and its Predictors among Older Adults with Alzheimer's Disease Initiating Cholinesterase Inhibitors. Drugs Aging 2024; 41:339-355. [PMID: 38467994 DOI: 10.1007/s40266-024-01103-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Cumulative anticholinergic burden refers to the cumulative effect of multiple medications with anticholinergic properties. However, concomitant use of cholinesterase inhibitors (ChEIs) and anticholinergic burden can nullify the benefit of the treatment and worsen Alzheimer's disease (AD). A literature gap exists regarding the extent of the cumulative anticholinergic burden and associated risk factors in AD. Therefore, this study evaluated the prevalence and predictors of cumulative anticholinergic burden among patients with AD initiating ChEIs. METHODS A retrospective longitudinal cohort study was conducted using the Medicare claims data involving parts A, B, and D from 2013 to 2017. The study sample included older adults (65 years and older) diagnosed with AD and initiating ChEIs (donepezil, rivastigmine, or galantamine). The cumulative anticholinergic burden was calculated based on the Anticholinergic Cognitive Burden scale and patient-specific dosing using the defined daily dose over the 1 year follow-up period after ChEI initiation. Incremental anticholinergic burden levels were dichotomized into moderate-high (sum of standardized daily anticholinergic exposure over a year (TSDD) score ≥ 90) versus low-no (score 0-89). The Andersen Behavioral Model was used as the conceptual framework for selecting the predictors under the predisposing, enabling, and need categories. A multivariable logistic regression model was used to evaluate the predictors of high-moderate versus low-no cumulative anticholinergic burden. A multinomial logistic regression model was also used to determine the factors associated with patients having moderate and high burdens compared to low/no burdens. RESULTS The study included 222,064 older adults with AD with incident ChEI use (mean age 82.24 ± 7.29, 68.9% females, 83.6% White). Overall, 80.48% had some anticholinergic burden during the follow-up, with 36.26% patients with moderate (TSDD scores 90-499), followed by 24.76% high (TSDD score > 500), and 19.46% with low (TSDD score 1-89) burden categories. Predisposing factors such as age; African American, Asian, or Hispanic race; and need factors included comorbidities such as dyslipidemia, syncope, delirium, fracture, pneumonia, epilepsy, and claims-based frailty index were less likely to be associated with the moderate-high anticholinergic burden. The factors that increased the odds of moderate-high burden were predisposing factors such as female sex; enabling factors such as dual eligibility and diagnosis year; and need factors such as baseline burden, behavioral and psychological symptoms of dementia, depression, insomnia, urinary incontinence, irritable bowel syndrome, anxiety, muscle spasm, gastroesophageal reflux disease, heart failure, and dysrhythmia. Most of these findings remained consistent with multinomial logistic regression. CONCLUSION: Four out of five older adults with AD had some level of anticholinergic burden, with over 60% having moderate-high anticholinergic burden. Several predisposing, enabling, and need factors were associated with the cumulative anticholinergic burden. The study findings suggest a critical need to minimize the cumulative anticholinergic burden to improve AD care.
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Affiliation(s)
- Ashna Talwar
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX, USA
| | | | - Jeffrey Sherer
- Department of Pharmacy Practice and Translational Research, College of Pharmacy, University of Houston, Houston, TX, USA
| | - Susan Abughosh
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX, USA
| | - Michael Johnson
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX, USA
| | - Rajender R Aparasu
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX, USA.
- Department of Pharmaceutical Health Outcomes and Policy, Adjunct Professor of Geriatrics, UTHealth McGovern Medical School, Health and Biomedical Sciences Building 2 - Office 4052, College of Pharmacy, University of Houston, 4349 Martin Luther King Boulevard, Houston, TX, 77204-5047, USA.
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Rajabali S, Asaana P, Nazari S, Wagg A. A Double-blind, Randomised Four-way Crossover Study to Compare the Effects of Fesoterodine 4 and 8 mg Once Daily and Qxybutynin 5 mg Twice Daily After Steady-state Dosing Versus Placebo on Cognitive Function in Overactive Bladder-wet Patients over the Age of 75 Years with Mild Cognitive Impairment. Eur Urol Focus 2024; 10:325-331. [PMID: 38402104 DOI: 10.1016/j.euf.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/19/2023] [Accepted: 02/14/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND AND OBJECTIVE There is a reported association between overactive bladder (OAB) treated with antimuscarinic drugs and an increased risk of a dementia diagnosis, although short-term data suggest that newer OAB antimuscarinics are cognitively safe. This study examined the cognitive safety of fesoterodine in older adults with mild cognitive impairment (MCI) and OAB. METHODS This four-way randomised crossover study examined the cognitive effects of fesoterodine 4 and 8 mg and oxybutynin 5 mg b.i.d. compared with placebo. Older adult patients with OAB and MCI were included. Treatment and washout periods were of 1-week duration, to reach steady-state drug levels. The primary outcome was continuity of attention at 1 and 4 h after the dose. The secondary outcomes included other cognitive domains, change in Montreal Cognitive Assessment score, and alertness. KEY FINDINGS AND LIMITATIONS Twenty-three patients completed the study (16 females and seven males). For the primary outcome, at 1 h after the dose, a trend towards worsening of continuity of attention was observed for fesoterodine 4 mg (p = 0.09) compared with placebo. At 4 h after the dose, a nonstatistically significant trend towards improvement compared with placebo was observed in the fesoterodine 4 mg group (p = 0.0633) compared with placebo. No differences were observed in any other treatment group at either time point. Apart from quality of working memory, associated with a statistically significant improvement with fesoterodine 4 mg, there was no difference in any comparison for other secondary outcomes. CONCLUSIONS Exposure to steady-state dosing of fesoterodine 4 and 8 mg or oxybutynin 5 mg b.i.d. was not associated with any detectable effect on cognitive function using a sensitive battery of cognitive tests in a group of older adult patients with MCI and OAB. PATIENT SUMMARY In this report, we investigated whether the medication fesoterodine, a member of a family of drugs called anticholinergics, commonly used for the treatment of a condition called overactive bladder that leads to accidental leakage of urine, affected the memory function of older adults with mild memory impairment. These people might be more sensitive to memory side effects. We found that at the doses most used by doctors, the drug had no effect on any of the memory functions we tested.
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Affiliation(s)
- Saima Rajabali
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Prosper Asaana
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Sahar Nazari
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Adrian Wagg
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.
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Michael HU, Enechukwu O, Brouillette MJ, Tamblyn R, Fellows LK, Mayo NE. The Prognostic Utility of Anticholinergic Burden Scales: An Integrative Review and Gap Analysis. Drugs Aging 2023; 40:763-783. [PMID: 37462902 DOI: 10.1007/s40266-023-01050-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Anticholinergic drugs are commonly prescribed, especially to older adults. Anticholinergic burden scales (ABS) have been used to evaluate the cumulative effects of multiple anticholinergics. However, studies have shown inconsistent results regarding the association between anticholinergic burden assessed with ABS and adverse clinical outcomes such as cognitive impairment, functional decline, and frailty. This review aims to identify gaps in research on the development, validation, and evaluation of ABS, and provide recommendations for future studies. METHOD A comprehensive search of five databases (MEDLINE, Embase, PsychInfo, CINAHL, CENTRAL) was conducted for relevant studies published from inception until 25 May 2023. Two reviewers screened for eligibility and assessed the quality of studies using different tools based on the study design and stage of the review framework. Research evidence was evaluated, and gaps were identified and grouped into evidence, knowledge, and methodological gaps, using evidence tables to summarize data. RESULTS Several evidence, knowledge, and methodological gaps in existing development, validation, and evaluation studies of ABS were identified. There is no universally accepted scale, and there is a need to define a clinically relevant threshold for measuring total anticholinergic burden. The current evidence has limitations, underrepresenting low- and middle-income countries, younger individuals, and populations with cognitive disabilities. The impact of anticholinergic burden on frailty is also understudied. Existing evaluation studies provide limited evidence on the benefit of reducing anticholinergic burden on clinical outcomes or the safety of anticholinergic deprescribing. There is also uncertainty regarding optimal reduction, clinically significant anticholinergic burden thresholds, and cost effectiveness. CONCLUSIONS Future research recommendations to bridge knowledge gaps include developing a risk assessment framework, refining ABS scales, establishing a standardized consensus scale, and creating a longitudinal measure of cumulative anticholinergic risk. Strategies to minimize bias, consider frailty, and promote multidisciplinary and multinational collaborations are also necessary to improve patient outcomes.
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Affiliation(s)
- Henry Ukachukwu Michael
- Division of Experimental Medicine, McGill University, Montreal, QC, Canada.
- Centre for Outcomes Research & Evaluation, Research Institute of McGill University Health Centre (RI-MUHC), 5252 de Maisonneuve, 2B:43, Montréal, QC, H4A 3S5, Canada.
| | | | - Marie-Josée Brouillette
- Department of Psychiatry, Faculty of Medicine, McGill University, Montreal, QC, Canada
- Chronic Viral Illness Service, McGill University Health Centre (MUHC), Montreal, QC, Canada
- Infectious Diseases and Immunity in Global Health Program, MUHC-RI, Montreal, QC, Canada
| | - Robyn Tamblyn
- Division of Experimental Medicine, McGill University, Montreal, QC, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Lesley K Fellows
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Nancy E Mayo
- Division of Experimental Medicine, McGill University, Montreal, QC, Canada
- Centre for Outcomes Research & Evaluation, Research Institute of McGill University Health Centre (RI-MUHC), 5252 de Maisonneuve, 2B:43, Montréal, QC, H4A 3S5, Canada
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
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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. [DOI: 10.12688/hrbopenres.13599.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] 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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Bishara D, Perera G, Harwood D, Taylor D, Sauer J, Funnell N, Gee S, Stewart R, Mueller C. Centrally-acting anticholinergic drugs- associations with mortality, hospitalisation and cognitive decline following dementia diagnosis in people receiving antidepressant and antipsychotic drugs. Aging Ment Health 2022; 26:1747-1755. [PMID: 34308718 DOI: 10.1080/13607863.2021.1947967] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/20/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Long-term use of anticholinergic medication in older people is associated with increased risk of cognitive decline and mortality, but this relationship could be confounded by the underlying illness the drugs are treating. To investigate associations between central anticholinergic antidepressants or antipsychotics and mortality, hospitalisation and cognitive decline in people with dementia. METHOD In cohorts of patients with a dementia diagnosis receiving antidepressant and/or antipsychotic medication (N = 4,380 and N = 2,335 respectively), assembled from a large healthcare database, central anticholinergic burden scores were estimated using the Anticholinergic Effect on Cognition (AEC) scale. Data were linked to national mortality and hospitalisation data sources, and Mini-Mental State Examination (MMSE) scores were used to investigate cognitive decline. RESULTS There was a reduced mortality risk in people receiving agents with high central anticholinergic burden compared to those with no or low burden which was statistically significant in the antidepressant cohort (Hazard ratio (HR): 0.88; 95% confidence interval (CI): 0.79-0.98; p = 0.023) but not the antipsychotic one (HR: 0.91; 95% CI: 0.82-1.02; p = 0.105). Patients on antidepressants with no central anticholinergic burden had accelerated cognitive decline compared with other groups, whereas no differences were found in the antipsychotic cohort. No significant associations were detected between antidepressant or antipsychotic-related central anticholinergic burden and hospitalisation. CONCLUSION These counter-intuitive findings may reflect factors underlying the choice of psychotropics rather than the agents themselves, although do not support a strong role for central anticholinergic drug actions on dementia outcomes. Further studies, including randomized switching of agents are needed to clarify this relationship.
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Affiliation(s)
- Delia Bishara
- Mental Health for Older Adults and Dementia Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Old Age Psychiatry, Mental Health for Older Adults Research, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Gayan Perera
- Department of Old Age Psychiatry, Mental Health for Older Adults Research, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Daniel Harwood
- Mental Health for Older Adults and Dementia Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK
| | - David Taylor
- Department of Old Age Psychiatry, Mental Health for Older Adults Research, Institute of Psychiatry, Psychology and Neuroscience, London, UK
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Justin Sauer
- Mental Health for Older Adults and Dementia Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Old Age Psychiatry, Mental Health for Older Adults Research, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Nicola Funnell
- Mental Health for Older Adults and Dementia Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK
| | - Siobhan Gee
- Department of Old Age Psychiatry, Mental Health for Older Adults Research, Institute of Psychiatry, Psychology and Neuroscience, London, UK
- Pharmacy Department, South London and Maudsley NHS Foundation Trust, London, UK
| | - Robert Stewart
- Mental Health for Older Adults and Dementia Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Old Age Psychiatry, Mental Health for Older Adults Research, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Christoph Mueller
- Mental Health for Older Adults and Dementia Clinical Academic Group, South London and Maudsley NHS Foundation Trust, London, UK
- Department of Old Age Psychiatry, Mental Health for Older Adults Research, Institute of Psychiatry, Psychology and Neuroscience, London, UK
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Taylor-Rowan M, Kraia O, Kolliopoulou C, Noel-Storr AH, Alharthi AA, Cross AJ, Stewart C, Myint PK, McCleery J, Quinn TJ. Anticholinergic burden for prediction of cognitive decline or neuropsychiatric symptoms in older adults with mild cognitive impairment or dementia. Cochrane Database Syst Rev 2022; 8:CD015196. [PMID: 35994403 PMCID: PMC9394684 DOI: 10.1002/14651858.cd015196.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Medications with anticholinergic properties are commonly prescribed to older adults with a pre-existing diagnosis of dementia or cognitive impairment. The cumulative anticholinergic effect of all the medications a person takes is referred to as the anticholinergic burden because of its potential to cause adverse effects. It is possible that a high anticholinergic burden may be a risk factor for further cognitive decline or neuropsychiatric disturbances in people with dementia. Neuropsychiatric disturbances are the most frequent complication of dementia that require hospitalisation, accounting for almost half of admissions; hence, identification of modifiable prognostic factors for these outcomes is crucial. There are various scales available to measure anticholinergic burden but agreement between them is often poor. OBJECTIVES Our primary objective was to assess whether anticholinergic burden, as defined at the level of each individual scale, was a prognostic factor for further cognitive decline or neuropsychiatric disturbances in older adults with pre-existing diagnoses of dementia or cognitive impairment. Our secondary objective was to investigate whether anticholinergic burden was a prognostic factor for other adverse clinical outcomes, including mortality, impaired physical function, and institutionalisation. SEARCH METHODS We searched these databases from inception to 29 November 2021: MEDLINE OvidSP, Embase OvidSP, PsycINFO OvidSP, CINAHL EBSCOhost, and ISI Web of Science Core Collection on ISI Web of Science. SELECTION CRITERIA We included prospective and retrospective longitudinal cohort and case-control observational studies, with a minimum of one-month follow-up, which examined the association between an anticholinergic burden measurement scale and the above stated adverse clinical outcomes, in older adults with pre-existing diagnoses of dementia or cognitive impairment. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, and undertook data extraction, risk of bias assessment, and GRADE assessment. We summarised risk associations between anticholinergic burden and all clinical outcomes in a narrative fashion. We also evaluated the risk association between anticholinergic burden and mortality using a random-effects meta-analysis. We established adjusted pooled rates for the anticholinergic cognitive burden (ACB) scale; then, as an exploratory analysis, established pooled rates on the prespecified association across scales. MAIN RESULTS: We identified 18 studies that met our inclusion criteria (102,684 older adults). Anticholinergic burden was measured using five distinct measurement scales: 12 studies used the ACB scale; 3 studies used the Anticholinergic Risk Scale (ARS); 1 study used the Anticholinergic Drug Scale (ADS); 1 study used the Anticholinergic Effect on Cognition (AEC) Scale; and 2 studies used a list developed by Tune and Egeli. Risk associations between anticholinergic burden and adverse clinical outcomes were highly heterogenous. Four out of 10 (40%) studies reported a significantly increased risk of greater long-term cognitive decline for participants with an anticholinergic burden compared to participants with no or minimal anticholinergic burden. No studies investigated neuropsychiatric disturbance outcomes. One out of four studies (25%) reported a significant association with reduced physical function for participants with an anticholinergic burden versus participants with no or minimal anticholinergic burden. No study (out of one investigating study) reported a significant association between anticholinergic burden and risk of institutionalisation. Six out of 10 studies (60%) found a significantly increased risk of mortality for those with an anticholinergic burden compared to those with no or minimal anticholinergic burden. Pooled analysis of adjusted mortality hazard ratios (HR) measured anticholinergic burden with the ACB scale, and suggested a significantly increased risk of death for those with a high ACB score relative to those with no or minimal ACB scores (HR 1.153, 95% confidence interval (CI) 1.030 to 1.292; 4 studies, 48,663 participants). An exploratory pooled analysis of adjusted mortality HRs across anticholinergic burden scales also suggested a significantly increased risk of death for those with a high anticholinergic burden (HR 1.102, 95% CI 1.044 to 1.163; 6 studies, 68,381 participants). Overall GRADE evaluation of results found low- or very low-certainty evidence for all outcomes. AUTHORS' CONCLUSIONS: There is low-certainty evidence that older adults with dementia or cognitive impairment who have a significant anticholinergic burden may be at increased risk of death. No firm conclusions can be drawn for risk of accelerated cognitive decline, neuropsychiatric disturbances, decline in physical function, or institutionalisation.
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Affiliation(s)
- Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Olga Kraia
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | | | - Ahmed A Alharthi
- Department of Clinical Pharmacy, Umm Al Qura University, Makkah, Saudi Arabia
| | - Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | | | - Phyo K Myint
- Division of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | | | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Sanghavi R, Pana TA, Mamayusupova H, Maidment I, Fox C, Boekholdt SM, Mamas MA, Wareham NJ, Khaw K, Myint PK. Higher anticholinergic burden from medications is associated with significant increase in markers of inflammation in the EPIC-Norfolk prospective population-based cohort study. Br J Clin Pharmacol 2022; 88:3297-3306. [PMID: 35118716 PMCID: PMC9373850 DOI: 10.1111/bcp.15261] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 01/30/2022] [Accepted: 01/31/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Higher medication anticholinergic burden is associated with increased risk of cardiovascular disease and cognitive decline. A mechanistic pathway has not been established. We aimed to determine whether inflammation may mediate these associations. METHODS Participants were drawn from the European Prospective Investigation into Cancer, Norfolk cohort (40-79 years at baseline). Anticholinergic burden score (ACB) was calculated at first (1HC) (1993/97) and second (2HC) (1998/2000) health checks. Fibrinogen and C-reactive protein (CRP) were measured during 1HC and tumour necrosis factor alpha (TNF-α) and interleukin 6 (IL-6) during 2HC. Cross-sectional associations between ACB and inflammatory markers were examined for both health checks. Prospective associations were also examined between 1HC ACB and 2HC inflammatory markers. Models were adjusted for age, sex, lifestyle factors, comorbidities and medications. RESULTS In total, 17 678 and 22 051 participants were included in cross-sectional analyses for CRP, and fibrinogen, respectively. Furthermore, 5101 participants with data on TNF-α and IL-6 were included in the prospective analyses. Cross-sectionally, compared to ACB = 0, ACB ≥ 4 was associated with higher fibrinogen, beta (95% confidence interval) = 0.134 g/L (0.070, 0.199), CRP 1.175 mg/L (0.715, 1.634), IL-6 0.593 pg/mL (0.254, 0.932) and TNF-α 0.137 pg/mL (0.033, 0.241). In addition, a point increase in ACB was associated with higher levels of all markers. Prospectively, compared to ACB = 0, ACB ≥ 4 was associated with higher IL-6(pg/mL) of 0.019 (-0.323, 0.361) and TNF-α (pg/mL) of 0.202% (0.81, 0.323). A unit increase in ACB was associated with a significantly higher TNF-α and IL-6. CONCLUSION Higher ACB was associated with higher inflammatory markers. Inflammation may mediate the relationship between anticholinergic medications and adverse outcomes.
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Affiliation(s)
- Ria Sanghavi
- College of Life SciencesUniversity of LeicesterUK
| | - Tiberiu A. Pana
- Aberdeen Diabetes and Cardiovascular Centre, School of Medicine, Medical Sciences & NutritionUniversity of AberdeenAberdeenScotlandUK
- Ageing Clinical and Experimental Research TeamUniversity of AberdeenUK
| | | | - Ian Maidment
- Pharmaceutical & Clinical Pharmacy Research GroupAston UniversityBirminghamUK
| | - Chris Fox
- Norwich Medical SchoolUniversity of East AngliaNorwichUK
| | - S. Matthijs Boekholdt
- Department of CardiologyAmsterdam University Medical Centre, location AMCAmsterdamThe Netherlands
| | - Mamas A. Mamas
- Keele Cardiovascular Research GroupKeele UniversityStoke‐on‐TrentUK
| | | | - Kay‐Tee Khaw
- Clinical Gerontology Unit, Department of Public Health & Primary CareUniversity of CambridgeCambridgeUK
| | - Phyo K. Myint
- Aberdeen Diabetes and Cardiovascular Centre, School of Medicine, Medical Sciences & NutritionUniversity of AberdeenAberdeenScotlandUK
- Ageing Clinical and Experimental Research TeamUniversity of AberdeenUK
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Abstract
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.
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Affiliation(s)
- Xiang Jiang Xu
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Maw Pin Tan
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Medical Sciences, Faculty of Healthcare and Medical Sciences, Sunway University, Selangor, Malaysia
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Nagai J, Ishikawa Y. Analysis of anticholinergic adverse effects using two large databases: The US Food and Drug Administration Adverse Event Reporting System database and the Japanese Adverse Drug Event Report database. PLoS One 2021; 16:e0260980. [PMID: 34855908 PMCID: PMC8638968 DOI: 10.1371/journal.pone.0260980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/21/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Anticholinergic adverse effects (AEs) are a problem for elderly people. This study aimed to answer the following questions. First, is an analysis of anticholinergic AEs using spontaneous adverse drug event databases possible? Second, what is the main drug suspected of inducing anticholinergic AEs in the databases? Third, do database differences yield different results? METHODS We used two databases: the US Food and Drug Administration Adverse Event Reporting System database (FAERS) and the Japanese Adverse Drug Event Report database (JADER) recorded from 2004 to 2020. We defined three types of anticholinergic AEs: central nervous system (CNS) AEs, peripheral nervous system (PNS) AEs, and a combination of these AEs. We counted the number of cases and evaluated the ratio of drug-anticholinergic AE pairs between FAERS and JADER. We computed reporting odds ratios (RORs) and assessed the drugs using Beers Criteria®. RESULTS Constipation was the most reported AE in FAERS. The ratio of drug-anticholinergic AE pairs was statistically significantly larger in FAERS than JADER. Overactive bladder agents were suspected drugs common to both databases. Other drugs differed between the two databases. CNS AEs were associated with antidementia drugs in FAERS and opioids in JADER. In the assessment using Beers Criteria®, signals were detected for almost all drugs. Between the two databases, a significantly higher positive correlation was observed for PNS AEs (correlation coefficient 0.85, P = 0.0001). The ROR was significantly greater in JADER. CONCLUSIONS There are many methods to investigate AEs. This study shows that the analysis of anticholinergic AEs using spontaneous adverse drug event databases is possible. From this analysis, various suspected drugs were detected. In particular, FAERS had many cases. The differences in the results between the two databases may reflect differences in the reporting countries. Further study of the relationship between drugs and CNS AEs should be conducted.
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Affiliation(s)
- Junko Nagai
- The Office of Institutional Research, Meiji Pharmaceutical University, Kiyose, Tokyo, Japan
- * E-mail:
| | - Yoichi Ishikawa
- Division of Clinical Pharmacy, Department of Pediatric Pharmaceutical Sciences, Education and Research Center for Pharmacy, Meiji Pharmaceutical University, Kiyose, Tokyo, Japan
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Anticholinergic burden for prediction of cognitive decline or neuropsychiatric symptoms in older adults with mild cognitive impairment or dementia. Cochrane Database Syst Rev 2021; 2021:CD015196. [PMCID: PMC8601112 DOI: 10.1002/14651858.cd015196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
This is a protocol for a Cochrane Review (prognosis). The objectives are as follows: Primary objective To assess whether anticholinergic burden, as defined at the level of each individual scale, is a prognostic factor for further cognitive decline or neuropsychiatric disturbances in people with mild cognitive impairment (MCI) or dementia.
Secondary objective To compare the prognostic validity of different anticholinergic burden scales. To examine the effect of type of dementia and severity of dementia on the association between anticholinergic burden and rate of cognitive decline or neuropsychiatric disturbances. To examine the effect of setting (care home versus non‐care home) on the association between anticholinergic burden and rate of cognitive decline or neuropsychiatric disturbances. To examine whether anticholinergic burden is a prognostic factor for other clinical outcomes in people with MCI or dementia
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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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McMichael AJ, Zafeiridi E, Ryan M, Cunningham EL, Passmore AP, McGuinness B. Anticholinergic drug use and risk of mortality for people with dementia in Northern Ireland. Aging Ment Health 2021; 25:1475-1482. [PMID: 33073601 DOI: 10.1080/13607863.2020.1830028] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Anticholinergic burden refers to the cumulative effect of medications which contain anticholinergic properties. We assessed how anticholinergic burden and different types of anticholinergic medications influence mortality rates among people with dementia in Northern Ireland. Our secondary aim was to determine what demographic characteristics predict the anticholinergic burden of people with dementia. METHODS Data were extracted from the Enhanced Prescribing database for 25,418 people who were prescribed at least one dementia management medication between 2010 and 2016. Information was also extracted on the number of times each available anticholinergic drug was prescribed between 2010 and 2016, allowing the calculation of an overall anticholinergic burden. Cox proportional hazard models were used to determine how anticholinergic burden influenced mortality whilst multilevel model regression determined what demographic characteristics influence overall anticholinergic burden. RESULTS Of the 25,418 people with dementia, only 15% (n = 3880) had no anticholinergic burden. Diazepam (42%) and risperidone (18%) were the two most commonly prescribed drugs. Unadjusted Cox proportional hazard models indicated that higher anticholinergic burden was associated with significantly higher mortality rates in comparison to people with dementia who had no anticholinergic burden (HR = 1.59: 95% CI = 1.07-2.36). In particular, urological (HR = 1.20: 95% CI = 1.05-1.38) and respiratory (HR = 1.17: 95% CI = 1.08-1.27) drugs significantly increased mortality rates. People with dementia living in areas with low levels of deprivation had significantly lower anticholinergic burden (HR=-.39: 95% CI=-.47:-30). CONCLUSIONS Reducing anticholinergic burden is essential for people with dementia. Further research should address the unfavourable prognosis of people living with dementia in highly deprived areas.
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Affiliation(s)
- A J McMichael
- Centre for Public Health, Institute for Clinical Sciences Block B, Queens University Belfast, Belfast, Northern Ireland
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Collin BG, Raju D, Katsikas S. The cognitive effects of anticholinergic drugs on apolipoprotein ε4 carriers and noncarriers in the Wisconsin Registry for Alzheimer's Prevention study. Neuropsychology 2021; 35:220-231. [PMID: 33764112 DOI: 10.1037/neu0000713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES The purpose of the study was to test the hypothesis that anticholinergic drug exposure is associated with cognitive decline in the Wisconsin Registry for Alzheimer's Prevention (WRAP) study. Secondary aims were to assess if the effects of anticholinergic drugs on different domains of cognitive functioning varied for the entire sample and by apolipoprotein ε4 status. METHODS The WRAP study includes a sample of 1,573 subjects who self-reported medication use and were administered several cognitive tests four times over a decade. Partial correlations assessed relationships between reported days of definite anticholinergic drug exposure with changes in cognitive performance. Linear mixed models were conducted testing main effects for anticholinergic drug use and interaction effects between anticholinergic drug use, apolipoprotein ε4 status, and time on neuropsychological assessment performance. RESULTS Partial correlations indicated that days of anticholinergic drug exposure was associated with a decline in mental status for the entire sample (r = -.043, p = .011), and immediate verbal memory (r = -.066, p = .043), delayed verbal memory (r = -.077, p = .018), psychomotor speed (r = -.066, p = .043), and cognitive flexibility (r = -.067, p = .040) of apolipoprotein ε4 carriers only. The linear mixed-model results suggested that anticholinergic drug users had a greater decline than nonusers in delayed memory, psychomotor speed, and cognitive flexibility. Apolipoprotein ε4 carrier, anticholinergic drug users performed worse in delayed memory than nonusers and noncarrier, anticholinergic drug users. CONCLUSIONS Anticholinergic drug use may have deleterious effects on the cognitive functioning of subjects in populations at risk for dementia, especially among apolipoprotein ε4 carriers. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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McMichael AJ, Zafeiridi E, Passmore P, Cunningham EL, McGuinness B. Factors Associated with Mortality Including Nursing Home Transitions: A Retrospective Analysis of 25,418 People Prescribed Anti-Dementia Drugs in Northern Ireland. J Alzheimers Dis 2021; 73:1233-1242. [PMID: 31903992 PMCID: PMC7081092 DOI: 10.3233/jad-190751] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Understanding factors associated with mortality after a dementia diagnosis can provide essential information to the person with dementia, their family, and caregivers. To date very little is known about the factors associated with mortality after a dementia diagnosis in Northern Ireland. OBJECTIVE To determine how demographic and other factors such as deprivation and comorbidity medications influence mortality rates after a dementia diagnosis in Northern Ireland and whether these factors are influenced through nursing home transitions. METHODS 25,418 people prescribed anti-dementia medication were identified through the enhanced prescribing database between 2010 and 2016. The impact of covariates including age, gender, marital status, deprivation measure, urban/rural classification, and comorbidity medications were examined using cox proportional hazard models with hazard ratios (HR) and 95% confidence intervals. RESULTS Between 2010 and 2016, 12,129 deaths occurred, with 114 deaths/1,000 person years. Males had significantly higher mortality rates in comparison to females (HR = 1.28; 95% CI = 1.23-1.33); this was true regardless of whether the person with dementia transitioned to a nursing home. People prescribed anti-dementia drugs living with lower levels of deprivation had significantly lower mortality rates in comparison to people living with the highest levels of deprivation (HR = 0.93; 95% CI = 0.89-0.97). Diabetic (HR = 1.18; 95% CI = 1.07-1.29) and anti-arrhythmic (HR = 2.44; 95% CI = 1.01-5.91) medication in particular significantly influenced mortality. CONCLUSION Male gender, higher comorbidity medications, and living in areas of higher deprivation significantly increased mortality rates for people prescribed anti-dementia drugs in our study population. When comorbidity medications were classified, only anti-arrhythmia and diabetic medications significantly increased mortality. Future research should continue to investigate factors which influence mortality after a dementia diagnosis.
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Affiliation(s)
- Alan J McMichael
- Queen's University Belfast, Centre for Public Health, Institute for Clinical Sciences, Block B, Belfast, Northern Ireland
| | - Evi Zafeiridi
- Queen's University Belfast, Centre for Public Health, Institute for Clinical Sciences, Block B, Belfast, Northern Ireland
| | - Peter Passmore
- Queen's University Belfast, Centre for Public Health, Institute for Clinical Sciences, Block B, Belfast, Northern Ireland
| | - Emma L Cunningham
- Queen's University Belfast, Centre for Public Health, Institute for Clinical Sciences, Block B, Belfast, Northern Ireland
| | - Bernadette McGuinness
- Queen's University Belfast, Centre for Public Health, Institute for Clinical Sciences, Block B, Belfast, Northern Ireland
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Taylor-Rowan M, Edwards S, Noel-Storr AH, McCleery J, Myint PK, Soiza R, Stewart C, Loke YK, Quinn TJ. Anticholinergic burden (prognostic factor) for prediction of dementia or cognitive decline in older adults with no known cognitive syndrome. Cochrane Database Syst Rev 2021; 5:CD013540. [PMID: 34097766 PMCID: PMC8169439 DOI: 10.1002/14651858.cd013540.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Medications with anticholinergic properties are commonly prescribed to older adults. The cumulative anticholinergic effect of all the medications a person takes is referred to as the 'anticholinergic burden' because of its potential to cause adverse effects. It is possible that high anticholinergic burden may be a risk factor for development of cognitive decline or dementia. There are various scales available to measure anticholinergic burden but agreement between them is often poor. OBJECTIVES To assess whether anticholinergic burden, as defined at the level of each individual scale, is a prognostic factor for future cognitive decline or dementia in cognitively unimpaired older adults. SEARCH METHODS We searched the following databases from inception to 24 March 2021: MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), CINAHL (EBSCOhost), and ISI Web of Science Core Collection (ISI Web of Science). SELECTION CRITERIA We included prospective and retrospective longitudinal cohort and case-control observational studies with a minimum of one year' follow-up that examined the association between an anticholinergic burden measurement scale and future cognitive decline or dementia in cognitively unimpaired older adults. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, and undertook data extraction, assessment of risk of bias, and GRADE assessment. We extracted odds ratios (OR) and hazard ratios, with 95% confidence intervals (CI), and linear data on the association between anticholinergic burden and cognitive decline or dementia. We intended to pool each metric separately; however, only OR-based data were suitable for pooling via a random-effects meta-analysis. We initially established adjusted and unadjusted pooled rates for each available anticholinergic scale; then, as an exploratory analysis, established pooled rates on the prespecified association across scales. We examined variability based on severity of anticholinergic burden. MAIN RESULTS We identified 25 studies that met our inclusion criteria (968,428 older adults). Twenty studies were conducted in the community care setting, two in primary care clinics, and three in secondary care settings. Eight studies (320,906 participants) provided suitable data for meta-analysis. The Anticholinergic Cognitive Burden scale (ACB scale) was the only scale with sufficient data for 'scale-based' meta-analysis. Unadjusted ORs suggested an increased risk for cognitive decline or dementia in older adults with an anticholinergic burden (OR 1.47, 95% CI 1.09 to 1.96) and adjusted ORs similarly suggested an increased risk for anticholinergic burden, defined according to the ACB scale (OR 2.63, 95% CI 1.09 to 6.29). Exploratory analysis combining adjusted ORs across available scales supported these results (OR 2.16, 95% CI 1.38 to 3.38), and there was evidence of variability in risk based on severity of anticholinergic burden (ACB scale 1: OR 2.18, 95% CI 1.11 to 4.29; ACB scale 2: OR 2.71, 95% CI 2.01 to 3.56; ACB scale 3: OR 3.27, 95% CI 1.41 to 7.61); however, overall GRADE evaluation of certainty of the evidence was low. AUTHORS' CONCLUSIONS There is low-certainty evidence that older adults without cognitive impairment who take medications with anticholinergic effects may be at increased risk of cognitive decline or dementia.
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Affiliation(s)
- Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | | | | | - Phyo K Myint
- Division of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Roy Soiza
- Department of General Internal Medicine, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | | | - Yoon Kong Loke
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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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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Lavrador M, Castel-Branco MM, Cabral AC, Veríssimo MT, Figueiredo IV, Fernandez-Llimos F. Association between anticholinergic burden and anticholinergic adverse outcomes in the elderly: Pharmacological basis of their predictive value for adverse outcomes. Pharmacol Res 2020; 163:105306. [PMID: 33248197 DOI: 10.1016/j.phrs.2020.105306] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Marta Lavrador
- University of Coimbra, Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal.
| | - M Margarida Castel-Branco
- University of Coimbra, Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal.
| | - Ana C Cabral
- University of Coimbra, Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal.
| | - Manuel T Veríssimo
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; University of Coimbra, Faculty of Medicine, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal.
| | - Isabel V Figueiredo
- University of Coimbra, Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal.
| | - Fernando Fernandez-Llimos
- University of Porto, Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy. Rua Jorge Viterbo 228, 4050-313 Porto, Portugal; CINTESIS - Center for Health Technology and Services Research, University of Porto, Porto, Portugal.
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Pasina L, Lucca U, Tettamanti M. Relation between anticholinergic burden and cognitive impairment: Results from the Monzino 80-plus population-based study. Pharmacoepidemiol Drug Saf 2020; 29:1696-1702. [PMID: 33098318 DOI: 10.1002/pds.5159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 10/08/2020] [Accepted: 10/20/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE We examined data collected in the Monzino 80-plus study to assess the relations between cognitive performance and ACB scores according to the hypothesis that a higher anticholinergic burden is associated with reduced cognitive performance. METHODS The Monzino 80-plus is an ongoing, prospective, door-to-door population-based study started in 2002 among all residents 80 years or older in eight municipalities of Varese province, Italy. To establish the relation between cognitive impairment and the anticholinergic drug burden we recorded the ACB score for each patient at baseline. The relations between ACB score and dementia or MMSE scores were also examined after exclusion of patients taking any antipsychotic. RESULTS A sample of 2140 elderly people was eligible for analysis. A significant dose-effect relationship was observed between total ACB score and diagnosis of dementia in univariate and multivariate models. Patients in ACB class ≥4 had about 4.5 times the risk of diagnosis of dementia. A relation was also found between higher ACB scores and lower MMSE scores; patients who scored 4 or more had a mean of 6.4 points lower than those not taking anticholinergic drugs. The dose-effect relationship between ACB score and diagnosis of dementia was not maintained after exclusion of patients using antipsychotics, while the association between higher ACB scores and lower MMSE scores was still present, with patients in ACB class ≥4 having a mean score about 4.4 lower. CONCLUSIONS There are clear relations between anticholinergic load and reduced cognitive performance, while the association with dementia remains uncertain. For primary care and geriatric clinicians, an ACB score ≥ 4 can be considered the cut-off to identify high-risk populations who may benefit from the evaluation of anticholinergic burden with the ACB scale.
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Affiliation(s)
- Luca Pasina
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Ugo Lucca
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Mauro Tettamanti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
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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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Abstract
INTRODUCTION Vibegron is a very selective new β3-adrenergic receptor agonist introduced recently to clinical practice for OAB patients, which offers an alternative option for to antimuscarinic drugs. AREAS COVERED This review presents the current knowledge concerning the mechanism of action, pharmacokinetics, and pharmacodynamics of vibegron. Moreover, it presents an overview of preclinical and phase II and phase III clinical studies on the efficacy, tolerability, and safety of this agent in patients suffering from OAB. EXPERT OPINION Clinical studies confirmed efficacy and safety of vibegron in OAB patients. Vibegron differ from well-known mirabegron with regards to its pharmacological profile because it is metabolized independently from CYP3A4, 2D6, or 2C9 and therefore is less likely to cause a drug-drug interaction. Moreover, since this drug does not penetrate the blood-brain barrier, it could become the drug of choice in OAB patients with cognitive impairment. These properties have paved the way in near future for better-tailored treatments for OAB patients.
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Affiliation(s)
- Tomasz Rechberger
- Second Department of Gynecology, Medical University of Lublin , Lublin, Poland
| | - Andrzej Wróbel
- Second Department of Gynecology, Medical University of Lublin , Lublin, Poland
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Wouters H, Hilmer SN, Gnjidic D, Van Campen JP, Teichert M, Van Der Meer HG, Schaap LA, Huisman M, Comijs HC, Denig P, Lamoth CJ, Taxis K. Long-Term Exposure to Anticholinergic and Sedative Medications and Cognitive and Physical Function in Later Life. J Gerontol A Biol Sci Med Sci 2020; 75:357-365. [PMID: 30668633 DOI: 10.1093/gerona/glz019] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 01/14/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Anticholinergic and sedative medications are frequently prescribed to older individuals. These medications are associated with short-term cognitive and physical impairment, but less is known about long-term associations. We therefore examined whether over 20 years cumulative exposure to these medications was related to poorer cognitive and physical functioning. METHODS Older adult participants of the Longitudinal Aging Study Amsterdam (LASA) were followed from 1992 to 2012. On seven measurement occasions, cumulative exposure to anticholinergic and sedative medications was quantified with the drug burden index (DBI), a linear additive pharmacological dose-response model. Cognitive functioning was assessed with the Mini-Mental State Examination (MMSE), Alphabet Coding Task (ACT, three trials), Auditory Verbal Learning Test (AVLT, learning and retention condition), and Raven Colored Progressive Matrices (RCPM, two trials). Physical functioning was assessed with the Walking Test (WT), Cardigan Test (CT), Chair Stands Test (CST), Balance Test (BT), and self-reported Functional Independence (FI). Data were analyzed with linear mixed models adjusted for age, education, sex, living with a partner, BMI, depressive symptoms, comorbidities (cardiovascular disease, diabetes, cancer, COPD, osteoarthritis, CNS diseases), and prescribed medications. RESULTS Longitudinal associations were found of the DBI with poorer cognitive functioning (less items correct on the three ACT trials, AVLT learning condition, and the two RCPM trials) and with poorer physical functioning (longer completion time on the CT, CST, and lower self-reported FI). CONCLUSIONS This longitudinal analysis of data collected over 20 years, showed that higher long-term cumulative exposure to anticholinergic and sedative medications was associated with poorer cognitive and physical functioning.
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Affiliation(s)
- Hans Wouters
- Department of PharmacoTherapy, -Epidemiology & -Economics, Faculty of Science and Engineering, University of Groningen, The Netherlands.,Department of General Practice and Elderly Care Medicine, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Sarah N Hilmer
- Department of Clinical Pharmacology and Aged Care, Kolling Institute, Royal North Shore Hospital
| | - Danijela Gnjidic
- Faculty of Pharmacy and Charles Perkins Centre, University of Sydney, Australia
| | - Jos P Van Campen
- Department of Geriatric Medicine, Onze Lieve Vrouwe Gasthuis (OLVG) hospital, Amsterdam, The Netherlands
| | - Martina Teichert
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, The Netherlands
| | - Helene G Van Der Meer
- Department of PharmacoTherapy, -Epidemiology & -Economics, Faculty of Science and Engineering, University of Groningen, The Netherlands
| | - Laura A Schaap
- Department of Health Sciences, Faculty of Earth & Life Sciences, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, The Netherlands
| | - Martijn Huisman
- Department of Epidemiology & Biostatistics, Amsterdam UMC, Location VUmc, The Netherlands.,Department of Sociology, VU University, Amsterdam, The Netherlands
| | - Hannie C Comijs
- Department Psychiatry, Amsterdam UMC, Location VUmc, The Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology
| | - Claudine J Lamoth
- Center of Human Movement Science, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Katja Taxis
- Department of PharmacoTherapy, -Epidemiology & -Economics, Faculty of Science and Engineering, University of Groningen, The Netherlands
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The association between antidepressants use and development of cognitive impairment among older women diagnosed with breast cancer. Eur Geriatr Med 2020; 11:1017-1026. [PMID: 32572725 DOI: 10.1007/s41999-020-00349-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 06/11/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE This study aimed to evaluate the association between the development of cognitive impairment and the use of antidepressants among older women with breast cancer. METHODS This retrospective cohort study used the United States National Cancer Institute's Surveillance, Epidemiology, and End Results-Medicare database to identify women who were 67 years old and older and had breast cancer between 2008 and 2013. Propensity scoring was used to account for confounding pre-treatment factors, and Cox proportional hazards modeling was used to examine the risk of developing cognitive impairment among patients based on whether they used antidepressants. RESULTS A total of 3174 women taking antidepressants (mean age 75.2 ± 6.4) were matched with 3174 women not taking antidepressants (mean age 75.4 ± 6.7). Antidepressant use was associated with a significantly increased risk of cognitive impairment (hazard ratio [HR]: 1.33, 95%; confidence interval [CI]: 1.18-1.48). Additionally, we found that older women without a history of depression or anxiety who use antidepressants have a higher risk of developing cognitive impairment than those who did not use antidepressants (HR: 1.53, 95%; CI: 1.34-1.75 and HR: 1.39, 95%; CI: 1.23-1.56, respectively). Subgroup analysis showed that the use of non-tricyclic antidepressants (TCAs) was associated with a higher risk of cognitive impairment. CONCLUSION We found that non-TCA antidepressant use in older women with breast cancer was associated with a higher risk of cognitive impairment. This association was also observed among older women without depression or anxiety who used antidepressants.
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Jenraumjit R, Chinwong S, Chinwong D, Kanjanarach T, Kshetradat T, Wongpakaran T, Wongpakaran N. Anticholinergics and benzodiazepines on cognitive impairment among elderly with Alzheimer's disease: a 1 year follow-up study. BMC Res Notes 2020; 13:4. [PMID: 31898553 PMCID: PMC6941288 DOI: 10.1186/s13104-019-4874-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 12/21/2019] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Age-associated decline in central cholinergic activity makes older adults susceptible to harmful effects of anticholinergics (ACs). Evidence exists of an association between effects of AC medications on cognition. This retrospective cohort study examines how ACs affect cognition among older adults with Alzheimer's disease (AD) who received acetylcholine esterase inhibitors (AChEIs) over the course of 12 months. RESULTS A total of 133 (80% women, mean age 78.38 years, SD 7.4) were recruited. No difference in sex, age and comorbid diseases was observed between participants who took ACs, benzodiazepines (BZDs) and AChEIs. The most common prescribed ACs was quetiapine, being used for behavioral and psychological symptoms (BPSD). Multilevel analysis showed that the change of mental state examination scores were significantly predicted in the group using ACs (t (169), - 2.52, p = .020) but not with the groups using BZD (t (162), 0.84, p = .440). Evidence showed that older adults with Alzheimer's disease and exposed to ACs exhibited lower global cognitive scores than those without AC exposure. Using ACs could be a trade-off between controlling BPSD and aggravating cognitive impairment. Highlighting the awareness of the potential anticholinergic effect is important and may be the best policy.
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Affiliation(s)
- Rewadee Jenraumjit
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, 239 Suthep Road, Muang Chiang Mai District, Chiang Mai, 50200, Thailand.
| | - Surarong Chinwong
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, 239 Suthep Road, Muang Chiang Mai District, Chiang Mai, 50200, Thailand
| | - Dujrudee Chinwong
- Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, 239 Suthep Road, Muang Chiang Mai District, Chiang Mai, 50200, Thailand
| | - Tipaporn Kanjanarach
- Department of Social and Administrative Pharmacy, Faculty of Pharmaceutical Sciences, Khon Kaen University, Khon Kaen, Thailand
| | - Thanat Kshetradat
- Department of Pharmacy, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai, Thailand
| | - Tinakon Wongpakaran
- Geriatric Psychiatry Unit, Department of Psychiatry, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Rd., T. Sriphum, A. Muang, Chiang Mai, 50200, Thailand
| | - Nahathai Wongpakaran
- Geriatric Psychiatry Unit, Department of Psychiatry, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Rd., T. Sriphum, A. Muang, Chiang Mai, 50200, Thailand.
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25
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Vezmar-Kovačević S. Pharmaceutical care in Alzheimer's disease. ARHIV ZA FARMACIJU 2020. [DOI: 10.5937/arhfarm2002069v] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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26
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López-Álvarez J, Sevilla-Llewellyn-Jones J, Agüera-Ortiz L. Anticholinergic Drugs in Geriatric Psychopharmacology. Front Neurosci 2019; 13:1309. [PMID: 31866817 PMCID: PMC6908498 DOI: 10.3389/fnins.2019.01309] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/22/2019] [Indexed: 12/31/2022] Open
Abstract
Drugs with anticholinergic action are widely prescribed in the elderly population due to their potential clinical benefits. However, these benefits are limited by adverse effects which may be serious in particular circumstances. This review presents different aspects of the use of anticholinergics in old age with a focus in psychogeriatric patients. We critically review published data on benefits and disadvantages of anticholinergics, which are often controversial. Prevalence, pathophysiology and measurement methods of the anticholinergic action of drugs are discussed. We also present the most important drawbacks resulting from its use, including effects on cognition in healthy and cognitively impaired people, in aged schizophrenia patients, emergence of delirium and psychiatric symptoms, influence in functionality, hospitalization, institutionalization and mortality, and the potential benefits and limitations of their discontinuation. Finally, we suggest practical recommendations for the safe use of anticholinergics in clinical conditions affecting elderly patients, such as dementia, schizophrenia and acute hallucinatory episodes, depression, anxiety, Parkinson's disease, cardiovascular conditions and urinary incontinence.
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Affiliation(s)
- Jorge López-Álvarez
- Servicio de Psiquiatría, Hospital 12 de Octubre (imas12), Madrid, Spain.,Instituto de Investigación, Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Julia Sevilla-Llewellyn-Jones
- Instituto de Psiquiatría y Salud Mental, Hospital Clínico San Carlos, Madrid, Spain.,Instituto de Investigación (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| | - Luis Agüera-Ortiz
- Servicio de Psiquiatría, Hospital 12 de Octubre (imas12), Madrid, Spain.,Instituto de Investigación, Hospital 12 de Octubre (imas12), Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental, Ministry of Science and Innovation, Madrid, Spain.,Departamento de Medicina Legal, Psiquiatría y Patología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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Dyer AH, Murphy C, Segurado R, Lawlor B, Kennelly SP. Is Ongoing Anticholinergic Burden Associated With Greater Cognitive Decline and Dementia Severity in Mild to Moderate Alzheimer’s Disease? J Gerontol A Biol Sci Med Sci 2019; 75:987-994. [DOI: 10.1093/gerona/glz244] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Use of anticholinergic medication is associated with an increased risk of cognitive impairment and/or dementia. Despite this, the impact of continuing medication with anticholinergic properties in those diagnosed with Alzheimer’s Disease (AD) is not clear.
Methods
Analysis of data from NILVAD, an 18-month randomized controlled trial of Nilvadipine in AD. Effects of ongoing Anticholinergic Cognitive Burden (ACB) on cognition (ADAS-Cog: Alzheimer’s Disease Cog Subsection) and dementia severity (CDR-sb: Clinical Dementia Rating – Sum of Boxes/DAD: Disability Assessment for Dementia) over 18 months was evaluated adjusting for important clinical covariates.
Results
Just over one-quarter (27.90%, n = 142/510) of patients with mild to moderate AD were prescribed a potential/definite anticholinergic. While ACB score was not associated with greater progression on the ADAS-Cog/CDR-sb over time, a higher total ACB predicted greater dementia severity on the DAD, which persisted after robust covariate adjustment (β Coef: −1.53, 95% CI: −2.83 to −0.23, p = .021). There was a significant interaction between APOE ε4 status and ACB score, with carriers experiencing greater progression on both the CDR-Sb (β Coef: 0.36, 95% CI: 0.05–0.67, p = .021) and DAD (β Coef: −3.84, 95% CI: −7.65 to 0.03, p = .049).
Conclusions
Ongoing use of anticholinergic medication was associated with greater dementia progression on the DAD, but not the CDR-sb. APOE ε 4 carriers may be particularly vulnerable to the effect of ongoing anticholinergic medication on dementia severity, with significant APOE ε 4 x ACB score interactions demonstrated on both the DAD and CDR-sb.
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Affiliation(s)
- Adam H Dyer
- Department of Age-Related Healthcare, Tallaght University Hospital, Dublin
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Claire Murphy
- Department of Age-Related Healthcare, Tallaght University Hospital, Dublin
| | - Ricardo Segurado
- Centre for Support and Training in Analysis and Research (CSTAR), University College Dublin, Dublin, Ireland
| | - Brian Lawlor
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Mercer’s Institute for Research on Ageing, St James’s Hospital, Dublin, Ireland
| | - Sean P Kennelly
- Department of Age-Related Healthcare, Tallaght University Hospital, Dublin
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
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Valladales‐Restrepo LF, Duran‐Lengua M, Machado‐Alba JE. Potentially inappropriate prescriptions of anticholinergics drugs in Alzheimer's disease patients. Geriatr Gerontol Int 2019; 19:913-917. [DOI: 10.1111/ggi.13748] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 06/04/2019] [Accepted: 07/02/2019] [Indexed: 01/20/2023]
Affiliation(s)
- Luis Fernando Valladales‐Restrepo
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnologica de Pereira‐Audifarma S.A Pereira Colombia
- Grupo de Biomedicina, Fundación Universitaria Autónoma de las Américas Pereira Colombia
| | | | - Jorge Enrique Machado‐Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnologica de Pereira‐Audifarma S.A Pereira Colombia
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Gamble DT, Clark AB, Luben RN, Wareham NJ, Khaw KT, Myint PK. Baseline anticholinergic burden from medications predicts incident fatal and non-fatal stroke in the EPIC-Norfolk general population. Int J Epidemiol 2019; 47:625-633. [PMID: 29452356 DOI: 10.1093/ije/dyx265] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2017] [Indexed: 11/14/2022] Open
Abstract
Background Stroke is primarily a disease of older age, with a substantial impact on global mortality and morbidity. Medications with anticholinergic effects are widely used, but no studies have been conducted to examine the relationship between anticholinergic burden (ACB) and stroke in a general population. Method The sample was drawn from the EPIC-Norfolk cohort. Baseline assessments were carried out during 1993-97 and participants were followed up until March 2016. Participants were divided into four groups according to their total ACB score at baseline; these groups were those with a total ACB score of 0, 1, 2-3 and >3. After exclusion, Cox proportional hazards models were constructed to determine the associations between the ACB score groups and the risk of incident stroke and stroke mortality. Sensitivity analysis and propensity score matched analyses were performed. Results In total 25 639 participants attended the first health check; 3917 participants were excluded, leaving 21 722 participants to be included. Participants had a mean age [standard deviation (SD)] of 58.9 (9.2) years (54.4% women). Of these, 2131 suffered incident stroke and 562 died from stroke. Mean follow-up was approximately 18 years for both outcomes. In the fully adjusted model, those with an ACB of >3 had 59% relative risk of incident stroke {hazard ratio [HR] [95% confidence interval (CI) 1.59 [1.34-1.89]} and 86% relative risk of stroke mortality [1.86 (1.37-2.53)] compared with those in ACB 0 category. Sensitivity analyses and propensity score matched analyses showed similar results. Conclusions Our results provide an incentive for the cautious use of medications with anticholinergic properties, to help reduce the global burden of stroke.
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Affiliation(s)
- David T Gamble
- Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Allan B Clark
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Robert N Luben
- Clinical Gerontology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Kay-Tee Khaw
- Clinical Gerontology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Phyo K Myint
- Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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30
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Ah Y, Suh Y, Jun K, Hwang S, Lee J. Effect of anticholinergic burden on treatment modification, delirium and mortality in newly diagnosed dementia patients starting a cholinesterase inhibitor: A population‐based study. Basic Clin Pharmacol Toxicol 2019; 124:741-748. [DOI: 10.1111/bcpt.13184] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/28/2018] [Indexed: 01/07/2023]
Affiliation(s)
- Young‐Mi Ah
- College of Pharmacy Yeungnam University Gyeongsangbuk‐do Korea
| | - Yewon Suh
- College of Pharmacy and Research Institute of Pharmaceutical Sciences Seoul National University Seoul Korea
| | - Kwanghee Jun
- College of Pharmacy and Research Institute of Pharmaceutical Sciences Seoul National University Seoul Korea
| | - Sunghee Hwang
- College of Pharmacy and Institute of Pharmaceutical Science and Technology Hanyang University Ansan Korea
| | - Ju‐Yeun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences Seoul National University Seoul Korea
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Jaïdi Y, Guilloteau A, Nonnonhou V, Bertholon LA, Badr S, Morrone I, Novella JL, Mahmoudi R. Threshold for a Reduction in Anticholinergic Burden to Decrease Behavioral and Psychological Symptoms of Dementia. J Am Med Dir Assoc 2018; 20:159-164.e3. [PMID: 30503588 DOI: 10.1016/j.jamda.2018.10.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 07/21/2018] [Accepted: 10/08/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND A high anticholinergic burden (AB) is associated with the occurrence of behavioral and psychological symptoms (BPSDs), which are frequent in dementia. OBJECTIVES Our aim was to determine the threshold for a reduction in AB that would lead to a clinically significant improvement in BPSDs (in terms of frequency, severity, and disruptiveness). DESIGN A single-center prospective study. SETTINGS Dedicated geriatric care unit specializing in the management of patients with dementia. PARTICIPANTS The study involved older patients with dementia, hospitalized for management of BPSDs. METHODS One hundred forty-seven patients were included (mean age = 84.1 ± 5.2 years). The AB was assessed using 3 scales, namely, the Anticholinergic Drug Scale (ADS), the Anticholinergic Cognitive Burden scale (ACB), and the Anticholinergic Risk Scale (ARS). A clinically significant improvement in BPSDs was defined as a reduction of 4 points in the frequency × severity (F×S) score of the Neuropsychiatric Inventory-Nursing Home (NPI-NH) questionnaire. The threshold for a reduction in AB that corresponded to a clinically significant improvement in BPSDs was determined by multiple linear regression. RESULTS One hundred forty-seven patients were included (mean age = 84.1 ± 5.2 years). Using the ADS, a reduction of 2 points in AB in patients with moderate-intensity BPSDs was associated with a clinically significant improvement in the F×S score of the NPI-NH [6.34, 95% confidence interval (CI) 4.54-8.14], and a reduction of 3 points was associated with a clinically significant improvement in the occupational disruptiveness score (4.26, 95% CI 3.11-5.41). CONCLUSIONS/IMPLICATIONS In older patients with dementia presenting BPSDs, the risk-benefit ratio of anticholinergic drugs is debatable and, where possible, drugs with a lower AB would be preferable. Because BPSDs are a frequent cause of hospitalization, a standardized approach to analysis and reduction of AB is warranted in this population. Depending on the scale used to assess anticholinergic burden (AB), a small reduction in AB is associated with a decrease in frequency, severity, and disruptiveness of moderate-intensity BPSDs. Drugs with a high AB should be avoided where possible in older patients with dementia, and drugs with a lower AB would be preferable. Heterogeneity between the assessment scales for AB precludes generalization of the impact of a reduction in AB on BPSDs.
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Affiliation(s)
- Yacine Jaïdi
- Department of Geriatrics and Internal Medicine, Reims University Hospitals, Maison Blanche Hospital, Reims, France; Faculty of Medicine, EA 3797, University of Reims Champagne-Ardenne, Reims, France
| | - Adrien Guilloteau
- Epidemiology and infection control unit, University hospital of Dijon, Dijon, France; INSERM U1231, EPICAD Team, Dijon, France
| | - Vignon Nonnonhou
- Department of Geriatrics and Internal Medicine, Reims University Hospitals, Maison Blanche Hospital, Reims, France
| | - Laurie-Anne Bertholon
- Department of Geriatrics and Internal Medicine, Reims University Hospitals, Maison Blanche Hospital, Reims, France
| | - Sarah Badr
- Department of Geriatrics and Internal Medicine, Reims University Hospitals, Maison Blanche Hospital, Reims, France
| | - Isabella Morrone
- Department of Geriatrics and Internal Medicine, Reims University Hospitals, Maison Blanche Hospital, Reims, France; Faculty of Medicine, EA 3797, University of Reims Champagne-Ardenne, Reims, France
| | - Jean-Luc Novella
- Department of Geriatrics and Internal Medicine, Reims University Hospitals, Maison Blanche Hospital, Reims, France; Faculty of Medicine, EA 3797, University of Reims Champagne-Ardenne, Reims, France
| | - Rachid Mahmoudi
- Department of Geriatrics and Internal Medicine, Reims University Hospitals, Maison Blanche Hospital, Reims, France; Faculty of Medicine, EA 3797, University of Reims Champagne-Ardenne, Reims, France.
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Welsh TJ, van der Wardt V, Ojo G, Gordon AL, Gladman JRF. Anticholinergic Drug Burden Tools/Scales and Adverse Outcomes in Different Clinical Settings: A Systematic Review of Reviews. Drugs Aging 2018; 35:523-538. [DOI: 10.1007/s40266-018-0549-z] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Campbell NL, Lane KA, Gao S, Boustani MA, Unverzagt F. Anticholinergics Influence Transition from Normal Cognition to Mild Cognitive Impairment in Older Adults in Primary Care. Pharmacotherapy 2018; 38:511-519. [PMID: 29600808 DOI: 10.1002/phar.2106] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
STUDY OBJECTIVE To determine the influence of anticholinergic medications on transitions in cognitive diagnosis of older adults in primary care. DESIGN This observational cohort study was conducted over a mean follow-up of 3.2 years. Anticholinergic exposure was defined by pharmacy dispensing and claims records. Cognitive diagnosis was performed by an expert panel at baseline and annually up to 4 years. DATA SOURCE Medication exposure and other clinical data were extracted from the Indiana Network for Patient Care (INPC). The cognitive diagnosis was derived from a cognitive screening and diagnosis study. PARTICIPANTS A total of 350 adults 65 years and older without dementia and receiving primary care in a safety net health care system. MEASUREMENT AND MAIN RESULTS Cognitive diagnosis followed a two-phase screening and consensus-based neuropsychiatric examination to determine a baseline diagnosis as normal cognition, mild cognitive impairment (MCI), or dementia, with a follow-up neuropsychiatric examination and consensus-based diagnosis repeated annually. The Anticholinergic Cognitive Burden scale was used to identify anticholinergics dispensed up to 10 years before enrollment and annually throughout the study. A total standard daily dose of anticholinergics was calculated by using pharmacy dispensing data from the INPC. Among 350 participants, a total of 978 diagnostic assessments were completed over a mean follow-up of 3.2 years. Compared with stable cognition, increasing use of strong anticholinergics calculated by total standard daily dose increased the odds of transition from normal cognition to MCI (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.01-1.31, p = 0.0342). Compared with stable MCI, strong anticholinergics did not influence the reversion of MCI to normal cognition (OR 0.95, 95% CI 0.86-1.05, p = 0.3266). CONCLUSION De-prescribing interventions in older adults with normal cognition should test anticholinergics as potentially modifiable risk factors for cognitive impairment.
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Affiliation(s)
- Noll L Campbell
- Purdue University College of Pharmacy, West Lafayette, IN.,Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, IN
| | - Kathleen A Lane
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Sujuan Gao
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN.,Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Malaz A Boustani
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN.,Sandra Eskenazi Center for Brain Care Innovation, Eskenazi Health, Indianapolis, IN.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Fred Unverzagt
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
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Reduction of the Anticholinergic Burden Makes It Possible to Decrease Behavioral and Psychological Symptoms of Dementia. Am J Geriatr Psychiatry 2018; 26:280-288. [PMID: 28890165 DOI: 10.1016/j.jagp.2017.08.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/04/2017] [Accepted: 08/07/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the impact of a reduction of the anticholinergic burden (AB) on the frequency and severity of behavioral and psychological symptoms of dementia (BPSD) and their repercussions on the care team (occupational disruptiveness). METHODS In this prospective, single-center study in an acute care unit for Alzheimer disease (AD) and related disorders, 125 elderly subjects (mean age: 84.4 years) with dementia presented with BPSD. The reduction of the AB was evaluated by the Anticholinergic Cognitive Burden Scale. BPSD were evaluated with the Neuropsychiatric Inventory-Nursing Home Version (NPI-NH). The effect of the reduction of the AB on the BPSD was studied using logistic regression adjusting for the variables of the comprehensive geriatric assessment. RESULTS Seventy-one subjects (56.8%) presenting with probable AD, 32 (25.6%) mixed dementia (AD and vascular), 17 (13.6%) vascular dementia, and 5 (4.0%) Lewy body dementia were included. Reducing the AB by at least 20% enabled a significant decrease in the frequency × severity scores of the NPI-NH (adjusted odds ratio: 3.5; 95% confidence interval: 1.6-7.9) and of the occupational disruptiveness score (adjusted odds ratio: 9.9; 95% confidence interval: 3.6-27.3). CONCLUSION AB reduction in elderly subjects with dementia makes is possible to reduce BPSD and caregiver burden. Recourse to treatments involving an AB must be avoided as much as possible in these patients, and preferential use of nonpharmacologic treatment management plans is encouraged.
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Rojo-Sanchís A, Vélez-Díaz-Pallarés M, Muñoz García M, Delgado Silveira E, Bermejo Vicedo T, Cruz-Jentoft A. Reduction of anticholinergic burden in older patients admitted to a multidisciplinary geriatric acute care unit. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.07.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Sanders LMJ, Hortobágyi T, van Staveren G, Taxis K, Boersma F, Klein HC, Bossers WJR, Blankevoort CG, Scherder EJA, Van der Zee EA, van Heuvelen MJG. Relationship between drug burden and physical and cognitive functions in a sample of nursing home patients with dementia. Eur J Clin Pharmacol 2017; 73:1633-1642. [PMID: 28921380 PMCID: PMC5684292 DOI: 10.1007/s00228-017-2319-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 08/03/2017] [Indexed: 11/24/2022]
Abstract
Purpose The Drug Burden Index (DBI) is a tool to quantify the anticholinergic and sedative load of drugs. Establishing functional correlates of the DBI could optimize drug prescribing in patients with dementia. In this cross-sectional study, we determined the relationship between DBI and cognitive and physical functions in a sample of patients with dementia. Methods Using performance-based tests, we measured physical and cognitive functions in 140 nursing home patients aged over 70 with all-cause dementia. We also determined anticholinergic DBI (AChDBI) and sedative DBI (SDBI) separately and in combination as total drug burden (TDB). Results Nearly one half of patients (48%) used at least one DBI-contributing drug. In 33% of the patients, drug burden was moderate (0 < TDB < 1) whereas in 15%, drug burden was high (TDB ≥ 1). Multivariate models yielded no associations between TDB, AChDBI, and SDBI, and physical or cognitive function (all p > 0.05). Conclusions A lack of association between drug burden and physical or cognitive function in this sample of patients with dementia could imply that drug prescribing is more optimal for patients with dementia compared with healthy older populations. However, such an interpretation of the data warrants scrutiny as several dementia-related factors may confound the results of the study. Electronic supplementary material The online version of this article (10.1007/s00228-017-2319-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- L M J Sanders
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands.
| | - T Hortobágyi
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - G van Staveren
- Emergency Department, Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - K Taxis
- Groningen Research Institute of Pharmacy (GRIP), University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - F Boersma
- Department of General Practice, Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - H C Klein
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - W J R Bossers
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - C G Blankevoort
- Department of Geriatric Psychiatry, Lentis, Hereweg 80, 9725 AG, Groningen, The Netherlands
| | - E J A Scherder
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands.,Department of Clinical Neuropsychology, VU University Amsterdam, Van der Boechorstraat 1, 1081 BT, Amsterdam, The Netherlands
| | - E A Van der Zee
- Groningen Institute for Evolutionary Life Sciences (GELIFES), University of Groningen, Nijenborgh 7, 9747 AG, Groningen, The Netherlands
| | - M J G van Heuvelen
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
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Anticholinergic Drug Use and Risk to Cognitive Performance in Older Adults with Questionable Cognitive Impairment: A Cross-Sectional Analysis. Drugs Aging 2017; 33:809-818. [PMID: 27638818 DOI: 10.1007/s40266-016-0400-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Age-associated decline in central cholinergic activity makes older adults susceptible to the harmful effects of anticholinergic (AC) medications; however, there is an inadequate understanding of the association and possible effects of AC drugs on cognition. This cross-sectional study examines the associations of AC medications on cognition among older adults with questionable cognitive impairment (QCI). METHODS For this cross-sectional study, we used a multicenter database of community-dwelling older adults (N = 7351) aged 60+ years with QCI, from September 2005 to March 2014, as the baseline data. The Anticholinergic Drug Scale was used to categorize AC drug load into no, low, or moderate/high groups. Individuals with a Clinical Dementia Rating-Sum of Boxes score between 0.5 and 2.5 were identified as having QCI, while cognitive performance was evaluated using the Neuropsychological Test Battery. The mean z-scores of neuropsychological tests were grouped into a global cognition score. RESULTS Participants who took AC medications were older, largely female, and had a higher prevalence of incontinence than those without AC exposure. Global cognition was significantly greater in the moderate/high-AC group than the no-AC group (-0.23 ± 0.53 vs. -0.32 ± 0.53). Multivariable linear regression showed that the global cognition score among the low- and moderate/high-AC groups, compared with the no-AC group, was 0.064 higher (p = 0.006 and p = 0.12, respectively). CONCLUSIONS This cross-sectional study indicates that older adults with QCI who were exposed to AC medications might have higher global cognitive scores than those without AC exposure. The observed associations indicate that older adults might experience some beneficial cognitive effects from AC drugs, possibly due to the therapeutic effects of these medications in controlling comorbidities, thus outweighing their adverse effects on cognition.
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Dauphinot V, Mouchoux C, Veillard S, Delphin-Combe F, Krolak-Salmon P. Anticholinergic drugs and functional, cognitive impairment and behavioral disturbances in patients from a memory clinic with subjective cognitive decline or neurocognitive disorders. ALZHEIMERS RESEARCH & THERAPY 2017; 9:58. [PMID: 28764796 PMCID: PMC5540419 DOI: 10.1186/s13195-017-0284-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 07/04/2017] [Indexed: 12/14/2022]
Abstract
Background Drugs with anticholinergic properties may be associated with various adverse clinical effects. The relationship between the anticholinergic (AC) burden and functional, global cognitive performance and behavior disturbances was assessed among elderly patients. Methods A cross-sectional study was conducted between January 2012 and June 2014 in a memory clinic among outpatients living at home and with subjective cognitive decline (SCD) or neurocognitive disorders (NCD). The AC burden was measured using the Anticholinergic Drug Scale (ADS), the Anticholinergic Risk Scale (ARS), the Anticholinergic Cognitive Burden (ACB), Chew’s score, Han’s score, and the number of drugs with AC activity. Functional, cognitive performance and behavior disturbances were assessed using the Instrumental Activities of Daily Living (IADL) scale (IADL), the Mini Mental State Examination (MMSE), and the Neuropsychiatric Inventory (NPI). Results Among 473 included patients, 46.3% were at major NCD. Patients took on average 5.3 ± 2.6 drugs. MMSE was lower when Han’s score (p = 0.04) and number of AC drugs were higher (p < 0.001). IADL was lower when AC burden was higher, whatever the AC measurement. NPI was higher when ACB, Han’s score, and number of AC drugs were higher. After adjustment, all AC scores remained associated with IADL, while Han’s score and number of drugs with AC remained associated with the MMSE. Conclusions In patients with SCD or NCD, AC burden is associated with lower functional score, whereas the cross-sectional association between AC burden and cognitive performance or behavioral disturbance varies according to AC scores. Particular attention should be paid when prescribing drugs with AC properties, especially among patients with memory complaints.
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Affiliation(s)
- Virginie Dauphinot
- Centre Mémoire de Ressources et de Recherche (CMRR) de Lyon, Hôpital des Charpennes, Hospices Civils de Lyon, 27 rue Gabriel Péri, 69100, Villeurbanne, France. .,Centre de Recherche Clinique (CRC) - VCF (Vieillissement-Cerveau-Fragilité), Hôpital des Charpennes, Hospices Civils de Lyon, Villeurbanne, France.
| | - Christelle Mouchoux
- Centre de Recherche Clinique (CRC) - VCF (Vieillissement-Cerveau-Fragilité), Hôpital des Charpennes, Hospices Civils de Lyon, Villeurbanne, France.,Hospices Civils de Lyon, Groupement Hospitalier, Service pharmaceutique, Lyon, France.,Université Lyon 1, INSERM, U1028; UMR CNRS 5292, Centre de Recherche en Neurosciences de Lyon, Lyon, France
| | - Sébastien Veillard
- Centre Mémoire de Ressources et de Recherche (CMRR) de Lyon, Hôpital des Charpennes, Hospices Civils de Lyon, 27 rue Gabriel Péri, 69100, Villeurbanne, France
| | - Floriane Delphin-Combe
- Centre Mémoire de Ressources et de Recherche (CMRR) de Lyon, Hôpital des Charpennes, Hospices Civils de Lyon, 27 rue Gabriel Péri, 69100, Villeurbanne, France
| | - Pierre Krolak-Salmon
- Centre Mémoire de Ressources et de Recherche (CMRR) de Lyon, Hôpital des Charpennes, Hospices Civils de Lyon, 27 rue Gabriel Péri, 69100, Villeurbanne, France.,Centre de Recherche Clinique (CRC) - VCF (Vieillissement-Cerveau-Fragilité), Hôpital des Charpennes, Hospices Civils de Lyon, Villeurbanne, France.,Université Lyon 1, INSERM, U1028; UMR CNRS 5292, Centre de Recherche en Neurosciences de Lyon, Lyon, France
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Risacher SL, McDonald BC, Tallman EF, West JD, Farlow MR, Unverzagt FW, Gao S, Boustani M, Crane PK, Petersen RC, Jack CR, Jagust WJ, Aisen PS, Weiner MW, Saykin AJ. Association Between Anticholinergic Medication Use and Cognition, Brain Metabolism, and Brain Atrophy in Cognitively Normal Older Adults. JAMA Neurol 2017; 73:721-32. [PMID: 27088965 DOI: 10.1001/jamaneurol.2016.0580] [Citation(s) in RCA: 206] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The use of anticholinergic (AC) medication is linked to cognitive impairment and an increased risk of dementia. To our knowledge, this is the first study to investigate the association between AC medication use and neuroimaging biomarkers of brain metabolism and atrophy as a proxy for understanding the underlying biology of the clinical effects of AC medications. OBJECTIVE To assess the association between AC medication use and cognition, glucose metabolism, and brain atrophy in cognitively normal older adults from the Alzheimer's Disease Neuroimaging Initiative (ADNI) and the Indiana Memory and Aging Study (IMAS). DESIGN, SETTING, AND PARTICIPANTS The ADNI and IMAS are longitudinal studies with cognitive, neuroimaging, and other data collected at regular intervals in clinical and academic research settings. For the participants in the ADNI, visits are repeated 3, 6, and 12 months after the baseline visit and then annually. For the participants in the IMAS, visits are repeated every 18 months after the baseline visit (402 cognitively normal older adults in the ADNI and 49 cognitively normal older adults in the IMAS were included in the present analysis). Participants were either taking (hereafter referred to as the AC+ participants [52 from the ADNI and 8 from the IMAS]) or not taking (hereafter referred to as the AC- participants [350 from the ADNI and 41 from the IMAS]) at least 1 medication with medium or high AC activity. Data analysis for this study was performed in November 2015. MAIN OUTCOMES AND MEASURES Cognitive scores, mean fludeoxyglucose F 18 standardized uptake value ratio (participants from the ADNI only), and brain atrophy measures from structural magnetic resonance imaging were compared between AC+ participants and AC- participants after adjusting for potential confounders. The total AC burden score was calculated and was related to target measures. The association of AC use and longitudinal clinical decline (mean [SD] follow-up period, 32.1 [24.7] months [range, 6-108 months]) was examined using Cox regression. RESULTS The 52 AC+ participants (mean [SD] age, 73.3 [6.6] years) from the ADNI showed lower mean scores on Weschler Memory Scale-Revised Logical Memory Immediate Recall (raw mean scores: 13.27 for AC+ participants and 14.16 for AC- participants; P = .04) and the Trail Making Test Part B (raw mean scores: 97.85 seconds for AC+ participants and 82.61 seconds for AC- participants; P = .04) and a lower executive function composite score (raw mean scores: 0.58 for AC+ participants and 0.78 for AC- participants; P = .04) than the 350 AC- participants (mean [SD] age, 73.3 [5.8] years) from the ADNI. Reduced total cortical volume and temporal lobe cortical thickness and greater lateral ventricle and inferior lateral ventricle volumes were seen in the AC+ participants relative to the AC- participants. CONCLUSIONS AND RELEVANCE The use of AC medication was associated with increased brain atrophy and dysfunction and clinical decline. Thus, use of AC medication among older adults should likely be discouraged if alternative therapies are available.
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Affiliation(s)
- Shannon L Risacher
- Center for Neuroimaging, Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indiana University Health Neuroscience Center, Indianapolis2Indiana Alzheimer Disease Center, Indiana University School of Medicine, Indianapolis
| | - Brenna C McDonald
- Center for Neuroimaging, Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indiana University Health Neuroscience Center, Indianapolis2Indiana Alzheimer Disease Center, Indiana University School of Medicine, Indianapolis
| | - Eileen F Tallman
- Center for Neuroimaging, Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indiana University Health Neuroscience Center, Indianapolis2Indiana Alzheimer Disease Center, Indiana University School of Medicine, Indianapolis
| | - John D West
- Center for Neuroimaging, Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indiana University Health Neuroscience Center, Indianapolis2Indiana Alzheimer Disease Center, Indiana University School of Medicine, Indianapolis
| | - Martin R Farlow
- Indiana Alzheimer Disease Center, Indiana University School of Medicine, Indianapolis3Department of Neurology, Indiana University School of Medicine, Indianapolis
| | - Fredrick W Unverzagt
- Indiana Alzheimer Disease Center, Indiana University School of Medicine, Indianapolis4Department of Psychiatry, Indiana University School of Medicine, Indianapolis
| | - Sujuan Gao
- Indiana Alzheimer Disease Center, Indiana University School of Medicine, Indianapolis5Department of Biostatistics, Indiana University School of Medicine, Indianapolis
| | - Malaz Boustani
- Indiana Alzheimer Disease Center, Indiana University School of Medicine, Indianapolis6Indiana University Center for Aging Research, Indianapolis7Regenstrief Institute Inc, Indianapolis, Indiana8Eskenzai Health, Indianapolis, Indiana
| | - Paul K Crane
- Department of Internal Medicine, University of Washington, Seattle
| | | | | | - William J Jagust
- Department of Neurology, University of California-Berkeley, Berkeley
| | - Paul S Aisen
- Alzheimer's Therapeutic Research Institute, University of Southern California, San Diego
| | - Michael W Weiner
- Departments of Radiology, Medicine, and Psychiatry, University of California-San Francisco, San Francisco15Department of Veterans Affairs Medical Center, San Francisco, California
| | - Andrew J Saykin
- Center for Neuroimaging, Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indiana University Health Neuroscience Center, Indianapolis2Indiana Alzheimer Disease Center, Indiana University School of Medicine, Indianapolis
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Corcos J, Przydacz M, Campeau L, Witten J, Hickling D, Honeine C, Radomski SB, Stothers L, Wagg A. CUA guideline on adult overactive bladder. Can Urol Assoc J 2017; 11:E142-E173. [PMID: 28503229 PMCID: PMC5426936 DOI: 10.5489/cuaj.4586] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Jacques Corcos
- Department of Urology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Mikolaj Przydacz
- Department of Urology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Lysanne Campeau
- Department of Urology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | | | - Duane Hickling
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Christiane Honeine
- Department of Urology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Sidney B. Radomski
- Division of Urology, Toronto Western Hospital, University of Toronto, University Health Network, Toronto, ON, Canada
| | - Lynn Stothers
- Department of Urological Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Adrian Wagg
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
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Pfistermeister B, Tümena T, Gaßmann KG, Maas R, Fromm MF. Anticholinergic burden and cognitive function in a large German cohort of hospitalized geriatric patients. PLoS One 2017; 12:e0171353. [PMID: 28187171 PMCID: PMC5302450 DOI: 10.1371/journal.pone.0171353] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 01/18/2017] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Previous studies suggest an association between use of anticholinergic drugs in elderly patients and cognitive impairment. However, there are still limited data on the association of anticholinergic drug use and cognitive impairment as well as contribution of individual drugs to anticholinergic load using large, well-documented patient cohorts treated in geriatric units from Europe. METHODS We investigated 797,440 prescriptions to 89,579 hospitalized patients treated in geriatric units within the GiB-DAT database. Data of all patients discharged between 1 January 2013 and 30 June 2015 was included. The Anticholinergic Cognitive Burden (ACB) scale was used to classify anticholinergic drugs as definite (score 2 or 3) and possible anticholinergics (score 1). Cognitive function was determined using Mini-Mental State Examination (MMSE) and the standardized scale for dementia (4D+S). RESULTS In two multivariable logistic regression models age, sex, number of drugs and ACB total scores were identified as variables independently associated with cognitive impairment as measured by MMSE (odds ratio per ACB unit 1.114, 95% CI 1.099-1.130) or the diagnosis dementia (odds ratio 1.159 per ACB unit, 95% CI 1.144-1.173, both p < 0.0001). High anticholinergic load was associated with patients with severe cognitive impairment (p < 0.05 for all pairwise comparisons). ACB score 3 anticholinergic drugs contributed 77.9% to the cumulative amount of ACB points in patients with an anticholinergic load of 3 and higher. CONCLUSIONS Using a cross-sectional study design, a significant positive association between anticholinergic drug load and cognitive impairment in European patients treated in specialised geriatric units was found. The most frequently used definitve anticholinergic drugs were quetiapine, amitriptyline and carbamazepine.
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Affiliation(s)
- Barbara Pfistermeister
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Institute of Experimental and Clinical Pharmacology and Toxicology, Fahrstraße 17, Erlangen, Germany
| | | | - Karl-Günter Gaßmann
- GiB-DAT Database, Nürnberg, Germany
- Waldkrankenhaus St. Marien gGmbH, Internal Medicine III, Geriatrics Center Erlangen, Erlangen, Germany
| | - Renke Maas
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Institute of Experimental and Clinical Pharmacology and Toxicology, Fahrstraße 17, Erlangen, Germany
| | - Martin F. Fromm
- Friedrich-Alexander-Universität Erlangen-Nürnberg, Institute of Experimental and Clinical Pharmacology and Toxicology, Fahrstraße 17, Erlangen, Germany
- * E-mail:
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O'Brien JT, Holmes C, Jones M, Jones R, Livingston G, McKeith I, Mittler P, Passmore P, Ritchie C, Robinson L, Sampson EL, Taylor JP, Thomas A, Burns A. Clinical practice with anti-dementia drugs: A revised (third) consensus statement from the British Association for Psychopharmacology. J Psychopharmacol 2017; 31:147-168. [PMID: 28103749 DOI: 10.1177/0269881116680924] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The British Association for Psychopharmacology coordinated a meeting of experts to review and revise its previous 2011 guidelines for clinical practice with anti-dementia drugs. As before, levels of evidence were rated using accepted standards which were then translated into grades of recommendation A-D, with A having the strongest evidence base (from randomised controlled trials) and D the weakest (case studies or expert opinion). Current clinical diagnostic criteria for dementia have sufficient accuracy to be applied in clinical practice (B) and both structural (computed tomography and magnetic resonance imaging) and functional (positron emission tomography and single photon emission computerised tomography) brain imaging can improve diagnostic accuracy in particular situations (B). Cholinesterase inhibitors (donepezil, rivastigmine, and galantamine) are effective for cognition in mild to moderate Alzheimer's disease (A), memantine for moderate to severe Alzheimer's disease (A) and combination therapy (cholinesterase inhibitors and memantine) may be beneficial (B). Drugs should not be stopped just because dementia severity increases (A). Until further evidence is available other drugs, including statins, anti-inflammatory drugs, vitamin E, nutritional supplements and Ginkgo biloba, cannot be recommended either for the treatment or prevention of Alzheimer's disease (A). Neither cholinesterase inhibitors nor memantine are effective in those with mild cognitive impairment (A). Cholinesterase inhibitors are not effective in frontotemporal dementia and may cause agitation (A), though selective serotonin reuptake inhibitors may help behavioural (but not cognitive) features (B). Cholinesterase inhibitors should be used for the treatment of people with Lewy body dementias (both Parkinson's disease dementia and dementia with Lewy bodies), and memantine may be helpful (A). No drugs are clearly effective in vascular dementia, though cholinesterase inhibitors are beneficial in mixed dementia (B). Early evidence suggests multifactorial interventions may have potential to prevent or delay the onset of dementia (B). Though the consensus statement focuses on medication, psychological interventions can be effective in addition to pharmacotherapy, both for cognitive and non-cognitive symptoms. Many novel pharmacological approaches involving strategies to reduce amyloid and/or tau deposition in those with or at high risk of Alzheimer's disease are in progress. Though results of pivotal studies in early (prodromal/mild) Alzheimer's disease are awaited, results to date in more established (mild to moderate) Alzheimer's disease have been equivocal and no disease modifying agents are either licensed or can be currently recommended for clinical use.
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Affiliation(s)
| | | | - Matthew Jones
- 3 Salford Royal NHS Foundation Trust, Salford, UK.,4 University of Manchester, Manchester, UK
| | - Roy Jones
- 5 The Research Institute for the Care of Older People, Bath, UK.,6 University of Bath, Bath, UK
| | | | | | | | | | - Craig Ritchie
- 10 Centre for Dementia Prevention, University of Edinburgh, Edinburgh, UK
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Huang Y, Zhao Z, Wei X, Zheng Y, Yu J, Zheng J, Wang L. Long-term trihexyphenidyl exposure alters neuroimmune response and inflammation in aging rat: relevance to age and Alzheimer's disease. J Neuroinflammation 2016; 13:175. [PMID: 27411393 PMCID: PMC4942910 DOI: 10.1186/s12974-016-0640-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 06/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical studies have shown an association between long-term anticholinergic (AC) drug exposure and Alzheimer's disease (AD) pathogenesis, which has been primarily investigated in Parkinson's disease (PD). However, long-term AC exposure as a risk factor for developing neurodegenerative disorders and the exact mechanisms and potential for disease progression remain unclear. Here, we have addressed the issue using trihexyphenidyl (THP), a commonly used AC drug in PD patients, to determine if THP can accelerate AD-like neurodegenerative progression and study potential mechanisms involved. METHODS Male Sprague-Dawley rats (SD) were intraperitoneally injected with THP (0.3 and 1.0 mg/kg) or normal saline (NS) for 7 months. Alterations in cognitive and behavioral performance were assessed using the Morris water maze (MWM) and open field tests. After behavior tests, whole genome oligo microarrays, quantitative real-time reverse transcription-polymerase chain reaction (qRT-PCR), immunohistochemistry, and immunofluorescence-confocal were used to investigate the global mechanisms underlying THP-induced neuropathology with aging. RESULTS Compared with NS controls, the MWM test results showed that THP-treated rats exhibited significantly extended mean latencies during the initial 3 months of testing; however, this behavioral deficit was restored between the fourth and sixth month of MWM testing. The same tendencies were confirmed by MWM probe and open field tests. Gene microarray analysis identified 68 (47 %) upregulated and 176 (53 %) downregulated genes in the "THP-aging" vs. "NS-aging" group. The most significant populations of genes downregulated by THP were the immune response-, antigen processing and presentation-, and major histocompatibility complex (MHC)-related genes, as validated by qRT-PCR. The decreased expression of MHC class I in THP-treated aging brains was confirmed by confocal analysis. Notably, long-term THP treatment primed hippocampal and cortical microglia to undergo an inflammatory phenotypic switch, causing microgliosis and microglia activation, which were positively accompanied by pathological misfolded tau lesions. CONCLUSIONS Our findings suggest that immune response and neuroinflammation represent a pivotal mechanism in THP-induced AD-like neuropathology processes with long-term exposure to AC drugs.
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Affiliation(s)
- Yuqi Huang
- Department of Pharmacology, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004, Ningxia, Peoples' Republic of China
| | - Zhe Zhao
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing, 100850, Peoples' Republic of China
| | - Xiaoli Wei
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing, 100850, Peoples' Republic of China
| | - Yong Zheng
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing, 100850, Peoples' Republic of China
| | - Jianqiang Yu
- Department of Pharmacology, Ningxia Medical University, 1160 Shengli Street, Yinchuan, 750004, Ningxia, Peoples' Republic of China
| | - Jianquan Zheng
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing, 100850, Peoples' Republic of China
| | - Liyun Wang
- State Key Laboratory of Toxicology and Medical Countermeasures, Beijing Institute of Pharmacology and Toxicology, Beijing, 100850, Peoples' Republic of China.
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Examination and Estimation of Anticholinergic Burden: Current Trends and Implications for Future Research. Drugs Aging 2016; 33:305-13. [DOI: 10.1007/s40266-016-0362-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Rababa M, Al-Ghassani AA, Kovach CR, Dyer EM. Proton Pump Inhibitors and the Prescribing Cascade. J Gerontol Nurs 2015; 42:23-31; quiz 32-3. [PMID: 26716458 DOI: 10.3928/00989134-20151218-04] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 11/10/2015] [Indexed: 12/13/2022]
Abstract
ACTIVITY OBJECTIVES: 1. Describe the prescribing cascade of proton pump inhibitors (PPI) in nursing home residents. 2. Identify the statistically significant factors related to the use of PPI and H2 receptor blockers. DISCLOSURE STATEMENT Neither the planners nor the authors have any conflicts of interest to disclose. The current study examined the use of proton pump inhibitor (PPI) drugs in 248 nursing home residents and factors associated with being prescribed a PPI. Ninety-three percent of residents taking a PPI had done so for longer than recommended durations. As anticholinergic burden, vitamin/supplement use, and number of oral products taken daily increased, residents were more likely to be taking a PPI. Higher anticholinergic burden (p = 0.031) and number of oral products taken daily (p = 0.04) were two statistically significant predictors in the final logistic regression model. Significant predictors of PPI use in the current study may be explained by the association between polypharmacy and dyspepsia and the lowering of esophageal sphincter pressure by anticholinergic drugs. High use of PPIs in nursing home residents may represent a prescribing cascade.
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Kolanowski A, Mogle J, Fick DM, Campbell N, Hill N, Mulhall P, Behrens L, Colancecco E, Boustani M, Clare L. Anticholinergic Exposure During Rehabilitation: Cognitive and Physical Function Outcomes in Patients with Delirium Superimposed on Dementia. Am J Geriatr Psychiatry 2015; 23:1250-1258. [PMID: 26419732 PMCID: PMC4691545 DOI: 10.1016/j.jagp.2015.07.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 07/09/2015] [Accepted: 07/09/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES We examined the association between anticholinergic medication exposure and subsequent cognitive and physical function in patients with delirium superimposed on dementia during rehabilitation. We also examined length of stay and discharge disposition by anticholinergic medication exposure. DESIGN In this secondary analysis we used control group data from an ongoing randomized clinical trial. SETTING/PARTICIPANTS Participants with delirium and dementia were enrolled at admission to post-acute care. These 99 participants had a mean age of 86.11 (±6.83) years; 67.6% were women; 98% were Caucasian; and 33% were positive for at least one APOE e4 allele. MEASURES We obtained daily measures of cognitive and physical function using: Digit Span; memory, orientation and attention items from the Montreal Cognitive Assessment; CLOX; the Confusion Assessment Method; and the Barthel Index. Anticholinergic medication exposure was measured weekly using the Anticholinergic Cognitive Burden Scale. RESULTS Using multilevel models for time we found that greater use of clinically relevant anticholinergic medications in the previous week reduced cognitive and physical function, as measured by Digit Span Backwards and the Barthel index, in the current week. There was no effect of anticholinergic medication use on delirium severity, and APOE status did not moderate any outcomes. Greater use of clinically relevant anticholinergic medications was related to longer length of stay but not discharge disposition. CONCLUSIONS For vulnerable older adults, anticholinergic exposure represents a potentially modifiable risk factor for poor attention, working memory, physical function, and greater length of stay during rehabilitation.
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Affiliation(s)
- Ann Kolanowski
- College of Nursing, Penn State, University Park, PA, USA.
| | | | | | - Noll Campbell
- Purdue University College of Pharmacy, West Lafayette, Indiana; Department of Pharmacy Practice
| | - Nikki Hill
- College of Nursing, Penn State, University Park, PA
| | | | - Liza Behrens
- College of Nursing, Penn State, University Park, PA
| | | | - Malaz Boustani
- Regenstrief Institute, Indianapolis, Indiana,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Linda Clare
- REACH: The Centre for Research in Ageing and Cognitive Health, College of Life and Environmental Sciences - Psychology, Washington Singer Laboratories, Exeter EX4 4QG, United Kingdom
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Different methods, different results--how do available methods link a patient's anticholinergic load with adverse outcomes? Eur J Clin Pharmacol 2015; 71:1299-314. [PMID: 26350641 DOI: 10.1007/s00228-015-1932-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 08/26/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Anticholinergic drugs are known to cause physical and cognitive impairment, particularly in older patients. The total of all anticholinergic influences to which a patient is exposed is referred to as anticholinergic load. Because the anticholinergic load is defined in various ways, this review aimed to describe differences in the development and evaluation of available methods calculating the anticholinergic load. METHODS From September 2014 to August 2015, two reviewers performed a literature search in PubMed considering relevant items of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. We aimed to identify articles which calculated the anticholinergic load with a scale or equation and investigated its association with patient-related outcomes. From the included studies, we descriptively analyzed the identification and scoring criteria of the scales and equations with a main emphasis on their association to the reported outcomes. RESULTS Out of 465 articles, 55 were included referring to 12 scales and one equation. Main discrepancies were located in eight different identification criteria for anticholinergic drugs, two different scoring principles, and 118 tests used for assessing outcomes. The methods most frequently detecting a significant association between the anticholinergic load and outcomes took into account the drugs' dosages and anticholinergic potencies. Interestingly, none of the methods included the patient's susceptibility for anticholinergic effects and they only rarely considered modulators of drug exposure. CONCLUSIONS Due to hugely varying tests for assessing outcomes, the methods are scarcely comparable. For a more valuable comparison, the anticholinergic load should be calculated with all scales and the equation and correlated with patient-related outcomes.
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Orme S, Morris V, Gibson W, Wagg A. Managing Urinary Incontinence in Patients with Dementia: Pharmacological Treatment Options and Considerations. Drugs Aging 2015; 32:559-67. [DOI: 10.1007/s40266-015-0281-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Antidepressant Use and Cognitive Decline: The Health and Retirement Study. Am J Med 2015; 128:739-46. [PMID: 25644319 PMCID: PMC4618694 DOI: 10.1016/j.amjmed.2015.01.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 01/07/2015] [Accepted: 01/07/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Depression is associated with cognitive impairment and dementia, but whether treatment for depression with antidepressants reduces the risk for cognitive decline is unclear. We assessed the association between antidepressant use and cognitive decline over 6 years. METHODS Participants were 3714 adults aged 50 years or more who were enrolled in the nationally representative Health and Retirement Study and had self-reported antidepressant use. Depressive symptoms were assessed using the 8-item Center for Epidemiologic Studies Depression Scale. Cognitive function was assessed at 4 time points (2004, 2006, 2008, 2010) using a validated 27-point scale. Change in cognitive function over the 6-year follow-up period was examined using linear growth models, adjusted for demographics, depressive symptoms, comorbidities, functional limitations, and antidepressant anticholinergic activity load. RESULTS At baseline, cognitive function did not differ significantly between the 445 (12.1%) participants taking antidepressants and those not taking antidepressants (mean, 14.9%; 95% confidence interval, 14.3-15.4 vs mean, 15.1%; 95% confidence interval, 14.9-15.3). During the 6-year follow up period, cognition declined in both users and nonusers of antidepressants, ranging from -1.4 change in mean score in those with high depressive symptoms and taking antidepressants to -0.5 change in mean score in those with high depressive symptoms and not taking antidepressants. In adjusted models, cognition declined in people taking antidepressants at the same rate as those not taking antidepressants. Results remained consistent across different levels of baseline cognitive function, age, and duration of antidepressant use (prolonged vs short-term). CONCLUSIONS Antidepressant use did not modify the course of 6-year cognitive change in this nationally representative sample.
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Atropinic burden of prescriptions forms in patients with Alzheimer disease: a cross-sectional study in a French PharmacoVigilance Database. Eur J Clin Pharmacol 2015; 71:891-5. [PMID: 25991052 DOI: 10.1007/s00228-015-1869-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 05/12/2015] [Indexed: 10/23/2022]
Abstract
AIM Atropinic drugs in patients with Alzheimer disease (AD) can decrease the effects of anticholinesterase drugs and/or induce adverse drug reactions (ADRs). Several atropinic risk scales defining an atropinic burden of drugs were proposed but were little used in AD patients. METHODS All ADRs' notifications of AD patients registered in the Midi-Pyrénées PharmacoVigilance Database between 1999 and 2013 were analyzed using Anticholinergic Drug Scale (ADS) and Anticholinergic Duran's list. The primary objective was to quantify atropinic burden in AD patients and the secondary one to investigate associated factors. RESULTS Among the 475 notifications, at least one atropinic drug was found in 282 notifications (59.4%) according to ADS and 214 (45.1%) according to Duran. Mean number of atropinics per notifications was 0.9 ± 0.9 (ADS) and 0.7 ± 0.9 (Duran). Mean atropinic burden per notifications was 1.2 ± 1.5 (ADS) and 0.9 ± 1.3 (Duran). Atropinic burden ≥ 3 was found in 87 notifications (18.2%) according to ADS and 50 (10.5%) according to Duran. There was no association between atropinic burden and age of patients. The number of drugs is associated to a high atropinic burden. CONCLUSION The present work found an association between an atropinic drug and an anticholinesterase agent in around 1 out of 2 AD patients and a clinically significant atropinic burden (≥ 3) in around 1 to 2 AD patients out of 10. The benefit harm balance of atropinic drugs must be discussed before each prescription in AD patients.
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