1
|
Dyer AH, Murphy C, Dolphin H, Morrison L, Briggs R, Lawlor B, Kennelly SP. Long-term antipsychotic use, orthostatic hypotension and falls in older adults with Alzheimer's disease. Eur Geriatr Med 2024; 15:527-537. [PMID: 38168729 DOI: 10.1007/s41999-023-00910-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE Antipsychotic use in Alzheimer disease (AD) is associated with adverse events and mortality. Whilst postulated to cause/exacerbate orthostatic hypotension (OH), the exact relationship between antipsychotic use and OH has never been explored in AD-a group who are particularly vulnerable to neuro-cardiovascular instability and adverse effects of medication on orthostatic blood pressure (BP) behaviour. METHODS We analysed longitudinal data from an 18-month trial of Nilvadipine in mild-moderate AD. We assessed the effect of long-term antipsychotic use (for the entire 18-month study duration) on orthostatic BP phenotypes measured on eight occasions, in addition to the relationship between antipsychotic use, BP phenotypes and incident falls. RESULTS Of 509 older adults with AD (aged 72.9 ± 8.3 years, 61.9% female), 10.6% (n = 54) were prescribed a long-term antipsychotic. Over 18 months, long-term antipsychotic use was associated with a greater likelihood of experiencing sit-to-stand OH (ssOH) (OR: 1.21; 1.05-1.38, p = 0.009) which persisted on covariate adjustment. Following adjustment for important clinical confounders, both antipsychotic use (IRR: 1.80, 1.11-2.92, p = 0.018) and ssOH (IRR: 1.44, 1.00-2.06, p = 0.048) were associated with a greater risk of falls/syncope over 18 months in older adults with mild-moderate AD. CONCLUSION Even in mild-to-moderate AD, long-term antipsychotic use was associated with ssOH. Both antipsychotic use and ssOH were associated with a greater risk of incident falls/syncope over 18 months. Further attention to optimal prescribing interventions in this cohort is warranted and may involve screening older adults with AD prescribed antipsychotics for both orthostatic symptoms and falls.
Collapse
Affiliation(s)
- Adam H Dyer
- Tallaght Institute for Memory and Cognition, Tallaght University Hospital, Dublin, Ireland.
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland.
| | - Claire Murphy
- Tallaght Institute for Memory and Cognition, Tallaght University Hospital, Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
- St Vincent's University Hospital, Dublin, Ireland
| | - Helena Dolphin
- Tallaght Institute for Memory and Cognition, Tallaght University Hospital, Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Laura Morrison
- Tallaght Institute for Memory and Cognition, Tallaght University Hospital, Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Robert Briggs
- St Mercer's Institute for Research on Ageing, St James's Hospital, Dublin, Ireland
| | - Brian Lawlor
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| | - Sean P Kennelly
- Tallaght Institute for Memory and Cognition, Tallaght University Hospital, Dublin, Ireland
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Welk B, McClure JA. The Impact of Anticholinergic Use for Overactive Bladder on Cognitive Changes in Adults with Normal Cognition, Mild Cognitive Impairment, or Dementia. EUR UROL SUPPL 2022; 46:22-29. [PMID: 36506252 PMCID: PMC9732452 DOI: 10.1016/j.euros.2022.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Abstract
Background Few studies have addressed whether anticholinergic (AC) medications for overactive bladder (OAB) cause cognitive decline in individuals with existing cognitive impairment, and whether the APOE ε4 gene increases this risk. Objective To determine whether OAB AC use is associated with a clinically relevant change in cognitive measures among adults with normal and abnormal cognition. Design setting and participants This was a retrospective cohort study using data from the National Alzheimer's Coordinating Center. Patients were enrolled at specialized centers in the USA between 2005 and 2019. Patients with existing OAB AC use, missing APOE ε4 status, and confounding neurologic diagnoses were excluded. New users of an OAB AC were matched 1:1 to patients not taking an OAB AC using propensity scores. Intervention New use of oxybutynin, tolterodine, solifenacin, trospium, darifenacin, or fesoterodine. Outcome measurements and statistical analysis The outcome was a change in cognitive function, measured as a ≥1-point increase on the Clinical Dementia Rating (CDR) instrument or a ≥3-point decrease on the Mini-Mental State Examination (MMSE). Conditional logistic regression with odds ratios (ORs) was conducted. We also tested for APOE ε4 effect modification. Results and limitations Among 18 835 eligible patients, 782 matched pairs were identified. The most common OAB ACs were oxybutynin (38%) and tolterodine (23%). There was no significant increase in the risk of a clinically relevant cognitive decline among OAB AC users (CDR: OR 1.38, 95% confidence interval [CI] 0.93-2.05; p = 0.11, MMSE: OR 1.06, 95% CI 0.79-1.43; p = 0.70). There was no significant interaction between APOE ε4 status and OAB AC use for the CDR (p = 0.38) or MMSE (p = 0.95) outcomes. Users of oxybutynin or tolterodine had numerically higher odds of a change on the CDR test (OR 1.65, 95% CI 0.98-2.77) that was close to statistical significance (p = 0.06). Limitations include the inability to determine medication dose or duration, and residual confounding. Conclusions OAB AC use was not associated with a significant change in cognitive function among individuals with normal and abnormal cognition. Further research is necessary to determine if oxybutynin and tolterodine are significantly more likely to cause cognitive decline. Patient summary Use of a specific class of overactive bladder medication was not associated with negative changes in brain function among patients with either normal or abnormal function. A genetic risk factor for Alzheimer's disease did not predispose individuals to cognitive decline when taking these drugs. Two of the drugs (oxybutynin and tolterodine) may lead to a higher risk of cognitive decline in comparison to other drugs, and this needs further research.
Collapse
Affiliation(s)
- Blayne Welk
- Department of Surgery and Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Corresponding author. Department of Surgery and Epidemiology and Biostatistics, Western University, St Joseph’s Health Care, 268 Grosvenor Street, London, Ontario N6A 4V2, Canada. Tel. +1 519 6466367; Fax: +1 519 6466037.
| | | |
Collapse
|
4
|
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.
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Meng D, Mohammadi-Nejad AR, Sotiropoulos SN, Auer DP. Anticholinergic drugs and forebrain magnetic resonance imaging changes in cognitively normal people and those with mild cognitive impairment. Eur J Neurol 2022; 29:1344-1353. [PMID: 35129272 PMCID: PMC9304308 DOI: 10.1111/ene.15251] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/13/2022] [Indexed: 01/24/2023]
Abstract
Background and purpose Anticholinergic (AC) medication use is associated with cognitive decline and dementia, which may be related to an AC‐induced central hypocholinergic state, but the exact mechanisms remain to be understood. We aimed to further elucidate the putative link between AC drug prescription, cognition, and structural and functional impairment of the forebrain cholinergic nucleus basalis of Meynert (NBM). Methods Cognitively normal (CN; n = 344) and mildly cognitively impaired (MCI; n = 224) Alzheimer’s Disease Neuroimaging Initiative Phase 3 participants with good quality 3‐T magnetic resonance imaging were included. Structural (regional gray matter [GM] density) and functional NBM integrity (functional connectivity [FC]) were compared between those on AC medication for > 1 year (AC+) and those without (AC−) in each condition. AC burden was classed as mild, moderate, or severe. Results MCI AC+ participants (0.55 ± 0.03) showed lower NBM GM density compared to MCI AC− participants (0.56 ± 0.03, p = 0.002), but there was no structural AC effect in CN. NBM FC was lower in CN AC+ versus CN AC− (3.6 ± 0.5 vs. 3.9 ± 0.6, p = 0.001), and in MCI AC+ versus MCI AC− (3.3 ± 0.2 vs. 3.7 ± 0.5, p < 0.001), with larger effect size in MCI. NBM FC partially mediated the association between AC medication burden and cognition. Conclusions Our findings provide novel support for a detrimental effect of mild AC medication on the forebrain cholinergic system characterized as functional central hypocholinergic that partially mediated AC‐related cognitive impairment. Moreover, structural tissue damage suggests neurodegeneration, and larger effect sizes in MCI point to enhanced susceptibility for AC medication in those at risk of dementia.
Collapse
Affiliation(s)
- Dewen Meng
- Radiological Sciences, Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK.,Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, UK.,National Institute for Health Research Nottingham Biomedical Research Centre, Queen's Medical Centre, University of Nottingham, Nottingham, UK
| | - Ali-Reza Mohammadi-Nejad
- Radiological Sciences, Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK.,Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, UK.,National Institute for Health Research Nottingham Biomedical Research Centre, Queen's Medical Centre, University of Nottingham, Nottingham, UK
| | - Stamatios N Sotiropoulos
- Radiological Sciences, Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK.,Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, UK.,National Institute for Health Research Nottingham Biomedical Research Centre, Queen's Medical Centre, University of Nottingham, Nottingham, UK
| | - Dorothee P Auer
- Radiological Sciences, Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK.,Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, Nottingham, UK.,National Institute for Health Research Nottingham Biomedical Research Centre, Queen's Medical Centre, University of Nottingham, Nottingham, UK
| | | |
Collapse
|
7
|
Anticholinergic and Sedative Medications and Dynamic Gait Parameters in Older Patients. Drugs Aging 2021; 38:1087-1096. [PMID: 34855162 DOI: 10.1007/s40266-021-00902-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Anticholinergic and sedative medications are associated with poorer physical function in older age. Gait and physical function have traditionally been assessed with the time needed to execute objective function tests. Accelerometer-based gait parameters provide a precise capturing of gait dynamics and patterns and as such have added value. OBJECTIVES This study examined the associations between cumulative exposure to anticholinergic and sedative medications and gait dimensions as assessed with accelerometer-based dynamic gait parameters. METHODS Data were collected from outpatients of a diagnostic geriatric day clinic who underwent a comprehensive geriatric assessment (CGA). Cumulative exposure to anticholinergic and sedative medications was quantified with the Drug Burden Index (DBI), a linear additive pharmacological dose-response model. From a total of 22 dynamic gait parameters, the gait dimensions 'Regularity', 'Complexity', 'Stability', 'Pace', and 'Postural Control' were derived using factor analysis (and standardized total scores for these dimensions were calculated accordingly). Data were analyzed with multivariable linear regression analysis, in which adjustment was made for the covariates age, gender, body mass index (BMI), Mini Mental State Examination (MMSE) score, Charlson Comorbidity Index (CCI) including dementia, and number of medications not included in the DBI. RESULTS A total of 184 patients participated, whose mean age was 79.8 years (± SD 5.8), of whom 110 (60%) were women and of whom 88 (48%) had polypharmacy (i.e., received treatment with ≥5 medications). Of the 893 medications that were prescribed in total, 157 medications (17.6%) had anticholinergic and/or sedative properties. Of the patients, 100 (54%) had no exposure (DBI = 0), 42 (23%) had moderate exposure (0 > DBI ≤ 1), while another 42 (23%) had high exposure (DBI >1) to anticholinergic and sedative medications. Findings showed that high cumulative exposure to anticholinergic and sedative medications was related with poorer function on the Regularity and Pace dimensions. Furthermore, moderate and high exposure were associated with poorer function on the Complexity dimension. CONCLUSIONS These findings show that in older patients with comorbidities, cumulative anticholinergic and sedative exposure is associated with poorer function on multiple gait dimensions.
Collapse
|
8
|
Dyer AH, Murphy C, Lawlor B, Kennelly SP, For The Nilvad Study Group. Long-term antipsychotic use and cognitive decline in community-dwelling older adults with mild-moderate Alzheimer disease: Data from NILVAD. Int J Geriatr Psychiatry 2021; 36:1708-1721. [PMID: 34173272 DOI: 10.1002/gps.5591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/12/2021] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Previous evidence has suggested that antipsychotic use may be associated with accelerated cognitive decline in those living with dementia. However, the cognitive effects of long-term antipsychotic use in community-dwelling older adults with mild-moderate Alzheimer disease (AD) has not been explored to date. METHODS We assessed the impact of long-term antipsychotic use on the rate of cognitive decline (Alzheimer's Disease Assessment Scale-Cognitive Subsection) and dementia progression (Clinical Dementia Rating-Sum of Boxes [CDR-Sb]/Disability Assessment for Dementia [DAD]) over 18 months in older adults with mild-moderate AD. RESULTS Of 509 participants with mild-moderate AD, one-tenth (54/509; 10.6%) were prescribed an antipsychotic for the 18-month study duration. Antipsychotic use was significantly associated with accelerated cognitive decline at both 12 (β: 3.53, 0.91-6.17, p = 0.008) and 18 months (β: 3.81, 0.49-7.14, p = 0.024) in addition to greater dementia progression at both 12 (β: 1.85, -0.97-2.73, p < 0.001 for CDR-Sb/β: -3.33, -5.56-1.10, p = 0.003 for DAD) and 18 months (β: 1.41, 0.16-2.67, p = 0.027 for CDR-Sb/β: -3.86, -6.64 to -1.08, p = 0.006 for DAD). APOE ε4 carriers experienced significantly greater cognitive decline with long-term antipsychotic use. CONCLUSIONS Long-term antipsychotic use was associated with greater cognitive decline and dementia progression in community-dwelling older adults with mild-moderate AD. Our findings are consistent with previous evidence encouraging cautious and careful consideration of risks versus benefits of antipsychotic usage in those with AD.
Collapse
Affiliation(s)
- Adam H Dyer
- Department of Age-Related Healthcare, Tallaght University Hospital, Dublin, Ireland.,Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Claire Murphy
- Department of Age-Related Healthcare, Tallaght University Hospital, Dublin, Ireland
| | - Brian Lawlor
- Mercer's Institute for Research on Ageing, St James's Hospital, Dublin, Ireland.,Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| | - Sean P Kennelly
- Department of Age-Related Healthcare, Tallaght University Hospital, Dublin, Ireland.,Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Ireland.,Global Brain Health Institute, Trinity College Dublin, Dublin, Ireland
| | | |
Collapse
|
9
|
Dyer AH, Laird E, Hoey L, Hughes CF, McNulty H, Ward M, Strain JJ, Molloy AM, Cunningham C, McCarroll K. Long-term anticholinergic, benzodiazepine and Z-drug use in community-dwelling older adults: What is the impact on cognitive and neuropsychological performance? Int J Geriatr Psychiatry 2021; 36:1767-1777. [PMID: 34227695 DOI: 10.1002/gps.5598] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/22/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Long-term use of anticholinergics, benzodiazepines and related drugs (or "Z-drugs") have been associated with cognitive impairment and dementia. However, the relationship of these medications with cognitive function and domain-specific neuropsychological performance in older adults without dementia, is unclear. METHODS 5135 older adults (74.0 ± 8.3 years; 67.4% female) without a diagnosis of dementia were recruited in Ireland to the Trinity-Ulster-Department of Agriculture (TUDA) study. Detailed cognitive and neuropsychological assessment was conducted using the Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB) and Repeatable Battery for Assessment of Neuropsychological Status (RBANS). RESULTS A total of 44% (2259 of 5153) used either a potential or definite anticholinergic medication. Overall, 9.7% (n = 500) used a definite anticholinergic medication. Regular benzodiazepine use was reported by 7% (n = 363), whilst 7.5% (n = 387) used a "Z-drug". Use of definite, but not potential anticholinergic medication was associated with poorer performance on all three assessments (β: -0.09; 95% CI: -0.14, -0.03, p = 0.002 for MMSE; β: -0.04; 95% CI: -0.06, -0.02; p < 0.001 for FAB; β: -4.15; 95% CI: -5.64, -2.66; p < 0.001 for RBANS) in addition to all domains of the RBANS. Regular benzodiazepine use was also associated with poorer neuropsychological test performance, especially in Immediate Memory (β: -4.98; 95% CI: -6.81, -3.15; p < 0.001) and Attention (β: -6.81; 95% CI: -8.60, -5.03; p < 0.001) RBANS domains. CONCLUSIONS Regular use of definite anticholinergic medications and benzodiazepines, but not potential anticholinergics or "Z-drugs", was associated with poorer overall and domain-specific neuropsychological performance in older adults.
Collapse
Affiliation(s)
- Adam H Dyer
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Eamon Laird
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Leane Hoey
- The Nutrition Innovation Centre for Food and Health (NICHE), School of Biomedical Sciences, Ulster University, Coleraine, NI, UK
| | - Catherine F Hughes
- The Nutrition Innovation Centre for Food and Health (NICHE), School of Biomedical Sciences, Ulster University, Coleraine, NI, UK
| | - Helene McNulty
- The Nutrition Innovation Centre for Food and Health (NICHE), School of Biomedical Sciences, Ulster University, Coleraine, NI, UK
| | - Mary Ward
- The Nutrition Innovation Centre for Food and Health (NICHE), School of Biomedical Sciences, Ulster University, Coleraine, NI, UK
| | - J J Strain
- The Nutrition Innovation Centre for Food and Health (NICHE), School of Biomedical Sciences, Ulster University, Coleraine, NI, UK
| | - Anne M Molloy
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Conal Cunningham
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| | - Kevin McCarroll
- Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland
| |
Collapse
|
10
|
Ramos H, Moreno L, Gil M, García-Lluch G, Sendra-Lillo J, Alacreu M. Pharmacists' Knowledge of Factors Associated with Dementia: The A-to-Z Dementia Knowledge List. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:9934. [PMID: 34639242 PMCID: PMC8508463 DOI: 10.3390/ijerph18199934] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/11/2021] [Accepted: 09/14/2021] [Indexed: 12/24/2022]
Abstract
Dementia is a neurodegenerative disease with no cure that can begin up to 20 years before its diagnosis. A key priority in patients with dementia is the identification of early modifiable factors that can slow the progression of the disease. Community pharmacies are suitable points for cognitive-impairment screening because of their proximity to patients. Therefore, the continuous training of professionals working in pharmacies directly impacts the public health of the population. The main purpose of this study was to assess community pharmacists' knowledge of dementia-related factors. Thus, we conducted a cross-sectional study of 361 pharmacists via an online questionnaire that quizzed their knowledge of a list of dementia-related factors, which we later arranged into the A-to-Z Dementia Knowledge List. We found that younger participants had a better knowledge of risk factors associated with dementia. The risk factors most often identified were a family history of dementia followed by social isolation. More than 40% of the respondents did not identify herpes labialis, sleep more than 9 h per day, and poor hearing as risk factors. A higher percentage of respondents were better able to identify protective factors than risk factors. The least known protective factors were internet use, avoidance of pollution, and the use of anti-inflammatory drugs. Pharmacists' knowledge of dementia-related factors should be renewed with the aim of enhancing their unique placement to easily implement cognitive-impairment screening.
Collapse
Affiliation(s)
- Hernán Ramos
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, 46115 Valencia, Spain; (H.R.); (L.M.); (M.G.); (G.G.-L.); (J.S.-L.)
- Muy Ilustre Colegio Oficial de Farmacéuticos, 46003 Valencia, Spain
| | - Lucrecia Moreno
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, 46115 Valencia, Spain; (H.R.); (L.M.); (M.G.); (G.G.-L.); (J.S.-L.)
- Department of Pharmacy, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain
| | - María Gil
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, 46115 Valencia, Spain; (H.R.); (L.M.); (M.G.); (G.G.-L.); (J.S.-L.)
- Muy Ilustre Colegio Oficial de Farmacéuticos, 46003 Valencia, Spain
| | - Gemma García-Lluch
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, 46115 Valencia, Spain; (H.R.); (L.M.); (M.G.); (G.G.-L.); (J.S.-L.)
| | - José Sendra-Lillo
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, 46115 Valencia, Spain; (H.R.); (L.M.); (M.G.); (G.G.-L.); (J.S.-L.)
- Muy Ilustre Colegio Oficial de Farmacéuticos, 46003 Valencia, Spain
| | - Mónica Alacreu
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, 46115 Valencia, Spain; (H.R.); (L.M.); (M.G.); (G.G.-L.); (J.S.-L.)
- Embedded Systems and Artificial Intelligence Group, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain
| |
Collapse
|
11
|
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.
Collapse
Affiliation(s)
- A J McMichael
- Centre for Public Health, Institute for Clinical Sciences Block B, Queens University Belfast, Belfast, Northern Ireland
| | | | | | | | | | | |
Collapse
|
12
|
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).
Collapse
|
13
|
Neelamegam M, Zgibor J, Chen H, O'rourke K, Bakour C, Rajaram L, Anstey KJ. The Effect of Cumulative Anticholinergic Use on the Cognitive Function of Older Adults: Results from the Personality and Total Health (PATH) Through Life Study. J Gerontol A Biol Sci Med Sci 2021; 75:1706-1714. [PMID: 32514523 DOI: 10.1093/gerona/glaa145] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Multiple comorbidities are common in older adults, resulting in polypharmacy that often includes medications with anticholinergic properties. These medications have multiple side effects, which are more pronounced in the older population. This study examined the association between the use of anticholinergics and changes in the cognitive function of older adults. METHODS The study population consisted of 2,222 individuals aged 65-69 years at baseline from the Personality and Total Health (PATH) Through Life Study in Australia. Medication data were obtained from the Pharmaceutical Benefits Scheme (PBS). Cognitive measures were obtained from neuropsychological battery assessment. Exposure to cumulative anticholinergic use was quantified to a total standardized daily dose (TSDD). The association between change in cognitive measures between baseline and 4-year follow-up, and cumulative use of anticholinergic was assessed through generalized linear models. RESULTS During the study period, 18.6% (n = 413) of participants filled at least one prescription for anticholinergics. Compared to those not on anticholinergics, participants on anticholinergics were more likely to be woman (62.7% compared to 45.1%) and spent lesser time engaging in vigorous physical activity (0.4 h/week compared to 0.9 h/week). Cumulative use of anticholinergic resulting in a TSDD exceeding 1,095 was significantly associated with poorer performance in Trail Making Test Part B (Model 1: β = 5.77, Model 2: β = 5.33, Model 3: β = 8.32, p < .01), indicating impairment in processing speed. CONCLUSIONS In our study, except for speed of processing, other cognitive domains measured were not affected by cumulative anticholinergic use over a 4-year period.
Collapse
Affiliation(s)
- Malinee Neelamegam
- College of Public Health, University of South Florida, Tampa.,Yale School of Public Health, Yale University, New Haven, Connecticut
| | - Janice Zgibor
- College of Public Health, University of South Florida, Tampa
| | - Henian Chen
- College of Public Health, University of South Florida, Tampa
| | | | - Chighaf Bakour
- College of Public Health, University of South Florida, Tampa
| | | | - Kaarin J Anstey
- Centre for Research on Ageing, Health and Wellbeing, Australian National University, Canberra.,School of Psychology, University of New South Wales, Sydney, Australia.,Neuroscience Research Australia, Sydney, Australia
| |
Collapse
|
14
|
Sedative Load in Community-Dwelling Older Adults with Mild-Moderate Alzheimer's Disease: Longitudinal Relationships with Adverse Events, Delirium and Falls. Drugs Aging 2020; 37:829-837. [PMID: 32924095 DOI: 10.1007/s40266-020-00800-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Older adults are frequently prescribed medications with sedative effects, which are associated with numerous adverse consequences. However, the prevalence and longitudinal associations of sedative medication use in community-dwelling older adults with mild-moderate Alzheimer's disease (AD) has not been explored to date. OBJECTIVES Our objective was to assess the prevalence of sedative medication use in community-dwelling older adults with mild-moderate AD and examine the longitudinal association between sedative medication use and adverse events (AEs). METHODS The association between baseline sedative load (SL) and AEs, unscheduled healthcare utilisation, delirium and falls was assessed in older adults with mild-moderate AD over 18 months using secondary analysis of NILVAD trial data (collected from 2014 to 2016). Baseline medication use was assessed, and the SL model was applied to each participant's medication individually. The SL model classifies medications into one of four categories: (1) primary sedatives, (2) medications with a sedating component or prominent side effect, (3) medications with sedation as a potential adverse reaction and (4) all other medications with no known sedative side effects. Medications in group 1 were assigned an SL score of 2, those in group 2 were assigned an SL score of 1, and those in categories 3 and 4 an SL score of 0. SL scores for each medication participants were taking were summed and the total SL calculated as an arithmetic sum of individual medications score. A total SL score ≥ 3 was classed as high. Statistical analysis was conducted using Poisson regression and mixed-effects linear regression, with adjustment for important clinical covariates. We also assessed the impact of SL on dementia progression and cognitive decline. RESULTS Over half (55.7% [284/510]) of those with mild-moderate AD (age 72.8 ± 8.3 years, 61.9% female) were prescribed a regular medication with sedation as a primary effect or prominent side effect, with 22.2% (113/510) having a high SL (≥ 3). The most common medications contributing to SL were antidepressants, antipsychotics, anxiolytics and hypnotics. Over 18 months, increasing baseline SL was associated with incident AEs (incidence rate ratio [IRR] 1.15; 95% confidence interval [CI] 1.11-1.19; p < 0.001), serious AEs (IRR 1.23; 95% CI 1.11-1.36; p < 0.001) and unscheduled general practitioner visits (IRR 1.23; 95% CI 1.13-1.34; p < 0.001). Further, increasing SL was associated with a greater likelihood of incident delirium (IRR 1.30; 95% CI 1.11-1.53; p < 0.001) and falls (IRR 1.20; 95% CI 1.03-1.42; p = 0.02). Associations persisted after robust covariate adjustment. SL was not associated with accelerated cognitive decline or AD progression. CONCLUSIONS In the current study, over half of older adults with mild-moderate AD were prescribed at least one drug with a sedative effect, and a significant minority had a high SL. Increasing baseline SL was associated with a greater likelihood of incident AEs, delirium and falls, highlighting the need for optimal prescribing in this potentially vulnerable cohort.
Collapse
|