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Mahmoudi R, Greten S, Veith Sanches L, Krey L, Ulaganathan S, Höglinger GU, Heck J, Wegner F, Klietz M. Impact of the Anticholinergic Burden on Disease-Specific Symptoms in Parkinsonian Syndromes. Brain Sci 2024; 14:805. [PMID: 39199497 PMCID: PMC11352570 DOI: 10.3390/brainsci14080805] [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: 07/12/2024] [Revised: 08/07/2024] [Accepted: 08/09/2024] [Indexed: 09/01/2024] Open
Abstract
Background: Anticholinergic adverse effects pose a relevant threat to patients, in particular elderly and cognitively impaired patients. Patients with Parkinsonian syndromes are especially at risk from anticholinergic adverse effects due to the often-required complex drug therapy. Aims: The aim of this study was to evaluate the potential effect of the anticholinergic burden on motor and non-motor symptoms in Parkinson's disease and atypical Parkinsonian syndromes. Methods: This cross-sectional, monocentric retrospective data analysis included 151 patients with Parkinson's disease (PD), 63 with progressive supranuclear palsy (PSP), and 36 with multiple system atrophy (MSA). The anticholinergic burden of patients' medications was determined using two established scores: the Anticholinergic Drug Scale (ADS) and the German Anticholinergic Burden Scale (GABS). These scores were compared between the different diseases and correlated with several disease-specific scores. Results: Anticholinergic burden was higher in patients with PD, in particular, compared to PSP. In the PD group, anticholinergic burden showed a weak correlation with almost all analyzed clinical scores and the number of administered drugs. The UMSARS I and II showed a significant correlation with the anticholinergic burden in MSA patients. In general, the GABS-measured anticholinergic burden was significantly higher compared to the ADS-measured. Conclusions: The calculated anticholinergic burden affected motor and non-motor symptoms in patients with various Parkinsonian syndromes poorly. Since the GABS also contains basic anti-parkinsonian drugs, this score tended to overestimate the anticholinergic burden in patients with Parkinsonian syndromes and, therefore, seemed less appropriate for this application.
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Affiliation(s)
- Romina Mahmoudi
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; (R.M.); (L.V.S.); (L.K.); (S.U.); (G.U.H.); (F.W.); (M.K.)
| | - Stephan Greten
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; (R.M.); (L.V.S.); (L.K.); (S.U.); (G.U.H.); (F.W.); (M.K.)
| | - Linda Veith Sanches
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; (R.M.); (L.V.S.); (L.K.); (S.U.); (G.U.H.); (F.W.); (M.K.)
| | - Lea Krey
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; (R.M.); (L.V.S.); (L.K.); (S.U.); (G.U.H.); (F.W.); (M.K.)
| | - Sarana Ulaganathan
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; (R.M.); (L.V.S.); (L.K.); (S.U.); (G.U.H.); (F.W.); (M.K.)
| | - Günter U. Höglinger
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; (R.M.); (L.V.S.); (L.K.); (S.U.); (G.U.H.); (F.W.); (M.K.)
- Department of Neurology, University Hospital of Munich, Ludwig-Maximilians-Universität (LMU) Munich, 80539 Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy) Munich, 80539 Munich, Germany
- German Center for Neurodegenerative Diseases (DZNE), 80539 Munich, Germany
| | - Johannes Heck
- Institute for Clinical Pharmacology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany;
| | - Florian Wegner
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; (R.M.); (L.V.S.); (L.K.); (S.U.); (G.U.H.); (F.W.); (M.K.)
| | - Martin Klietz
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany; (R.M.); (L.V.S.); (L.K.); (S.U.); (G.U.H.); (F.W.); (M.K.)
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Rodrigues DA, Herdeiro MT, Mateos-Campos R, Figueiras A, Roque F. Potentially inappropriate anticholinergic drug use among older adults in primary healthcare: prevalence and determinants. Expert Opin Drug Saf 2024:1-7. [PMID: 39105534 DOI: 10.1080/14740338.2024.2385479] [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: 03/19/2024] [Accepted: 05/22/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Considering the vulnerability of older adults to adverse drug reactions, medications with strong anticholinergic properties are considered potentially inappropriate for this population. This study aims to characterize older adults' profile of anticholinergics use and to identify the factors associated with their potentially inappropriate use. RESEARCH DESIGN AND METHODS A retrospective study was conducted on 1200 older adults in primary health care centers of Portugal between April 2021 and August 2022. Potentially inappropriate use was assessed according to the 2023 Beers criteria. Logistic regression analyses were performed to determine associations between independent variables and potentially inappropriate use. RESULTS A 8.9% (95% CI 0.074-0.107) of the older adults were exposed to one or more potentially inappropriate anticholinergics, and amitriptyline was the most used (2.0%). Multivariate analysis revealed that use was associated with a higher mean number of medications (OR 1.173, 95% CI 1.115-1.234), diagnoses of depression (OR 2.889, 95% CI 1.785-4.674) and psychiatric disorders (OR 1.654, 95% CI 1.003-2.729). CONCLUSIONS This study underscores the importance of vigilance in prescribing anticholinergic medications to older adults, particularly those with higher medication burdens and mental health diagnoses. By identifying factors associated with potentially inappropriate use, healthcare providers can better tailor medication regimens to mitigate risks and optimize the well-being of older adults.
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Affiliation(s)
- Daniela A Rodrigues
- Biotechnology Research, Innovation and Design for Health Products (BRIDGES) - Research Laboratory on Epidemiology and Population Health, Polytechnic of Guarda (IPG), Guarda, Portugal
- Health Sciences Research Centre, University of Beira Interior (CICS-UBI), Covilhã, Portugal
- PhD Student, University of Salamanca, Salamanca, Spain
| | - Maria Teresa Herdeiro
- Department of Medical Sciences, Institute of Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - Ramona Mateos-Campos
- Area of Preventive Medicine and Public Health, Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Spain
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela/IDIS), A Coruña, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública/CIBERESP), Carlos III Institute of Health, Madrid, Spain
| | - Fátima Roque
- Biotechnology Research, Innovation and Design for Health Products (BRIDGES) - Research Laboratory on Epidemiology and Population Health, Polytechnic of Guarda (IPG), Guarda, Portugal
- Health Sciences Research Centre, University of Beira Interior (CICS-UBI), Covilhã, Portugal
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Kayahan Satış N, Naharcı Mİ. Investigating the association of anticholinergic burden with depression in older adults: a cross-sectional study. Psychogeriatrics 2024; 24:597-604. [PMID: 38484758 DOI: 10.1111/psyg.13102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 01/09/2024] [Accepted: 02/15/2024] [Indexed: 04/30/2024]
Abstract
BACKGROUND Although depression and anticholinergic drug use are common comorbidities that impair health status in later life, there are insufficient data on their relationship. This study aimed to investigate the relationship between depressive symptoms and anticholinergic use in older individuals. METHODS Community-dwelling older adults (≥65 years) admitted to the tertiary referral geriatric outpatient clinic were included. Participants were evaluated for depressive symptoms using the Geriatric Depression Scale (GDS) with a cut-off score of ≥6 for depression. Exposure to anticholinergic drugs was assessed using the anticholinergic cognitive burden (ACB) scale and three subgroups were created: ACB = 0, ACB = 1, and ACB ≥ 2. The relationship between these two parameters was assessed using multivariate logistic regression analysis considering other potential variables. RESULTS The study included 1232 participants (mean age 78.4 ± 7.2 years and 65.2% female) and the prevalence of depression was 24%. After adjusting for potential confounders, compared to ACB = 0, having ACB ≥ 2 was related to depression symptoms (odds ratio (OR): 1.56, 95% CI: 1.04-2.35, P = 0.034), whereas having ACB = 1 did not increase the risk (OR: 1.27, 95% CI: 0.88-1.83, P = 0.205). CONCLUSION Our findings indicate that special attention should be paid to drug therapy in preventing depression in older adults, as exposure to a high anticholinergic load is negatively associated with psychological status.
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Affiliation(s)
- Neslihan Kayahan Satış
- Gülhane Faculty of Medicine and Gülhane Training and Research Hospital, Division of Geriatrics, University of Health Sciences, Ankara, Turkey
| | - Mehmet İlkin Naharcı
- Gülhane Faculty of Medicine and Gülhane Training and Research Hospital, Division of Geriatrics, University of Health Sciences, Ankara, Turkey
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Özaydın FN. Frequency of Single or Combined Anticholinergic Medication Usage as Potentially Inappropriate Medications among the Oldest-Old Age Subgroup. PSYCHIAT CLIN PSYCH 2024; 34:43-49. [PMID: 38883881 PMCID: PMC11177634 DOI: 10.5152/pcp.2024.23664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 01/01/2024] [Indexed: 06/18/2024] Open
Abstract
Background The use of medications with anticholinergic effects can have negative effects on older patients, such as cognitive dysfunction and falls. The aim of this study was to determine the frequency of use of anticholinergic medication among the oldest-old age group and to analyze the factors associated with its use. Methods This is a descriptive study. The data were collected by visiting the oldest-olds at their homes, where the oldest-olds lived alone or with his or her family. The sample size was calculated as 354 using EpiInfo. The generic name of the medication used, the age, sex, and city of residence of the patient were recorded. The medications were analyzed using guidelines showing the anticholinergic effect, classified as 1 (low), 2 (moderate), and ≥3 (strong), and the frequency of usage by the oldest-olds was determined. Results A total of 549 oldest-olds participated in the research. Of the oldest-olds, 57.92% (n = 318) were using one or more anticholinergic medications. The median number of anticholinergic medications used by the oldest-olds was 1 (range: 0.00-6.00). Medications with strong anticholinergic effects (≥3) were used by 14.94% (n = 82) of the oldest-olds. The most commonly used were medications with low anticholinergic effects. However, the concomitant use of anticholinergic medications increased the total anticholinergic effect. Conclusion The oldest-old age group used medications with anticholinergic effects. A strong anticholinergic effect was obtained when medications with low or moderate anticholinergic effects were combined. Medications with anticholinergic effects should also be reviewed in the safety analysis of medications used by the oldest-old.
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Affiliation(s)
- Fuat Nihat Özaydın
- Department of Pharmacology, Istanbul Atlas University, School of Medicine, Istanbul, Turkey
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Temporal Trends Over Two Decades in the Use of Anticholinergic Drugs Among Older Community-Dwelling People in Helsinki, Finland. Drugs Aging 2022; 39:705-713. [PMID: 35913553 PMCID: PMC9463322 DOI: 10.1007/s40266-022-00968-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Knowledge of the adverse effects of drugs with anticholinergic properties (DAPs) has increased in recent decades. However, research on the temporal trends of the clinical use of DAPs is still sparse. OBJECTIVES The aim of this study was to investigate the temporal trends of DAP use over two decades in the older community-dwelling population and to explore the medication classes contributing to the use of DAPs. METHODS The study involved random samples of ≥ 75-year-old community-dwelling Helsinki citizens in 1999, 2009, and 2019 from the Helsinki Ageing Study. A postal questionnaire inquired about their health, functioning, and medications. The medications were categorized as DAPs according to Duran's list. In addition, we grouped DAPs into various medication groups. RESULTS The prevalence and burden of DAPs on Duran's list showed a decreasing trend over the years. In 1999 the prevalence was 20% and the burden 0.35, in 2009 they were 22% and 0.35, respectively, and in 2019 they were 16% and 0.23, respectively. There were no differences in how the 75- and 80-year-olds used DAPs compared with those aged 85 years and older. The proportion of typical antipsychotics, benzodiazepines, hypnotics, urinary antispasmodics, and asthma/chronic obstructive pulmonary disease medications decreased, whereas the proportion of atypical antipsychotics, antidepressants, strong opioids, and antihistamines increased. In particular the use of mirtazapine increased-to 3.9% in 2019. In 2019 the three most prevalent groups of DAPs were antidepressants (7.4%), opioids (2.7%), and antihistamines (2.4%). CONCLUSIONS The decrease in the use of DAPs on Duran's list is a welcome change. Although the use of old, strong DAPs has decreased, new DAPs have simultaneously emerged. Physicians need continuous education in prescribing DAPs and more recent information on the use and effects of DAPs is needed in order to decrease their exposure among the rapidly growing older population.
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Pinto ECP, Silva AMR, Cabrera MAS, Baldoni ADO, Alfieri DF, Andrade GFD, Girotto E. [The use of anticholinergic drugs and associated factors in middle-aged adults and the elderly]. CIENCIA & SAUDE COLETIVA 2022; 27:2279-2290. [PMID: 35649016 DOI: 10.1590/1413-81232022276.12452021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/16/2021] [Indexed: 11/22/2022] Open
Abstract
The objective of this article was to describe the use of anticholinergic drugs and possible factors associated with their use, in middle-aged adults and in the elderly. This is a cross-sectional study, based on data from a population-based study called VIGICARDIO. All respondents aged 44 or older interviewed in 2015 were included. Anticholinergic Drug Scale (ADS) was used to determine anticholinergic burden (ACB), categorized as significant (≥3) and non-significant (< 3). Poisson regression was conducted with crude and adjusted analysis to investigate the factors associated with ACB. There was a prevalence of 20.7% of significant ACB among respondents, higher among middle-aged adults (24.1%). After adjusted analysis, significant ACB (≥ 3) remained in the non-elderly age group with polypharmacy and sporadic use of two or more drugs. In the elderly, sporadic use of two or more medications and hospitalization in the last year continued to be associated with significant ACB. The results indicate a higher prevalence of ACB among middle-aged adults, polymedicated and in sporadic use of medications, which suggests that the investigation of the use of anticholinergicsin this age group requires greater attention.
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Affiliation(s)
- Eliz Cassieli Pereira Pinto
- Programa de Pós-Graduação em Saúde Coletiva, Centro de Ciências da Saúde, Universidade Estadual de Londrina. Avenida Robert Koch 60, Vila Operária. 86.038-440 Londrina PR Brasil.
| | - Ana Maria Rigo Silva
- Programa de Pós-Graduação em Saúde Coletiva, Centro de Ciências da Saúde, Universidade Estadual de Londrina. Avenida Robert Koch 60, Vila Operária. 86.038-440 Londrina PR Brasil.
| | - Marcos Aparecido Sarria Cabrera
- Programa de Pós-Graduação em Saúde Coletiva, Centro de Ciências da Saúde, Universidade Estadual de Londrina. Avenida Robert Koch 60, Vila Operária. 86.038-440 Londrina PR Brasil.
| | - André de Oliveira Baldoni
- Programa de Pós-Graduação em Ciências da Saúde, Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade Federal de São João del-Rei. Divinópolis MG Brasil
| | - Daniela Frizon Alfieri
- Departamento de Ciências Farmacêuticas, Universidade Estadual de Londrina. Londrina PR Brasil
| | - Giovana Frazon de Andrade
- Programa de Pós-Graduação em Saúde Coletiva, Centro de Ciências da Saúde, Universidade Estadual de Londrina. Avenida Robert Koch 60, Vila Operária. 86.038-440 Londrina PR Brasil.
| | - Edmarlon Girotto
- Programa de Pós-Graduação em Saúde Coletiva, Centro de Ciências da Saúde, Universidade Estadual de Londrina. Avenida Robert Koch 60, Vila Operária. 86.038-440 Londrina PR Brasil.
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Tristancho-Pérez Á, Villalba-Moreno Á, Santos-Rubio MD, Belda-Rustarazo S, Santos-Ramos B, Sánchez-Fidalgo S. Concordance Among 10 Different Anticholinergic Burden Scales in At-Risk Older Populations. J Patient Saf 2022; 18:e816-e821. [PMID: 34693926 PMCID: PMC9162063 DOI: 10.1097/pts.0000000000000929] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the concordance among 10 anticholinergic scales for the measurement of anticholinergic drug exposure in at-risk elderly complex chronic patients in primary care. METHODS An 8-month cross-sectional, multicenter study was carried out in a cohort of complex chronic patients older than 65 years in treatment with at least 1 drug with anticholinergic activity. Demographic, pharmacological, and clinical data were collected. Anticholinergic burden and risk were detected using the 10 scales included on the anticholinergic burden calculator (http://www.anticholinergicscales.es/). We used κ statistics to evaluated the concordance 2 to 2 (according to risk: high, medium, low or without risk) among the included scales. RESULTS Four hundred seventy-three patients were recruited (60.3% female, median age of 84 years [interquartile range = 10]). Eighty was the total number of anticholinergic drugs with any scale (1197 prescriptions), with a median of 2 drugs with anticholinergic activity per patient (interquartile range = 2). The κ statistics comparing all the 10 scales ranged from -0.175 (Drug Burden Index versus Chew Scale) to 0.708 (Anticholinergic Activity Scale [AAS] versus Chew Scale). The best concordance was obtained between AAS and Chew Scale (κ = 0.708), followed by Clinician-Rated Anticholinergic Scale and Duran Scale (κ = 0.632) and AAS and Anticholinergic Cognitive Burden Scale (κ = 0.618), being considered substantial strengths of concordance. CONCLUSIONS The agreement among the 10 scales in elderly patients with complex chronic conditions was highly variable. Great care should be taken when assessing anticholinergic drug exposure using existing scales because of the wide variability among them. The only scales that showed agreement were the AAS-Chew, Clinician-Rated Anticholinergic Scale-Duran, and AAS-Anticholinergic Cognitive Burden Scale pairs. In the rest of the cases, the scales are not interchangeable.
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Affiliation(s)
| | | | | | | | | | - Susana Sánchez-Fidalgo
- Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
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Nawaz H, Sargent L, Quilon H, Cloud LJ, Testa CM, Snider JD, Lageman SK, Baron MS, Berman BD, Zimmerman K, Price ET, Mukhopadhyay ND, Barrett MJ. Anticholinergic Medication Burden in Parkinson's Disease Outpatients. JOURNAL OF PARKINSON'S DISEASE 2022; 12:599-606. [PMID: 34806617 DOI: 10.3233/jpd-212769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Individuals with Parkinson's disease (PD) may be especially vulnerable to future cognitive decline from anticholinergic medications. OBJECTIVE To characterize anticholinergic medication burden, determine the co-occurrence of anticholinergic and cholinesterase inhibitors, and to assess the correlations among anticholinergic burden scales in PD outpatients. METHODS We studied 670 PD outpatients enrolled in a clinic registry between 2012 and 2020. Anticholinergic burden was measured with the Anticholinergic Cognitive Burden Scale (ACB), Anticholinergic Drug Scale (ADS), Anticholinergic Risk Scale (ARS), and Drug Burden Index-Anticholinergic component (DBI-Ach). Correlations between scales were assessed with weighted kappa coefficients. RESULTS Between 31.5 to 46.3% of PD patients were taking medications with anticholinergic properties. Among the scales applied, the ACB produced the highest prevalence of medications with anticholinergic properties (46.3%). Considering only medications with definite anticholinergic activity (scores of 2 or 3 on ACB, ADS, or ARS), the most common anticholinergic drug classes were antiparkinsonian (8.2%), antipsychotic (6.4%), and urological (3.3%) medications. Cholinesterase inhibitors and medications with anticholinergic properties were co-prescribed to 5.4% of the total cohort. The most highly correlated scales were ACB and ADS (κ= 0.71), ACB and ARS (κ= 0.67), and ADS and ARS (κ= 0.55). CONCLUSION A high proportion of PD patients (20%) were either taking antiparkinsonian, urological, or antipsychotic anticholinergic medications or were co-prescribed anticholinergic medications and cholinesterase inhibitors. By virtue of its detection of a high prevalence of anticholinergic medication usage and its high correlation with other scales, our data support use of the ACB scale to assess anticholinergic burden in PD patients.
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Affiliation(s)
- Huma Nawaz
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Lana Sargent
- School of Nursing, Virginia Commonwealth University, Richmond, VA, USA.,Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA.,Geriatric Pharmacotherapy Program, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA.,Institute for Inclusion, Inquiry & Innovation (iCubed): Health & Wellness in Aging Populations Core, Richmond, VA, USA
| | | | - Leslie J Cloud
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Claudia M Testa
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Jon D Snider
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Sarah K Lageman
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA.,Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
| | - Mark S Baron
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA.,Southeast Veterans Affairs Parkinson's Disease Research, Education and Clinical Center (PADRECC), Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Brian D Berman
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Kristin Zimmerman
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA
| | - Elvin T Price
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA.,Geriatric Pharmacotherapy Program, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA.,Institute for Inclusion, Inquiry & Innovation (iCubed): Health & Wellness in Aging Populations Core, Richmond, VA, USA
| | - Nitai D Mukhopadhyay
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Matthew J Barrett
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
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Sumbul-Sekerci B, Bilgic B, Pasin O, Emre M, Hanagasi HA. Anticholinergic Burden, Polypharmacy, and Cognition in Parkinson's Disease Patients with Mild Cognitive Impairment: A Cross-Sectional Observational Study. Dement Geriatr Cogn Disord 2022; 51:386-395. [PMID: 36273437 PMCID: PMC9909708 DOI: 10.1159/000526863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/30/2022] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Anticholinergic burden may be an important risk factor for the cognitive impairment. Especially in polypharmacy, even drugs with low anticholinergic effects may contribute to a significant anticholinergic burden. The drugs with anticholinergic effects are used in treatment of motor and nonmotor symptoms of Parkinson's disease (PD). Therefore, it is important to screen for polypharmacy and anticholinergic burden in PD patients with mild cognitive impairment (MCI). METHODS This cross-sectional study was conducted with 58 patients with PD. PD-MCI was diagnosed according to MDS Level 2 Comprehensive Assessment. Cognitive performance (attention - working memory, executive functions, language, memory, and visuospatial functions) of patients was evaluated. The anticholinergic burden was scored by Anticholinergic Cognitive Burden (ACB) Scale, Anticholinergic Risk Scale (ARS), and Anticholinergic Drug Scale (ADS). RESULTS There was no significant difference in anticholinergic burden between PD-MCI and PD-normal cognition. A significant concordance was observed between ACB, ARS, and ADS scores (p < 0.001; Kendall's W = 0.653). While the variable predicting anticholinergic burden was the total number of drugs for ACB and ADS scales, it was the number of antiparkinson drugs for ARS scale. CONCLUSION Patients with PD are at high risk for polypharmacy and anticholinergic burden. Anticholinergic burden should be considered in the selection of drugs, especially for comorbidities in patients with PD. No significant correlation was found between the cognition and anticholinergic burden in patients with PD-MCI. Although the risk scores of antiparkinson and other drugs were different among the 3 scales, significant concordance was observed between scales.
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Affiliation(s)
- Betul Sumbul-Sekerci
- Department of Clinical Pharmacy, Faculty of Pharmacy, Bezmialem Vakıf University, Istanbul, Turkey
- Department of Neuroscience, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
- *Betul Sumbul-Sekerci,
| | - Basar Bilgic
- Behavioral Neurology and Movement Disorders Unit, Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ozge Pasin
- Department of Biostatistics, Faculty of Medicine, Bezmialem Vakıf University, Istanbul, Turkey
| | - Murat Emre
- Behavioral Neurology and Movement Disorders Unit, Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Hasmet A. Hanagasi
- Behavioral Neurology and Movement Disorders Unit, Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Bag Soytas R, Arman P, Suzan V, Emiroglu Gedik T, Unal D, Suna Erdincler D, Doventas A, Yavuzer H. Association between anticholinergic drug burden with sarcopenia, anthropometric measurements, and comprehensive geriatric assessment parameters in older adults. Arch Gerontol Geriatr 2021; 99:104618. [PMID: 34990930 DOI: 10.1016/j.archger.2021.104618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/27/2021] [Accepted: 12/27/2021] [Indexed: 11/02/2022]
Abstract
BACKGROUND Older patients use multiple drugs due to their comorbidities and most of these drugs have anticholinergic drug burden (ADB). We aimed to investigate the association between ADB and sarcopenia, anthropometric measurements, and comprehensive geriatric assessment (CGA) parameters in older adults. METHODS Patients ≥65 years who applied to geriatrics outpatient clinic between January 2019-March 2020 were included. Patients with cognitive dysfunction were excluded. CGA tests were conducted on patients. Handgrip strength (HGS), bioelectrical impedance analysis (BIA), and a 6-meter walking test were used for sarcopenia definition. The Anticholinergic Cognitive Burden (ACB) scale was used to calculate the ADB. RESULTS Totally 256 patients (women/men:180/76) were included. The mean age was 82±6.8. Two groups were created as without ADB (n=116) and with ADB (n=140). Sarcopenia was higher in the ADB group (p=0.04). In women and men as ADB increased HGS decreased (respectively; p=0.023 r=-0.170, p=0.031 r=-0.248) and Basic Activities of Daily Living (BADL) test score increased (respectively; p= <0.001 r= 0.292, p=0.04 r= 0.244). In the linear regression (LR) analysis age and BADL test score had significant association with ADB in women (respectively; p=0.001, p=0.023). CONCLUSION The finding that sarcopenia is higher in the patients with ADB and HGS decreases as ADB increases, suggesting that ADB may be a risk factor for sarcopenia by decreasing HGS. Also, it has been determined that, especially in older women, as ADB increases, the dependence on basic daily living activities increases.
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Affiliation(s)
- Rabia Bag Soytas
- Department of Geriatrics, Başakşehir Çam ve Sakura City Hospital, Istanbul, Turkey.
| | - Pinar Arman
- Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Department of Internal Medicine, Division of Geriatrics, Istanbul, Turkey
| | - Veysel Suzan
- Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Department of Internal Medicine, Division of Geriatrics, Istanbul, Turkey
| | - Tugce Emiroglu Gedik
- Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Department of Internal Medicine, Division of Geriatrics, Istanbul, Turkey
| | - Damla Unal
- Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Department of Internal Medicine, Division of Geriatrics, Istanbul, Turkey
| | - Deniz Suna Erdincler
- Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Department of Internal Medicine, Division of Geriatrics, Istanbul, Turkey
| | - Alper Doventas
- Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Department of Internal Medicine, Division of Geriatrics, Istanbul, Turkey
| | - Hakan Yavuzer
- Istanbul University-Cerrahpasa, Cerrahpasa Faculty of Medicine, Department of Internal Medicine, Division of Geriatrics, Istanbul, Turkey
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A meta-analysis of observational studies on anticholinergic burden and fracture risk: evaluation of conventional burden scales. J Pharm Health Care Sci 2021; 7:30. [PMID: 34465380 PMCID: PMC8408921 DOI: 10.1186/s40780-021-00213-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/10/2021] [Indexed: 11/29/2022] Open
Abstract
Background Anticholinergic burden potentially increases the risk of fracture. Although there are various anticholinergic burden scales, little is known about the inter-scale compatibility regarding the relationship of anticholinergic burden with fracture risk. We performed meta-analysis to examine the association of fracture risk with anticholinergic burden measured using various scales. Methods Primary literature was retrieved from PubMed (1966 to March, 2021), the Cochrane Library (1974 to March, 2021), Scopus (1970 to March, 2021), and Ichushi-web (1983 to March, 2021). Cohort and case-control studies that evaluated the association between any fracture and anticholinergic drugs were included. Additionally, we included studies in which patients were administered anticholinergic drugs included on the anticholinergic risk scale (ARS), anticholinergic cognitive burden (ACB), anticholinergic drug scale, or drug burden index-anticholinergic component. Random effects models were used to calculate pooled relative risk (RR) and 95% confidence interval (CI) due to heterogeneity among the studies. Publication bias was examined by funnel plots and the Begg’s test. Results A total of 49 datasets from 10 studies were included in the meta-analysis. Six of the 10 studies included only patients aged over 65 years, who accounted for 93% of the total study population (453,186/487,247). Meta-analysis indicated a positive relationship between use of anticholinergic drugs and fracture risk, regardless of the anticholinergic burden scale used. However, the relationship between anticholinergic burden and fracture risk varied depending on the scale used. Fracture risk increased linearly with increasing anticholinergic burden measured using ARS. ARS 1 point was associated with 28% increase in fracture risk, ARS 1–2 point(s) with 39%, ARS 2 points with 54%, ARS 3 points with 66%, and ARS ≥ 4 points with 77%. On the other hand, ACB 1 point and ACB 2 points were associated with similar fracture risk (pooled RR [95% CI]: overall; 1.28 [1.18–1.39], 1 point; 1.12 [1.06–1.18], 2 points; 1.15 [1.08–1.23]). Conclusions This result suggests that the relationship between anticholinergic drug burden and fracture risk may differ depending on the anticholinergic burden scale used. Supplementary Information The online version contains supplementary material available at 10.1186/s40780-021-00213-y.
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12
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The evaluation of relationship between polypharmacy and anticholinergic burden scales. North Clin Istanb 2021; 8:139-144. [PMID: 33851077 PMCID: PMC8039107 DOI: 10.14744/nci.2020.17136] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE: Polypharmacy and anticholinergic burden are the indicators for the evaluation of the quality of pharmacotherapy in older adults. The aim of this study was to consider which anticholinergic burden scales are more related with polypharmacy among older patients. METHODS: Four hundred and twenty older adults were evaluated retrospectively in this cross-sectional study. The patient’s demographic data, comorbidities, the drugs, and number of drugs were recorded. Anticholinergic burden scales were calculated by a tool named anticholinergic burden calculator. RESULTS: The participants’ mean age was 73.08±8.71. The prevalence of polypharmacy was 32.14%. The highest relationship with polypharmacy was observed for drug burden index (DBI) (odds ratio 10.87, p<0.001). CONCLUSION: Our study demonstrated that polypharmacy and DBI scores were more related than other anticholinergic burden scales in older adults.
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13
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Hwang S, Chung JE, Jun K, Ah YM, Kim KI, Lee JY. Comparative associations between anticholinergic burden and emergency department visits for anticholinergic adverse events in older Korean adults: a nested case-control study using national claims data for validation of a novel country-specific scale. BMC Pharmacol Toxicol 2021; 22:2. [PMID: 33413627 PMCID: PMC7792041 DOI: 10.1186/s40360-020-00467-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Considering the limited generalizability of previous anticholinergic burden scales, the Korean Anticholinergic Burden Scale (KABS) as a scale specific to the Korean population was developed. We aimed to validate the KABS by detecting the associations between high anticholinergic burden, measured with the KABS, and emergency department (ED) visits compared to the pre-existing validated scales in older Korean adults. METHODS A nested case-control study was conducted using national claims data. The cases included the first anticholinergic ED visits between July 1 and December 31, 2016. Anticholinergic ED visits were defined as ED visits with a primary diagnosis of constipation, delirium, dizziness, fall, fracture, or urinary retention. Propensity score-matched controls were identified. Average daily AB scores during 30 days before the index date were measured. Multivariate logistic regression analyses were performed. RESULTS In total, 461,034 were included. The highest proportion of those with high AB was identified with KABS (5.0%). Compared with those who had a KABS score of 0, older adults with a score ≥ 3 were at higher risk for overall anticholinergic ED visits (aOR, 1.62, 95% CI, 1.53-1.72), as well as visits for falls/fractures (aOR: 1.54, 95% CI: 1.40-1.69), dizziness (aOR: 1.44, 95% CI: 1.30-1.59), delirium (aOR: 2.96, 95% CI: 2.28-3.83), constipation (aOR: 1.84, 95% CI: 1.68-2.02), and urinary retention (aOR: 2.13, 95% CI: 1.79-2.55). High AB by KABS showed a stronger association with overall anticholinergic ED visits and visits due to delirium and urinary retention than those by other scales. CONCLUSIONS In conclusion, KABS is superior to pre-existing scales in identifying patients with high AB and predicting high AB-related ED visits in older Korean adults.
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Affiliation(s)
- Sunghee Hwang
- College of Pharmacy and Institute of Pharmaceutical Science and Technology, Hanyang University, Ansan, Gyeonggi-do, Republic of Korea
| | - Jee Eun Chung
- College of Pharmacy and Institute of Pharmaceutical Science and Technology, Hanyang University, Ansan, Gyeonggi-do, Republic of Korea
| | - Kwanghee Jun
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea
| | - Young-Mi Ah
- College of Pharmacy, Yeungnam University, Gyeongsan-si, Gyeongsangbuk-do, Republic of Korea
| | - Kwang-Il Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seognam-si, Gyeonggi-do, Republic of Korea
| | - Ju-Yeun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Republic of Korea.
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14
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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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15
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Reinold J, Schäfer W, Christianson L, Barone-Adesi F, Riedel O, Pisa FE. Anticholinergic Burden and Fractures: A Systematic Review with Methodological Appraisal. Drugs Aging 2020; 37:885-897. [PMID: 33094444 PMCID: PMC7704512 DOI: 10.1007/s40266-020-00806-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2020] [Indexed: 11/28/2022]
Abstract
Introduction Medications with anticholinergic activity (MACs) are used to treat diseases common in older adults. Evidence on the association between anticholinergic burden (AB) and increased risk of fractures and osteoporosis or reduced bone mineral density (BMD) is inconsistent. Our aim was to conduct a systematic review of observational studies on AB with fractures and osteoporosis or reduced BMD and provide methodological appraisal of included studies. Methods We searched MEDLINE, EMBASE, Science Citation Index and CENTRAL as well as grey literature from database inception up to August 2020. Eligibility criteria were: observational design, AB-exposure measured through a scale, fracture of any type or osteoporosis or reduced BMD as outcome, and reported measure of association between exposure and outcome. No restrictions related to time, language or type of data were applied. Eligibility and risk of bias assessment as well as data extraction were performed independently by two reviewers. Risk of bias of the included studies was assessed using the Newcastle–Ottawa Scale and the RTI Item Bank. Results The majority of the nine included studies had low risk of bias but heterogeneous methodology. No study used a new user design. Seven studies reported an increased risk of fractures associated with AB. In four studies using the Anticholinergic Risk Scale (ARS), adjusted risk of fractures was increased by 2–61% for ARS = 1, by 0–97% for ARS = 2, by 19–84% for ARS = 3, and by 56–96% for ARS ≥ 4; in three studies the ARS was aggregated, risk increased by 39% for ARS = 1–2 and 17% for ARS = 2–3. Two studies reported increased risk of fractures of 14 and 52% in the highest AB-category and one study reported that change in ARS of ≥ 3 during hospitalization was associated with a 321% increased risk in fractures. Two studies did not find an association between AB and fractures. The association between AB and osteoporosis or reduced BMD could only be assessed in two studies, one reporting increased risk of lower BMD at Ward’s triangle, the other reporting no association between AB and BMD T-score change at the femoral neck. Discussion Our study suggests an association between AB and increased risk of fractures with possible dose-exposure gradient in studies using the ARS. The low number of studies and heterogeneity of methods calls for the conduct of more studies. Plain language summary We conducted a study investigating the risk of fractures associated with anticholinergic burden, which is the result of taking one or more medication with anticholinergic activity. The results of our study suggest that persons who experience anticholinergic burden might have a higher risk of fractures. However, since we were only able to include nine studies, more studies conducted in a similar way are needed. Electronic supplementary material The online version of this article (10.1007/s40266-020-00806-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jonas Reinold
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany.
| | - Wiebke Schäfer
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
| | - Lara Christianson
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
| | - Francesco Barone-Adesi
- Department of Translational Medicine, University of Eastern Piedmont, Via Solaroli 17, 28100, Novara, Italy
| | - Oliver Riedel
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
| | - Federica Edith Pisa
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
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16
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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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17
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Wouters H, Hilmer SN, Twisk J, Teichert M, Van Der Meer HG, Van Hout HPJ, Taxis K. Drug Burden Index and Cognitive and Physical Function in Aged Care Residents: A Longitudinal Study. J Am Med Dir Assoc 2020; 21:1086-1092.e1. [PMID: 32736845 DOI: 10.1016/j.jamda.2020.05.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 05/12/2020] [Accepted: 05/17/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Anticholinergic/antimuscarinic and sedative medications (eg, benzodiazepines) have been found to be associated with poorer cognitive and physical function and mobility impairment in older age. However, previous studies were mostly conducted among community-dwelling older individuals and had often a cross-sectional design. Accordingly, our aim was to examine longitudinal associations between cumulative exposure to anticholinergic and sedative medications and cognitive and physical function among residents from aged care homes. DESIGN Longitudinal study. SETTING AND PARTICIPANTS A total of 4624 residents of Dutch aged care homes of whom data were collected between June 2005 and April 2014. METHODS Outcome measures were collected with the Long-Term Care Facilities assessment from the international Residential Assessment Instrument (interRAI-LTCF) and included the Cognitive Performance Scale, the Activities of Daily Living (ADL) Hierarchy scale, a timed 4-meter walk test, distance walked, hours of physical activity, and days being outside. Cumulative exposure to anticholinergic and sedative medications was calculated with the Drug Burden Index (DBI), a linear additive pharmacological dose-response model. Associations were examined with linear mixed models to take the potential dependence of observations into account (ie, data were collected at repeated assessment occasions of residents who were clustered in aged care homes). Analyses were adjusted for sex, age, dementia, comorbidity (neurological, psychiatric, cardiovascular, oncological, and pulmonary), fractures, depressive symptoms, and medications excluded from the DBI. RESULTS We observed significant longitudinal associations between a higher DBI and poorer ADLs, fewer hours of physical activity, and fewer days being outside. We found no significant longitudinal association between a higher DBI and poorer cognitive function. CONCLUSIONS AND IMPLICATIONS Over time, cumulative exposure to anticholinergic and sedative medications is associated with poorer physical but not cognitive function in aged care residents. Careful monitoring of aged care residents with high cumulative anticholinergic and sedative medication exposure is needed.
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Affiliation(s)
- Hans Wouters
- Department of PharmacoTherapy, PharmacoEpidemiology & PharmacoEconomics, University of Groningen, Groningen Research Institute of Pharmacy, Groningen, the Netherlands; General Practitioners Research Institute, Groningen, the Netherlands.
| | - Sarah N Hilmer
- Department of Clinical Pharmacology and Aged Care, Kolling Institute, Royal North Shore Hospital, University of Sydney, Sydney, Australia
| | - Jos Twisk
- Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health, the Netherlands
| | - Martina Teichert
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, the Netherlands
| | - Helene G Van Der Meer
- Department of PharmacoTherapy, PharmacoEpidemiology & PharmacoEconomics, University of Groningen, Groningen Research Institute of Pharmacy, Groningen, the Netherlands
| | - Hein P J Van Hout
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Public Health, the Netherlands
| | - Katja Taxis
- Department of PharmacoTherapy, PharmacoEpidemiology & PharmacoEconomics, University of Groningen, Groningen Research Institute of Pharmacy, Groningen, the Netherlands
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18
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Egberts A, Moreno-Gonzalez R, Alan H, Ziere G, Mattace-Raso FUS. Anticholinergic Drug Burden and Delirium: A Systematic Review. J Am Med Dir Assoc 2020; 22:65-73.e4. [PMID: 32703688 DOI: 10.1016/j.jamda.2020.04.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To investigate the association between anticholinergic drug burden (ADB), measured with anticholinergic drug scales, and delirium and delirium severity. DESIGN Systematic review. SETTING AND PARTICIPANTS All available studies. METHODS A systematic literature search was performed in Medline, Embase, PsycINFO, Web of Science, CINAHL, Cochrane library, and Google Scholar. Studies evaluating the association between ADB (measured as a total score) and delirium or delirium severity, published in English, were eligible for inclusion. RESULTS Sixteen studies, including 148,756 persons, were included. Fifteen studies investigated delirium. ADB was measured with the Anticholinergic Risk Scale (ARS, n = 5), the Anticholinergic Cognitive Burden Scale (ACB, n = 6), the list of Chew (n = 1), the Anticholinergic Drug Scale (ADS, n = 5), a modified version of the ARS (n = 1), and a modified version of the ACB (n = 1). A high ADB, measured with the ARS, was associated with delirium (5/5). Also with the modified version of the ARS and ACB, an association was found between a high ADB and delirium during 3-month (1/1) and 1-year follow-up (1/1), respectively. When ADB was assessed with other scales, the results were inconclusive, with only 1 positive association for the ACB (1/6) and ADS (1/5) each. The possible association between ADB and delirium severity has also been investigated (ADS n = 2, Summers Drug Risk Number n = 1). One study found an association between a high ADB, measured with the ADS, and an increase in severity of delirium. CONCLUSIONS AND IMPLICATIONS ADB assessed with the ARS is consistently associated with delirium. The association found between the modified versions of the ARS and ACB and delirium needs confirmation. When ADB was assessed with other scales, the findings were inconclusive. The current findings suggest that the ARS might be a useful tool to identify patients at increased risk for delirium.
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Affiliation(s)
- Angelique Egberts
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands; Department of Hospital Pharmacy, Franciscus Gasthuis and Vlietland, Rotterdam and Schiedam, the Netherlands.
| | - Rafael Moreno-Gonzalez
- Section of Geriatric Medicine, Department of Internal Medicine, Bellvitge University Hospital, Barcelona, Spain
| | - Hava Alan
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Gijsbertus Ziere
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Francesco U S Mattace-Raso
- Section of Geriatric Medicine, Department of Internal Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Jun K, Ah YM, Hwang S, Chung JE, Lee JY. Prevalence of anticholinergic burden and risk factors amongst the older population: analysis of insurance claims data of Korean patients. Int J Clin Pharm 2020; 42:453-461. [PMID: 32281075 DOI: 10.1007/s11096-020-01010-7] [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: 08/22/2019] [Accepted: 03/07/2020] [Indexed: 02/08/2023]
Abstract
Background Despite growing interest in the negative clinical outcomes of multiple anticholinergic use, limited studies have evaluated anticholinergic burden in the geriatric population nationally. Objective To evaluate the prevalence of high anticholinergic burden using the newly developed Korean Anticholinergic Burden Scale in comparison with previous tools and to identify associated factors. Setting National insurance data from a cross section (20%) of older Koreans (2016). Methods Anticholinergic burden was measured using the Korean scale in comparison to the Anticholinergic Drug Scale, Anticholinergic Cognitive Burden, and Anticholinergic Risk Scale. High anticholinergic burden was defined as a summed score of ≥ 3 for concurrent medications or a dose-standardized average daily score of ≥ 3, using each anticholinergic scale. Main outcomes measured Prevalence and predictors of high anticholinergic burden. Results Data of 1,292,323 patients were analyzed. According to the Korean scale, the prevalence of high anticholinergic burden was 25.5%. This result was similar to that from the Anticholinergic Drug Scale (24.9%) and Anticholinergic Cognitive Burden (22.2%). Factors associated with an increased likelihood of anticholinergic burden include: age, gender (female), high Charlson comorbidity index score, polypharmacy, medical aid beneficiary, co-morbidities (such as schizophrenia, depression, urinary incontinence, and Parkinson's disease), frequent healthcare visits, various healthcare facilities utilized, and predominantly visiting hospital-level facilities. According to the Korean Anticholinergic Burden Scale, the major drugs contributing to the anticholinergic burden were ranitidine, chlorpheniramine, tramadol, and dimenhydrinate. Conclusion This study showed that 1 in 4 older Koreans are exposed to high anticholinergic burden. The predictors identified in this research might assist pharmacists in early interventions for their patients.
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Affiliation(s)
- Kwanghee Jun
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 1, Gwanak-ro, Gwanak-gu, Seoul, 08826, Republic of Korea
| | - Young-Mi Ah
- College of Pharmacy, Yeungnam University, Gyeongsan, Gyeongsangbuk-do, 38541, Republic of Korea
| | - Sunghee Hwang
- College of Pharmacy and Institute of Pharmaceutical Science and Technology, Hanyang University, Ansan, Gyeonggi-do, 15588, Republic of Korea
| | - Jee Eun Chung
- College of Pharmacy and Institute of Pharmaceutical Science and Technology, Hanyang University, Ansan, Gyeonggi-do, 15588, Republic of Korea
| | - Ju-Yeun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, 1, Gwanak-ro, Gwanak-gu, Seoul, 08826, Republic of Korea.
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20
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Tanaka A, Arai Y, Hirata T, Abe Y, Oguma Y, Urushihara H. [Effects of polypharmacy and anticholinergic/sedative drugs on the physical/cognitive/mental related outcomes of community-dwelling elderly people: The Kawasaki Wellbeing Project]. Nihon Ronen Igakkai Zasshi 2020; 56:504-515. [PMID: 31761857 DOI: 10.3143/geriatrics.56.504] [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] [Indexed: 11/11/2022]
Abstract
AIM To assess the burdens of polypharmacy and the drug burden index in community-dwelling elder people. METHODS The survey was conducted on 396 participants who participated in The Kawasaki Wellbeing Project from March to December 2017. We investigated the associations between the drug burden and the physical/cognitive/mental outcomes. The drug burden was determined by calculating the number of medications and the drug burden index (DBI) based on the use of anticholinergic and sedative drugs. A multivariate regression analysis was conducted for the outcome measures ADL, IADL, MMSE, J-CHS, and EQ5D5L after adjusting for the sex, age, number of diseases, education level, smoking history, and alcohol history. RESULTS A total of 389 subjects were analyzed, the mean age of the population was 86 years old, and 187 people (48%) were male. Polypharmacy was reported in 243 people (62%), and DBI exposure was reported for 142 people (36.5%). We found that this population was physically healthy, with a median ADL of 100, and had high quality of life, with a median EQ5D5L of 0.895. Polypharmacy was found to be related to the J-CHS (β: 0.04) and EQ5D5L (-0.01). The DBI was also related to the EQ5D5L (-0.04). CONCLUSION These results showed that even though this population was healthier than the general Japanese elderly population, the drug burden of polypharmacy and high dosages of anticholinergic/sedative drugs exerted significant negative effects on frailty and the quality of life. Additional research should be conducted to investigate the long-term effects of polypharmacy and anticholinergic/sedative drugs on elderly people.
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Affiliation(s)
- Asahi Tanaka
- Division of Drug Development and Regulatory Science, Faculty of Pharmacy, Keio University
| | - Yasumichi Arai
- Center for Supercentenarian Medical Research, Keio University School of Medicine
| | - Takumi Hirata
- Center for Supercentenarian Medical Research, Keio University School of Medicine.,Department of Preventive Medicine and Epidemiology, Tohoku Medical Megabank Organization, Tohoku University
| | - Yukiko Abe
- Center for Supercentenarian Medical Research, Keio University School of Medicine
| | - Yuko Oguma
- Sports Medicine Research Center, Graduate School of Health Management, Keio University
| | - Hisashi Urushihara
- Division of Drug Development and Regulatory Science, Faculty of Pharmacy, Keio University
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21
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Hanlon P, Quinn TJ, Gallacher KI, Myint PK, Jani BD, Nicholl BI, Lowrie R, Soiza RL, Neal SR, Lee D, Mair FS. Assessing Risks of Polypharmacy Involving Medications With Anticholinergic Properties. Ann Fam Med 2020; 18:148-155. [PMID: 32152019 PMCID: PMC7062487 DOI: 10.1370/afm.2501] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/24/2019] [Accepted: 08/16/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Anticholinergic burden (ACB), the cumulative effect of anticholinergic medications, is associated with adverse outcomes in older people but is less studied in middle-aged populations. Numerous scales exist to quantify ACB. The aims of this study were to quantify ACB in a large cohort using the 10 most common anticholinergic scales, to assess the association of each scale with adverse outcomes, and to assess overlap in populations identified by each scale. METHODS We performed a longitudinal analysis of the UK Biobank community cohort (502,538 participants, baseline age: 37-73 years, median years of follow-up: 6.2). The ACB was calculated at baseline using 10 scales. Baseline data were linked to national mortality register records and hospital episode statistics. The primary outcome was a composite of all-cause mortality and major adverse cardiovascular event (MACE). Secondary outcomes were all-cause mortality, MACE, hospital admission for fall/fracture, and hospital admission with dementia/delirium. Cox proportional hazards models (hazard ratio [HR], 95% CI) quantified associations between ACB scales and outcomes adjusted for age, sex, socioeconomic status, body mass index, smoking status, alcohol use, physical activity, and morbidity count. RESULTS Anticholinergic medication use varied from 8% to 17.6% depending on the scale used. For the primary outcome, ACB was significantly associated with all-cause mortality/MACE for each scale. The Anticholinergic Drug Scale was most strongly associated with mortality/MACE (HR = 1.12; 95% CI, 1.11-1.14 per 1-point increase in score). The ACB was significantly associated with all secondary outcomes. The Anticholinergic Effect on Cognition scale was most strongly associated with dementia/delirium (HR = 1.45; 95% CI, 1.3-1.61 per 1-point increase). CONCLUSIONS The ACB was associated with adverse outcomes in a middle- to older-aged population. Populations identified and effect size differed between scales. Scale choice influenced the population identified as potentially requiring reduction in ACB in clinical practice or intervention trials.
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Affiliation(s)
- Peter Hanlon
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Katie I Gallacher
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Phyo K Myint
- Institute of Applied Health Sciences, University of Aberdeen, Foresterhill, Aberdeen, Scotland, United Kingdom.,Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, Scotland, United Kingdom
| | - Bhautesh Dinesh Jani
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Barbara I Nicholl
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Richard Lowrie
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, West Glasgow Ambulatory Care Unit, Glasgow, Scotland, United Kingdom
| | - Roy L Soiza
- Institute of Applied Health Sciences, University of Aberdeen, Foresterhill, Aberdeen, Scotland, United Kingdom.,Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, Scotland, United Kingdom
| | - Samuel R Neal
- Institute of Applied Health Sciences, University of Aberdeen, Foresterhill, Aberdeen, Scotland, United Kingdom
| | - Duncan Lee
- School of Mathematics and Statistics, University of Glasgow, University Place, Glasgow, Scotland, United Kingdom
| | - Frances S Mair
- General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
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22
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Valladales-Restrepo LF, Duran-Lengua M, Castro-Osorio EE, Machado-Alba JE. Consistency between anticholinergic burden scales in the elderly with fractures. PLoS One 2020; 15:e0228532. [PMID: 32092055 PMCID: PMC7039428 DOI: 10.1371/journal.pone.0228532] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 12/30/2019] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE Falls and bone fractures are important causes of morbidity and mortality in the elderly. The objective of this study was to identify the degree of consistency between the anticholinergic scales used for patients diagnosed with fractures. METHODS This was an analytical agreement study conducted in patients diagnosed with vertebral and nonvertebral fractures in Colombia. The quadratic-weighted kappa coefficient was used to identify the consistency between the Anticholinergic Drug Scale-ADS, Anticholinergic Cognitive Burden Scale-ACB and Anticholinergic Risk Scale-ARS in assessing the prescriptions of fracture patients during the month prior to the fracture, during their stay as an inpatient and at discharge, according to Landis criteria. RESULTS 220 patients with fractures were included, with a mean age of 75.3±10.3 years, and 68.2% were women. The ACB scale identified the highest anticholinergic burden (26.8%) in prescriptions made the month before the fracture, and the highest agreement was between ACB and ADS (0.717); during hospitalization and at discharge, the cholinergic antagonists were best identified with ADS (77.7% and 72.1%, respectively), with the best agreement between ACB and ARS (0.613 and 0.568, respectively). The prescription of tramadol was found in 64.1% of hospitalized patients and in 61.4% of patients at the time of discharge. CONCLUSIONS The scales evaluated show marked discrepancies between them, with highly variable frequencies of anticholinergic drugs identified at the different prescription times, and with low agreement among them, which is why the scales are not interchangeable in patients with bone fractures.
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Affiliation(s)
- Luis Fernando Valladales-Restrepo
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Risaralda, Colombia
- Grupo Biomedicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia
| | | | - Edgar Eduardo Castro-Osorio
- Internal Medicine, Geriatrics, Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Hospital Universitario de Caldas, Manizales, Colombia
| | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Risaralda, Colombia
- * E-mail:
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23
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Chapuis J, Siu-Paredes F, Pavageau C, Amador G, Rude N, Denis F. Anticholinergic Drugs and Oral Health-related Quality of Life in Patients with Schizophrenia: A Pilot Study. Transl Neurosci 2020; 11:10-16. [PMID: 32104590 PMCID: PMC7029653 DOI: 10.1515/tnsci-2020-0003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/16/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE The aim of this study was to explore, in a sample population of people with schizophrenia (PWS), the role of the anticholinergic burden on the perception of oral health-related quality of life (OHrQoL) in France. METHODS A pilot study was performed between March 2014 and January 2016. PWS were recruited from a population in Côte d'Or department in France. Dental status was investigated using the Decayed, Missing, or Filled Teeth (DMFT) index, the Xerostomia Index (XI), and the Global Oral Health Assessment Index (GOHAI) for OHrQoL. The anticholinergic impregnation score was recorded using the anticholinergic impregnation scale (AIS). RESULTS A sample of 62 people was selected. The DMFT score was 16.5± 8.7, the XI score was 22.9±7.8, the GOHAI score was 43.0±8.8, and the AIS score was 3.1±2.8. In total, 169 drugs were prescribed to the people of our sample, and 114 different anticholinergic drugs were observed. The most frequently used anticholinergic drugs (51.40%), in the study had a low antimuscarinic potency (1 point according to AIS scale). The multiple linear regression model showed that the OHrQoL scores were significantly lower when the DMFT scores, XI score, and anticholinergic scores were high. CONCLUSIONS This pilot study highlighted the potential role of the anticholinergic burden on the OHrQoL of PWS. A study with a validated specific scale for the OHrQoL and a standard anticholinergic burden scale should be conducted to clarify the role of anticholinergic drugs on the OHrQoL for PWS.
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Affiliation(s)
- Justine Chapuis
- University Hospital of Tours ,Odontology Department, 37170Chambray-lès-Tours, France
| | - Francesca Siu-Paredes
- EA 481 Integrative Neurosciences and Clinical. University Hospital of Besançon, 25000Besançon, France
- Université Champagne Ardenne. Faculté d’odontologie de Reims, 51100Reims, France
| | - Claire Pavageau
- University Hospital of Tours. Service d’odontologie du CHU de Tours, 37170Chambray-lès-Tours, France
| | - Gilles Amador
- Université de Nantes, Faculté d'Odontologie de Nantes, 44000Nantes, France
| | - Nathalie Rude
- EA 481 Integrative Neurosciences and Clinical. University Hospital of Besançon, 25000Besançon, France
| | - Frédéric Denis
- University Hospital of Tours ,Odontology Department, 37170Chambray-lès-Tours, France
- Université de Nantes, Faculté d'Odontologie de Nantes, 44000Nantes, France
- EA 75-05 Education, Ethique, Santé. Université de Tours, Faculté de Médecine, 37032Tours, France
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24
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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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25
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Association between anticholinergic (atropinic) drug exposure and cognitive function in longitudinal studies among individuals over 50 years old: a systematic review. Eur J Clin Pharmacol 2019; 75:1631-1644. [DOI: 10.1007/s00228-019-02744-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 08/09/2019] [Indexed: 12/19/2022]
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26
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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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27
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O'Connell J, Henman MC, Burke É, Donegan C, McCallion P, McCarron M, O'Dwyer M. Association of Drug Burden Index with grip strength, timed up and go and Barthel index activities of daily living in older adults with intellectual disabilities: an observational cross-sectional study. BMC Geriatr 2019; 19:173. [PMID: 31234775 PMCID: PMC6591943 DOI: 10.1186/s12877-019-1190-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 06/17/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Drug Burden Index (DBI), a measure of exposure to medications with anticholinergic and sedative activity, has been associated with poorer physical function in older adults in the general population. While extensive study has been conducted on associations between DBI and physical function in older adults in the general population, little is known about associations in older adults with intellectual disabilities (ID). This is the first study which aims to examine the association between DBI score and its two sub-scores, anticholinergic and sedative burden, with two objective measures of physical performance, grip strength and timed up and go, and a measure of dependency, Barthel Index activities of daily living, in older adults with ID. METHODS Data from Wave 2 (2013/2014) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA) was analysed. Analysis of Covariance (ANCOVA) was used to detect associations and produce adjusted means for the physical function and dependency measures with respect to categorical DBI scores and the anticholinergic and sedative sub-scores (DBA and DBS). RESULTS After adjusting for confounders (age, level of ID, history of falls, comorbidities and number of non-DBI medications, Down syndrome (grip strength only) and gender (timed up and go and Barthel Index)), neither grip strength nor timed up and go were significantly associated with DBI, DBA or DBS score > 0 (p > 0.05). Higher dependency in Barthel Index was associated with DBS exposure (p < 0.001). CONCLUSIONS DBI, DBA or DBS scores were not significantly associated with grip strength or timed up and go. This could be as a result of established limitations in physical function in this cohort, long-term exposure to these types of medications or lifelong sedentary lifestyles. Higher dependency in Barthel Index activities of daily living was associated with sedative drug burden, which is an area which can be examined further for review.
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Affiliation(s)
- Juliette O'Connell
- School of Pharmacy and Pharmaceutical Sciences and IDS-TILDA, School of Nursing and Midwifery, Trinity College, Dublin, Ireland.
| | - Martin C Henman
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland
| | - Éilish Burke
- IDS-TILDA, School of Nursing and Midwifery, Trinity College, Dublin, Ireland
| | - Clare Donegan
- School of Pharmacy and Pharmaceutical Sciences and IDS-TILDA, School of Nursing and Midwifery, Trinity College, Dublin, Ireland
| | | | - Mary McCarron
- Dean of Faculty of Health Sciences, Trinity College, Dublin, Ireland
| | - Máire O'Dwyer
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland
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28
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van der Meer HG, Wouters H, Teichert M, Griens F, Pavlovic J, Pont LG, Taxis K. Feasibility, acceptability and potential effectiveness of an information technology-based, pharmacist-led intervention to prevent an increase in anticholinergic and sedative load among older community-dwelling individuals. Ther Adv Drug Saf 2019; 10:2042098618805881. [PMID: 31019675 PMCID: PMC6463339 DOI: 10.1177/2042098618805881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 09/18/2018] [Indexed: 12/15/2022] Open
Abstract
Background: Anticholinergic/sedative medications are frequently used by older people,
despite their negative impacts on cognitive and physical function. We
explore the feasibility, acceptability and potential effectiveness of an
innovative information technology (IT)-based intervention to prevent an
increase in anticholinergic/sedative load in older people. Methods: This was a prospective study in 51 Dutch community pharmacies. Pharmacists
used an IT-based tool to identify patients aged ⩾65 years,
with existing high anticholinergic/sedative loads (drug burden index
⩾2) and a newly initiated anticholinergic/sedative medication. We
determined the following. Feasibility: number of eligible patients
identified. Acceptability: pharmacists’ satisfaction with the
intervention, pharmacists’ time investment and patients’
willingness to reduce medication use. Potential effectiveness: number of
recommendations, rate of agreement of general practitioners (GPs) with
proposed recommendations and factors associated with agreement. To evaluate
the latter, pharmacists conducted medication reviews and proposed
recommendations to GPs for 5–10 patients selected by the IT-based
tool. Results: We included 305 patients from 47 pharmacies. Feasibility: a mean of 17.0
(standard deviation, 8.8) patients were identified per pharmacy.
Acceptability: 43 pharmacists (91.5%) were satisfied with the intervention.
The median time investment per patient was 33 min (range
6.5–210). Of 35 patients, 30 (85.7%) were willing to reduce
medication use. Potential effectiveness: pharmacists proposed 351
recommendations for 212 patients (69.5%). GPs agreed with recommendations
for 108 patients (35.4%). Agreement to stop a medication was reached in
19.8% of recommendations for newly initiated medications (37 of 187) and for
15.2% of recommendations for existing medications (25 of 164). Agreement was
more likely for recommendations on codeine [odds ratio (OR) 3.30; 95%
confidence interval (CI) 1.14–9.57] or medications initiated by a
specialist (OR 2.85; 95% CI 1.19–6.84) and less likely for
pharmacies with lower level of collaboration with GPs (OR 0.15; 95% CI
0.02–0.97). Conclusion: This innovative IT-based intervention was feasible, acceptable and
potentially effective. In one-third of patients an increase in
anticholinergic/sedative load was prevented within reasonable time
investment.
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Affiliation(s)
- Helene G van der Meer
- University of Groningen, Unit PharmacoTherapy, -Epidemiology & -Economy, HPC: XB45, Antonius Deusinglaan 1, 9711 AV Groningen, the Netherlands
| | - Hans Wouters
- University Medical Centre Groningen, Groningen, The Netherlands
| | - Martina Teichert
- Leiden University Medical Centre, Leiden, The NetherlandsRoyal Dutch Pharmacists Association, The Hague, The Netherlands
| | - Fabiënne Griens
- Foundation for Pharmaceutical Statistics, The Hague, The Netherlands
| | | | - Lisa G Pont
- University of Technology Sydney, Sydney, New South Wales, Australia
| | - Katja Taxis
- University of Groningen, Groningen, The Netherlands
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van der Meer HG, Taxis K, Teichert M, Griens F, Pont LG, Wouters H. Anticholinergic and sedative medication use in older community-dwelling people: A national population study in the Netherlands. Pharmacoepidemiol Drug Saf 2019; 28:315-321. [PMID: 30747477 PMCID: PMC6593836 DOI: 10.1002/pds.4698] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/18/2018] [Accepted: 10/16/2018] [Indexed: 11/24/2022]
Abstract
Purpose To identify the proportion of older adults with a high anticholinergic/sedative load and to identify patient subgroups based on type of central nervous system (CNS)‐active medication used. Methods A cross‐sectional study of a nationwide sample of patients with anticholinergic/sedative medications dispensed by 1779 community pharmacies in the Netherlands (90% of all community pharmacies) in November 2016 was conducted. Patients aged older than 65 years with a high anticholinergic/sedative load defined as having a drug burden index (DBI) greater than 1 were included. Proportion of patients with a high anticholinergic/sedative load was calculated by dividing the number of individuals in our study population by the 2.4 million older patients using medications dispensed from study pharmacies. Patient subgroups based on type of CNS‐active medications used were identified with latent class analysis. Results Overall, 8.7% (209 472 individuals) of older adults using medications had a DBI greater than 1. Latent class analysis identified four patient subgroups (classes) based on the following types of CNS‐active medications used: “combined psycholeptic/psychoanaleptic medication” (class 1, 57.9%), “analgesics” (class 2, 17.9%), “antiepileptic medication” (class 3, 17.8%), and “anti‐Parkinson medication” (class 4, 6.3%). Conclusions A large proportion of older adults in the Netherlands had a high anticholinergic/sedative load. Four distinct subgroups using specific CNS‐active medication were identified. Interventions aiming at reducing the overall anticholinergic/sedative load should be tailored to these subgroups.
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Affiliation(s)
- Helene G van der Meer
- PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Katja Taxis
- PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
| | - Martina Teichert
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Fabiënne Griens
- Foundation for Pharmaceutical Statistics, The Hague, the Netherlands
| | - Lisa G Pont
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney, Ultimo, Australia
| | - Hans Wouters
- PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands.,Department General Practice and Elderly Care Medicine, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
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Andre L, Gallini A, Montastruc F, Coley N, Montastruc JL, Vellas B, Andrieu S, Gardette V. Anticholinergic exposure and cognitive decline in older adults: effect of anticholinergic exposure definitions in a 3-year analysis of the multidomain Alzheimer preventive trial (MAPT) study. Br J Clin Pharmacol 2018; 85:71-99. [PMID: 30098049 DOI: 10.1111/bcp.13734] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 06/19/2018] [Accepted: 07/27/2018] [Indexed: 01/02/2023] Open
Abstract
AIM The aim of the present study was to assess the association between anticholinergic (atropinic) burden and cognitive decline in older adults over the course of 3 years. METHODS We used data from Multidomain Alzheimer Preventive Trial (MAPT) study participants aged ≥70 years and at risk of cognitive decline. Cognitive function was assessed with a composite score [Mini-Mental State Examination (MMSE) orientation, Free and Cued Selective Reminding Test, Category Naming Test, Digit Symbol Substitution Test] at 12, 24 and 36 months. Participants declining by more than 0.236 points on the composite score (representing the lowest quintile of 1-year cognitive change) during any 1-year period were considered to have undergone cognitive decline. Anticholinergic exposure was defined by four methods for each of four anticholinergic scales (Anticholinergic Drug Scale, Anticholinergic Cognitive Burden, Anticholinergic Risk Scale, the Durán list). The association between cognitive decline and time-varying anticholinergic exposure [primary analysis using the Durán list and maximal anticholinergic score (0, 1 or 3)] was assessed using Cox proportional hazards models. Other cognitive decline definitions were used in sensitivity analyses. RESULTS At baseline, among 1396 patients included, 7.4-23.5% were exposed to anticholinergic agents, depending on the anticholinergic scale used. Sixty-four per cent of participants experienced cognitive decline during follow-up. Regardless of the anticholinergic scale/exposure measurement used, no significant association was observed with cognitive decline {primary analysis: compared with non-anticholinergic agent users, hazard ratio [HR] = 1.14 [95% confidence interval (CI) = 0.95, 1.38] for anticholinergic score = 1; HR = 0.92 [95% CI = 0.65, 1.30] for score = 3}. Results were stable in sensitivity analyses. CONCLUSION We found no significant association between anticholinergic exposure and cognitive decline in older adults using anticholinergic scales and definitions of exposure.
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Affiliation(s)
- Laurine Andre
- UMR INSERM 1027, Université de Toulouse, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), France.,Gérontopôle de Toulouse, Institut du Vieillissement, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France.,Service d'Epidémiologie, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France
| | - Adeline Gallini
- UMR INSERM 1027, Université de Toulouse, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), France.,Service d'Epidémiologie, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France
| | - François Montastruc
- UMR INSERM 1027, Université de Toulouse, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), France.,Service de Pharmacologie Médicale et Clinique, Centre Midi-Pyrénées de PharmacoVigilance, Pharmacoépidémiologie et d'Informations sur le Médicament, Centre Hospitalier Universitaire, Faculté de Médecine, Toulouse, France
| | - Nicola Coley
- UMR INSERM 1027, Université de Toulouse, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), France.,Service d'Epidémiologie, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France
| | - Jean-Louis Montastruc
- UMR INSERM 1027, Université de Toulouse, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), France.,Service de Pharmacologie Médicale et Clinique, Centre Midi-Pyrénées de PharmacoVigilance, Pharmacoépidémiologie et d'Informations sur le Médicament, Centre Hospitalier Universitaire, Faculté de Médecine, Toulouse, France
| | - Bruno Vellas
- UMR INSERM 1027, Université de Toulouse, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), France.,Gérontopôle de Toulouse, Institut du Vieillissement, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France
| | - Sandrine Andrieu
- UMR INSERM 1027, Université de Toulouse, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), France.,Service d'Epidémiologie, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France
| | - Virginie Gardette
- UMR INSERM 1027, Université de Toulouse, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), France.,Service d'Epidémiologie, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France
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van der Meer HG, Wouters H, Pont LG, Taxis K. Reducing the anticholinergic and sedative load in older patients on polypharmacy by pharmacist-led medication review: a randomised controlled trial. BMJ Open 2018; 8:e019042. [PMID: 30030308 PMCID: PMC6059312 DOI: 10.1136/bmjopen-2017-019042] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To evaluate if a pharmacist-led medication review is effective at reducing the anticholinergic/sedative load, as measured by the Drug Burden Index (DBI). DESIGN Randomised controlled single blind trial. SETTING 15 community pharmacies in the Northern Netherlands. PARTICIPANTS 157 community-dwelling patients aged ≥65 years who used ≥5 medicines for ≥3 months, including at least one psycholeptic/psychoanaleptic medication and who had a DBI≥1. INTERVENTION A medication review by the community pharmacist in collaboration with the patient's general practitioner and patient. PRIMARY AND SECONDARY OUTCOMES MEASURES The primary outcome was the proportion of patients whose DBI decreased by at least 0.5. Secondary outcomes were the presence of anticholinergic/sedative side effects, falls, cognitive function, activities of daily living, quality of life, hospital admission and mortality. Data were collected at baseline and 3 months follow-up. RESULTS Mean participant age was 75.7 (SD, 6.9) years in the intervention arm and 76.6 (SD, 6.7) years in the control arm, the majority were female (respectively 69.3% and 72.0%). Logistic regression analysis showed no difference in the proportion of patients with a≥0.5 decrease in DBI between intervention arm (17.3%) and control arm (15.9%), (OR 1.04, CI 0.47 to 2.64, p=0.927). Intervention patients scored higher on the Digit Symbol Substitution Test, measure of cognitive function (OR 2.02, CI 1.11 to 3.67, p=0.021) and reported fewer sedative side effects (OR 0.61, CI 0.40 to 0.94, p=0.024) at follow-up. No significant difference was found for other secondary outcomes. CONCLUSIONS Pharmacist-led medication review as currently performed in the Netherlands was not effective in reducing the anticholinergic/sedative load, measured with the DBI, within the time frame of 3 months. Preventive strategies, signalling a rising load and taking action before chronic use of anticholinergic/sedative medication is established may be more successful. TRIAL REGISTRATION NUMBER NCT02317666.
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Affiliation(s)
- Helene G van der Meer
- Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, Epidemiology and Economics, University of Groningen, Groningen, Netherlands
| | - Hans Wouters
- Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, Epidemiology and Economics, University of Groningen, Groningen, Netherlands
- Department of General Practice, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Lisa G Pont
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Katja Taxis
- Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, Epidemiology and Economics, University of Groningen, Groningen, Netherlands
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Anticholinergic Burden and Most Common Anticholinergic-acting Medicines in Older General Practice Patients. Zdr Varst 2018; 57:140-147. [PMID: 29983780 PMCID: PMC6032175 DOI: 10.2478/sjph-2018-0018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 05/14/2018] [Indexed: 11/21/2022] Open
Abstract
Introduction Anticholinergic burden in older adults has been correlated with cognitive decline, delirium, dizziness and confusion, falls and hospitalisations. Nevertheless, anticholinergic-acting medications remain commonly prescribed in up to a third of older adults in primary care population. Our aim was to study the anticholinergic burden in older adults in Slovenian ambulatory setting and explore the most commonly involved medications which could be avoided by the physicians. Methods A cross-sectional study was conducted in 30 general practices in Slovenia as part of a larger trial. Data on prescribed medications were collected for randomly chosen adults of over 65 years of age visiting general practice, who were taking at least one regularly prescribed medication. Anticholinergic burden was calculated using Duran’s scale and Drug Burden Index. Results Altogether, 622 patients were included, 356 (57.2%) female, average age of 77.2 (±6.2), with an average of 5.6 medications. At least one anticholinergic medication was present in 78 (12.5 %) patients. More than half (N=41, 52.6%) of anticholinergic prescriptions were psychotropic medications. Most common individual medications were diazepam (N=10, 1.6%), quetiapine (N=9, 1.4%) and ranitidine (N=8, 1.3%). Conclusions Though the prevalence of anticholinergic medications was low compared to international research, the most commonly registered anticholinergic prescriptions were medications that should be avoided according to guidelines of elderly prescriptions. It would be probably clinically feasible to further decrease the anticholinergic burden of older adults in Slovenian primary care setting by avoiding or replacing these medications with safer alternatives.
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Turró-Garriga O, Calvó-Perxas L, Vilalta-Franch J, Blanco-Silvente L, Castells X, Capellà D, Garre-Olmo J. Measuring anticholinergic exposure in patients with dementia: A comparative study of nine anticholinergic risk scales. Int J Geriatr Psychiatry 2018; 33:710-717. [PMID: 29292848 DOI: 10.1002/gps.4844] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 11/27/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To describe the prevalence and concordance of anticholinergic exposure according to 9 published scales, to quantify the relative weight of the drug subtypes included in each scale, and to identify clinical variables related to anticholinergic exposure. METHODS Observational and cross-sectional study using 5323 cases of dementia diagnosed in the 7 hospitals of the public health care system of the Health Region of Girona (Spain) between 2007 and 2014 and registered by the Registry of Dementias of Girona (ReDeGi). We used the Pharmacy database that includes all the drugs prescribed by specialist and primary care physicians and dispensed in pharmacies. We calculated the anticholinergic exposure using the scoring rules of each scale. Age, gender, place of residence, dementia subtype, Clinical Dementia Rating score, Mini-Mental Status Examination score, and Blessed Dementia Rating Score at the moment of dementia diagnose were retrieved from the ReDeGi. RESULTS Prevalence of the annual anticholinergic exposure ranged from 36.3% to 69.0% according to the different scales, the concordance among scales was poor to moderate, and the central nervous system drugs accounted the most for anticholinergic exposure. Being in a nursing home, having depressive symptoms, having a non-Alzheimer's dementia subtype, the number of drug treatments, and the severity of dementia were main determinants of anticholinergic exposure. CONCLUSIONS There is a large difference in outcomes among the 9 anticholinergic risk scales. Clinicians and researchers should be aware of these differences when using these instruments in patients with dementia.
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Affiliation(s)
- Oriol Turró-Garriga
- Girona Biomedical Research Institute [IDIBGI], Girona, Spain.,Institut d'Assistència Sanitària, Girona, Spain
| | | | - Joan Vilalta-Franch
- Girona Biomedical Research Institute [IDIBGI], Girona, Spain.,Institut d'Assistència Sanitària, Girona, Spain.,Department of Medical Sciences, University of Girona, Girona, Spain
| | | | - Xavier Castells
- Department of Medical Sciences, University of Girona, Girona, Spain
| | - Dolors Capellà
- Department of Medical Sciences, University of Girona, Girona, Spain
| | - Josep Garre-Olmo
- Girona Biomedical Research Institute [IDIBGI], Girona, Spain.,Institut d'Assistència Sanitària, Girona, Spain.,Department of Medical Sciences, University of Girona, Girona, Spain
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de Germay S, Lapeyre-Mestre M, Montastruc JL, Montastruc F. [Atropinic burden and anticholinergic drugs: Interest and application in clinical practice in the elderly]. Therapie 2018; 76:665-673. [PMID: 29625707 DOI: 10.1016/j.therap.2018.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 01/26/2018] [Accepted: 02/20/2018] [Indexed: 11/18/2022]
Abstract
Anticholinergic drugs (also called antimuscarinics or atropinics) increase the risk of falls, cognitive impairment and/or mortality in older patients. These drugs belong to the lists of potentially inappropriate medications in the elderly. The aim of this review was to present and discuss the different tools available to measure the atropinic risk in drug exposure of older patients. Several scales, developed from biological and/or clinical criteria, allow to classify anticholinergic drugs according to their atropinic potency and to assign to them an atropinic burden. Total atropinic burden of patient drug exposure can be calculated as the sum of atropinic score of each drug. Other tools include drug daily doses to better estimate the atropinic risk. These different methods are a precious help to decrease atropinic exposure in the elderly. Nevertheless, they have to be considered as upgradable and it is necessary to adapt them regularly according to the introduction of new drugs in clinical practice.
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Affiliation(s)
- Sibylle de Germay
- Service de pharmacologie médicale et clinique, centre hospitalier universitaire et faculté de médecine de Toulouse, 37, allées Jules-Guesde, 31000 Toulouse, France; UMR Inserm 1027, faculté de médecine, université de Toulouse, 31000 Toulouse, France.
| | - Maryse Lapeyre-Mestre
- Service de pharmacologie médicale et clinique, centre hospitalier universitaire et faculté de médecine de Toulouse, 37, allées Jules-Guesde, 31000 Toulouse, France; UMR Inserm 1027, faculté de médecine, université de Toulouse, 31000 Toulouse, France; Centre Midi-Pyrénées d'évaluation et d'information sur la pharmacodépendance et d'addictovigilance (CEIP-A), centre hospitalier universitaire de Toulouse, 31000 Toulouse, France
| | - Jean-Louis Montastruc
- Service de pharmacologie médicale et clinique, centre hospitalier universitaire et faculté de médecine de Toulouse, 37, allées Jules-Guesde, 31000 Toulouse, France; UMR Inserm 1027, faculté de médecine, université de Toulouse, 31000 Toulouse, France; Centre Midi-Pyrénées de pharmacovigilance, de pharmacoépidémiologie et d'informations sur le médicament et pharmacopôle Midi-Pyrénées, 31000 Toulouse, France
| | - François Montastruc
- Service de pharmacologie médicale et clinique, centre hospitalier universitaire et faculté de médecine de Toulouse, 37, allées Jules-Guesde, 31000 Toulouse, France; UMR Inserm 1027, faculté de médecine, université de Toulouse, 31000 Toulouse, France; Centre Midi-Pyrénées de pharmacovigilance, de pharmacoépidémiologie et d'informations sur le médicament et pharmacopôle Midi-Pyrénées, 31000 Toulouse, France
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Hsu WH, Wen YW, Chen LK, Hsiao FY. Comparative Associations Between Measures of Anti-cholinergic Burden and Adverse Clinical Outcomes. Ann Fam Med 2017; 15:561-569. [PMID: 29133497 PMCID: PMC5683870 DOI: 10.1370/afm.2131] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 05/16/2017] [Accepted: 06/22/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE No consensus has been reached regarding which anticholinergic scoring system works most effectively in clinical settings. The aim of this population-based cohort study was to examine the association between anticholinergic medication burden, as defined by different scales, and adverse clinical outcomes among older adults. METHODS From Taiwan's Longitudinal Health Insurance Database, we retrieved data on monthly anticholinergic drug use measured by the Anticholinergic Risk Scale (ARS), the Anticholinergic Cognitive Burden Scale (ACB), and the Drug Burden Index - Anticholinergic component (DBI-Ach) for 116,043 people aged 65 years and older during a 10-year follow-up. For all 3 scales, a higher score indicates greater anticholinergic burden. We used generalized estimating equations to examine the association between anticholinergic burden (ARS and ACB: grouped from 0 to ≥4; DBI-Ach: grouped as 0, 0-0.5, and 0.5-1) and adverse outcomes, and stratified individuals by age-group (aged 65-74, 75-84, and ≥85 years). RESULTS Compared with the ARS and DBI-Ach, the ACB showed the strongest, most consistent dose-response relationships with risks of all 4 adverse outcomes, particularly in people aged 65 to 84 years. For example, among those 65 to 74 years old, going from an ACB score of 1 to a score of 4 or greater, individuals' adjusted odds ratio increased from 1.41 to 2.25 for emergency department visits; from 1.32 to 1.92 for all-cause hospitalizations; from 1.10 to 1.71 for fracture-specific hospitalizations; and from 3.13 to 10.01 for incident dementia. CONCLUSIONS Compared with the 2 other scales studied, the ACB shows good dose-response relationships between anticholinergic burden and a variety of adverse outcomes in older adults. For primary care and geriatrics clinicians, the ACB may be a helpful tool for identifying high-risk populations for interventions.
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Affiliation(s)
- Wen-Han Hsu
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Wen Wen
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan City, Taiwan
| | - Liang-Kung Chen
- Aging and Health Research Center, National Yang-Ming University, Taipei, Taiwan.,Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Public Health, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Fei-Yuan Hsiao
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan .,School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
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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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Xu D, Anderson HD, Tao A, Hannah KL, Linnebur SA, Valuck RJ, Culbertson VL. Assessing and predicting drug-induced anticholinergic risks: an integrated computational approach. Ther Adv Drug Saf 2017; 8:361-370. [PMID: 29090085 PMCID: PMC5638173 DOI: 10.1177/2042098617725267] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 07/19/2017] [Indexed: 11/17/2022] Open
Abstract
Background: Anticholinergic (AC) adverse drug events (ADEs) are caused by inhibition of muscarinic receptors as a result of designated or off-target drug–receptor interactions. In practice, AC toxicity is assessed primarily based on clinician experience. The goal of this study was to evaluate a novel concept of integrating big pharmacological and healthcare data to assess clinical AC toxicity risks. Methods: AC toxicity scores (ATSs) were computed using drug–receptor inhibitions identified through pharmacological data screening. A longitudinal retrospective cohort study using medical claims data was performed to quantify AC clinical risks. ATS was compared with two previously reported toxicity measures. A quantitative structure–activity relationship (QSAR) model was established for rapid assessment and prediction of AC clinical risks. Results: A total of 25 common medications, and 575,228 exposed and unexposed patients were analyzed. Our data indicated that ATS is more consistent with the trend of AC outcomes than other toxicity methods. Incorporating drug pharmacokinetic parameters to ATS yielded a QSAR model with excellent correlation to AC incident rate (R2 = 0.83) and predictive performance (cross validation Q2 = 0.64). Good correlation and predictive performance (R2 = 0.68/Q2 = 0.29) were also obtained for an M2 receptor-specific QSAR model and tachycardia, an M2 receptor-specific ADE. Conclusions: Albeit using a small medication sample size, our pilot data demonstrated the potential and feasibility of a new computational AC toxicity scoring approach driven by underlying pharmacology and big data analytics. Follow-up work is under way to further develop the ATS scoring approach and clinical toxicity predictive model using a large number of medications and clinical parameters.
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Affiliation(s)
- Dong Xu
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, Idaho State University, 1311 East Central Drive, Meridian, ID 83642, USA
| | - Heather D Anderson
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Aoxiang Tao
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, Idaho State University, Meridian, ID, USA
| | - Katia L Hannah
- School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sunny A Linnebur
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Robert J Valuck
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO, USA School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Vaughn L Culbertson
- Department of Pharmacy Practice and Administrative Sciences, College of Pharmacy, Idaho State University, 1311 East Central Drive, Meridian, ID 83642, USA
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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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Granas AG, Stendal Bakken M, Ruths S, Taxis K. Deprescribing for frail older people - Learning from the case of Mrs. Hansen. Res Social Adm Pharm 2017; 14:612-616. [PMID: 28733142 DOI: 10.1016/j.sapharm.2017.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 07/10/2017] [Indexed: 01/12/2023]
Abstract
Drug treatment is often an essential part in treatment and prevention of diseases in older people, but there is much concern about inappropriate medication use. This paper aims to describe the complexity of medication safety issues and clinical judgments when optimizing prescribing in older individuals. It uses the case of Mrs. Hansen, an aged nursing home resident, to illustrate the facilitators and barriers of this process. With decreasing life expectancy, medication use should shift from cure to care, focusing on symptomatic treatment to increase the patient's well-being. In Mrs. Hansen's case, the number of (potentially) dangerous medications were reduced, and non-pharmacological alternatives were considered. There were some medicines added, as underprescribing can also be a problem in older people. Deprescribing long-standing treatment can be interpreted by the patient and family as "giving up hope". More clinical evidence and practical communication tools are needed to guide deprescribing decisions, taking medical and patient-centered priorities into account. Studies evaluating such interventions should select outcome measures that are particularly relevant for frail old individuals.
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Affiliation(s)
- Anne Gerd Granas
- School of Pharmacy, The Faculty of Mathematics and Natural Sciences, University of Oslo, Norway
| | - Marit Stendal Bakken
- Kavli Research Centre for Geriatrics and Dementia, Haraldsplass Deaconess Hospital, PB 6165, N-5892, Bergen, Norway
| | - Sabine Ruths
- Research Unit for General Practice, Uni Research Health, Bergen, Norway; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Katja Taxis
- University of Groningen, Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, -Epidemiology and -Economics, Ant Deusinglaan 1, 9713 AV, Groningen, The Netherlands.
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Wauters M, Klamer T, Elseviers M, Vaes B, Dalleur O, Degryse J, Durán C, Christiaens T, Azermai M, Vander Stichele R. Anticholinergic Exposure in a Cohort of Adults Aged 80 years and Over: Associations of the MARANTE Scale with Mortality and Hospitalization. Basic Clin Pharmacol Toxicol 2017; 120:591-600. [PMID: 27995743 DOI: 10.1111/bcpt.12744] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 12/02/2016] [Indexed: 12/25/2022]
Abstract
Anticholinergics are frequently prescribed for older adults and can lead to adverse drug events. The novel MARANTE (Muscarinic Acetylcholinergic Receptor ANTagonist Exposure) scale measures the anticholinergic exposure by incorporating potency and dosages of each medication into its calculations. The aims were to assess prevalence and intensity of the anticholinergic exposure in a longitudinal cohort study of community-dwelling patients aged 80 years and over (n = 503) and to study the impact on mortality and hospitalization. Chronic medication use at baseline (November 2008-September 2009) was entered and codified with the Anatomical Therapeutic Chemical classification. Time-to-event analysis until first hospitalization or death was performed at 18 months after inclusion, using Kaplan-Meier curves. Cox regression was performed to control for covariates. Mean age was 84 years (range 80-102), and mean number of medications was 5 (range 0-16). Prevalence of anticholinergic use was 31.8%, with 9% taking ≥2 anticholinergics (range 0-4). Main indications for anticholinergics were depression, pain and gastric dysfunction. Female gender, the level of multi-morbidity and the number of medications were associated with anticholinergic use. Mortality and hospitalization rate were 8.9% and 31.0%, respectively. After adjustment for the level of multi-morbidity and medication intake, multi-variable analysis showed increased risks of mortality (HR 2.3, 95% CI: 1.07-4.78) and hospitalization (HR 1.7; 95% CI: 1.13-2.59) in those with high anticholinergic exposure. The longitudinal study among Belgian community-dwelling oldest old demonstrated great anticholinergic exposure, which was associated with increased risk of mortality and hospitalization after 18 months.
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Affiliation(s)
- Maarten Wauters
- Heymans Institute of Pharmacology, Clinical Pharmacology Research Unit, Ghent University, Ghent, Belgium
| | - Therese Klamer
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Monique Elseviers
- Heymans Institute of Pharmacology, Clinical Pharmacology Research Unit, Ghent University, Ghent, Belgium.,Centre For Research and Innovation in Care (CRIC), University of Antwerp, Wilrijk, Belgium
| | - Bert Vaes
- Department of Public and Primary Health Care, Catholic University of Leuven, Leuven, Belgium.,Institute of Health and Society, Catholic University of Louvain, Louvain-le-Neuve, Brussels, Belgium
| | - Olivia Dalleur
- Institute of Health and Society, Catholic University of Louvain, Louvain-le-Neuve, Brussels, Belgium
| | - Jan Degryse
- Department of Public and Primary Health Care, Catholic University of Leuven, Leuven, Belgium.,Institute of Health and Society, Catholic University of Louvain, Louvain-le-Neuve, Brussels, Belgium
| | - Carlos Durán
- Heymans Institute of Pharmacology, Clinical Pharmacology Research Unit, Ghent University, Ghent, Belgium.,Ecuadorian Center for Clinical Research, Health Information and Assessment (CIEC), Yachay Public Company, Quito, Ecuador
| | - Thierry Christiaens
- Heymans Institute of Pharmacology, Clinical Pharmacology Research Unit, Ghent University, Ghent, Belgium
| | - Majda Azermai
- Heymans Institute of Pharmacology, Clinical Pharmacology Research Unit, Ghent University, Ghent, Belgium
| | - Robert Vander Stichele
- Heymans Institute of Pharmacology, Clinical Pharmacology Research Unit, Ghent University, Ghent, Belgium
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Quantification of anticholinergic and sedative drug load with the Drug Burden Index: a review of outcomes and methodological quality of studies. Eur J Clin Pharmacol 2016; 73:257-266. [PMID: 27909739 PMCID: PMC5306241 DOI: 10.1007/s00228-016-2162-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 11/10/2016] [Indexed: 12/11/2022]
Abstract
Purpose The Drug Burden Index (DBI) is a non-invasive method to quantify patients’ anticholinergic and sedative drug burden from their prescriptions. This systematic review aimed to summarise the evidence on the associations between the DBI and clinical outcomes and methodological quality of studies. Methods A search in PubMed and Embase (search terms: ‘drug’, ‘burden’, and ‘index’) was performed and experts were contacted. We excluded publications that did not report empirical results or clinical outcomes. Methodological quality was assessed using the Newcastle-Ottawa Scale. Potential omissions of relevant clinical outcomes and populations were studied. Results Of the 2998 identified publications, 21 were eligible. Overall, methodological quality of studies was good. In all but one study, adjustment was made for prevalent co-morbidity. The DBI was examined in diverse older individuals, i.e. both males and females from different settings and countries. However, no studies were conducted in other relevant patient groups, e.g. psychiatric patients. Exposure to anticholinergic and sedative drugs was thoroughly ascertained, though the specific calculation of the DBI differed across studies. Outcomes were assessed from medical records, record linkage or validated objective tests or questionnaires. Many studies found associations between the DBI and outcomes including hospitalisation, physical and cognitive function. Cognitive function and quality of life were understudied and the number and scope of longitudinal studies was limited. Conclusions An accumulating body of evidence supports the validity of the DBI. Longitudinal studies of cognitive function and quality of life and in other patient groups, e.g. psychiatric patients, are warranted. Electronic supplementary material The online version of this article (doi:10.1007/s00228-016-2162-6) contains supplementary material, which is available to authorized users.
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The effect of comprehensive geriatric assessment on anticholinergic exposure assessed by four ranked anticholinergic lists. Arch Gerontol Geriatr 2016; 68:195-201. [PMID: 27837709 DOI: 10.1016/j.archger.2016.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 08/30/2016] [Accepted: 10/29/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Older people often use multiple drugs, and some of them have anticholinergic activity. Anticholinergic drugs may cause adverse reactions, and therefore their use should be limited. To identify anticholinergic load, several ranked lists with different drugs and scoring systems have been developed and used widely in research. We investigated, if a comprehensive geriatric assessment (CGA) decreased the anticholinergic drug score in a 4-year period. We used four different anticholinergic ranked lists to determine the anticholinergic score and to describe how the results differ depending on the list used. METHODS We analyzed data from population-based intervention study, in which a random sample of 1000 persons aged ≥75 years were randomized to either an intervention group or a control group. Those in the intervention group underwent CGA including medication assessment annually between 2004 and 2007. Current medication use was assessed annually. The anticholinergic load was calculated by using four ranked lists of anticholinergic drugs (Boustani's, Carnahan's, Chew's and Rudolph's) for each person and for each year. RESULTS CGA had no statistically significant effect on anticholinergic exposure during the 4-year follow-up, but improvements towards more appropriate medication use were observed especially in the intervention group. However, age, gender and functional comorbidity index were associated to higher anticholinergic exposure, depending on the list used. CONCLUSIONS Repeated CGAs may result as more appropriate anticholinergic medication use. The selection of the list may affect the results and therefore the selection of the list is important.
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Crispo JAG, Willis AW, Thibault DP, Fortin Y, Hays HD, McNair DS, Bjerre LM, Kohen DE, Perez-Lloret S, Mattison DR, Krewski D. Associations between Anticholinergic Burden and Adverse Health Outcomes in Parkinson Disease. PLoS One 2016; 11:e0150621. [PMID: 26939130 PMCID: PMC4777375 DOI: 10.1371/journal.pone.0150621] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 02/17/2016] [Indexed: 11/24/2022] Open
Abstract
Background Elderly adults should avoid medications with anticholinergic effects since they may increase the risk of adverse events, including falls, delirium, and cognitive impairment. However, data on anticholinergic burden are limited in subpopulations, such as individuals with Parkinson disease (PD). The objective of this study was to determine whether anticholinergic burden was associated with adverse outcomes in a PD inpatient population. Methods Using the Cerner Health Facts® database, we retrospectively examined anticholinergic medication use, diagnoses, and hospital revisits within a cohort of 16,302 PD inpatients admitted to a Cerner hospital between 2000 and 2011. Anticholinergic burden was computed using the Anticholinergic Risk Scale (ARS). Primary outcomes were associations between ARS score and diagnosis of fracture and delirium. Secondary outcomes included associations between ARS score and 30-day hospital revisits. Results Many individuals (57.8%) were prescribed non-PD medications with moderate to very strong anticholinergic potential. Individuals with the greatest ARS score (≥4) were more likely to be diagnosed with fractures (adjusted odds ratio (AOR): 1.56, 95% CI: 1.29–1.88) and delirium (AOR: 1.61, 95% CI: 1.08–2.40) relative to those with no anticholinergic burden. Similarly, inpatients with the greatest ARS score were more likely to visit the emergency department (adjusted hazard ratio (AHR): 1.32, 95% CI: 1.10–1.58) and be readmitted (AHR: 1.16, 95% CI: 1.01–1.33) within 30-days of discharge. Conclusions We found a positive association between increased anticholinergic burden and adverse outcomes among individuals with PD. Additional pharmacovigilance studies are needed to better understand risks associated with anticholinergic medication use in PD.
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Affiliation(s)
- James A G Crispo
- McLaughlin Centre for Population Health Risk Assessment, University of Ottawa, Ottawa, Ontario, Canada.,Fulbright Canada Student, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Allison W Willis
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America.,Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Dylan P Thibault
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America.,Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Yannick Fortin
- McLaughlin Centre for Population Health Risk Assessment, University of Ottawa, Ottawa, Ontario, Canada
| | - Harlen D Hays
- Cerner Corporation, Kansas City, Missouri, United States of America
| | - Douglas S McNair
- Cerner Corporation, Kansas City, Missouri, United States of America
| | - Lise M Bjerre
- C. T. Lamont Primary Health Care Research Centre, Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dafna E Kohen
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Santiago Perez-Lloret
- Cardiology Research Institute, University of Buenos Aires, National Research Council (ININCA-UBA-CONICET), Buenos Aires, Argentina
| | - Donald R Mattison
- McLaughlin Centre for Population Health Risk Assessment, University of Ottawa, Ottawa, Ontario, Canada.,Risk Sciences International, Ottawa, Ontario, Canada
| | - Daniel Krewski
- McLaughlin Centre for Population Health Risk Assessment, University of Ottawa, Ottawa, Ontario, Canada.,Risk Sciences International, Ottawa, Ontario, Canada
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van der Meer HG, Wouters H, van Hulten R, Pras N, Taxis K. Decreasing the load? Is a Multidisciplinary Multistep Medication Review in older people an effective intervention to reduce a patient's Drug Burden Index? Protocol of a randomised controlled trial. BMJ Open 2015; 5:e009213. [PMID: 26700279 PMCID: PMC4691761 DOI: 10.1136/bmjopen-2015-009213] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Older people often use medications with anticholinergic or sedative side effects which increase the risk of falling and worsen cognitive impairment. The Drug Burden Index (DBI) is a measure of the burden of anticholinergic and sedative medications. Medication reviews are typically done by a pharmacist in collaboration with a general practitioner to optimise the medication use and reduce these adverse drug events. We will evaluate whether a Multidisciplinary Multistep Medication Review (3MR) is an effective intervention to reduce a patient's DBI. METHODS A randomised controlled trial including 160 patients from 15 community pharmacies will be conducted. Per pharmacy, 1 pharmacist will perform a structured 3MR in close collaboration with the general practitioner, including the objective to reduce the DBI. ANALYSIS Primary outcome--the difference in proportion of patients having a decrease in DBI ≥ 0.5 in the intervention and control groups at follow-up. Secondary outcomes--anticholinergic and sedative side effects, falls, cognitive function, activities of daily living, quality of life, hospital admission, and mortality. ETHICS AND DISSEMINATION The burden of patients will be kept at a minimum. The 3MR can be considered as usual care by the pharmacist and general practitioner. Medical specialists will be consulted, if necessary. The intervention is specifically aimed at older community-dwelling patients in an attempt to optimise prescribing, in particular, to reduce medication with anticholinergic and sedative properties. Study results will be published in peer-reviewed journals and will be distributed through information channels targeting professionals. TRIAL REGISTRATION NUMBER NCT02317666; Pre-results.
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Affiliation(s)
- Helene G van der Meer
- Department of Pharmacy, Section of Pharmacotherapy and Pharmaceutical Care, Groningen Research Institute of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Groningen, Groningen, The Netherlands
| | - Hans Wouters
- Department of Pharmacy, Section of Pharmacotherapy and Pharmaceutical Care, Groningen Research Institute of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Groningen, Groningen, The Netherlands
| | - Rolf van Hulten
- Department of Pharmacy, Section of Pharmacotherapy and Pharmaceutical Care, Groningen Research Institute of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Groningen, Groningen, The Netherlands
| | - Niesko Pras
- Department of Pharmacy, Section of Pharmacotherapy and Pharmaceutical Care, Groningen Research Institute of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Groningen, Groningen, The Netherlands
| | - Katja Taxis
- Department of Pharmacy, Section of Pharmacotherapy and Pharmaceutical Care, Groningen Research Institute of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Groningen, Groningen, The Netherlands
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Zia A, Kamaruzzaman S, Myint PK, Tan MP. Anticholinergic burden is associated with recurrent and injurious falls in older individuals. Maturitas 2015; 84:32-7. [PMID: 26531071 DOI: 10.1016/j.maturitas.2015.10.009] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Revised: 10/11/2015] [Accepted: 10/12/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE While the anticholinergic activity of medications has been linked to cognitive decline, few studies have linked anticholinergic burden with falls in older people. We evaluated the relationship between anticholinergic burden and recurrent and injurious falls among community-dwelling older adults. STUDY DESIGN This case-control study was performed on 428 participants aged ≥65 years, 263 cases with two or more falls or one injurious fall in the preceding 12 months, and 165 controls with no falls in the preceding 12 months. Anticholinergic burden was determined using the anticholinergic cognitive burden (ACB) scale. Upper and lower limb functional abilities were assessed with timed up and go (TUG), functional reach (FR) and grip strength (GS). Logistic regression analysis was employed to calculate the mediation effect of TUG, FR and GS on ACB associated falls. RESULTS Univariate analysis revealed a significant association between an ACB score of ≥1 with falls (OR, 1.8; 95% CI; 1.1-3.0; p=0.01) and significantly poorer TUG and FR. The association between ACB≥1 and falls was no longer significant after adjustment for either TUG (OR for ACB associated falls, 1.4; 95% CI, 0.88-2.4; p=0.14) or FR (OR for ACB associated falls, 1.4; 95% CI, 0.89-2.4, p=0.12) but remained significant with GS. CONCLUSION The association between recurrent and injurious falls and the use of any medications listed in the ACB scale was mediated through gait and balance impairment but not by muscular weakness, providing a novel insight into the potential mechanistic link between ACB and falls. Future studies should determine whether TUG and FR measurements could help inform risk to benefit decisions where ACB medications are being considered.
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Affiliation(s)
- Anam Zia
- Ageing and Age-Associated Disorders Research Group, University of Malaya, Kuala Lumpur, Malaysia.
| | - S Kamaruzzaman
- Ageing and Age-Associated Disorders Research Group, University of Malaya, Kuala Lumpur, Malaysia; Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
| | - Phyo Kyaw Myint
- AGEING, Epidemiology Group, School of Medicine & Dentistry, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - M P Tan
- Ageing and Age-Associated Disorders Research Group, University of Malaya, Kuala Lumpur, Malaysia; Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Centre of Innovation in Medical Engineering, University of Malaya, Kuala Lumpur, Malaysia.
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