Utilization of Lower-Dose Cyclobenzaprine in the Older Inpatient

Background In older inpatients, anticholinergic medications can increase the risk of complications that may increase length of stay (LOS). Cyclobenzaprine is an anticholinergic medication associated with mental status changes, falls, and injuries in older patients. Objective The purpose of this study is to determine whether use of a lower cyclobenzaprine dose (5 mg) compared with higher dosing (10 mg) will affect LOS, 30-day readmission rates, and need for injectable psychotropic agents in inpatients 65 years of age and older. Methods This was a retrospective cohort analysis comparing outcomes in patients 65 years of age and older who received either a 5 mg or 10 mg cyclobenzaprine dose during their inpatient admission over a 2.5-year period. The primary outcome was hospital LOS, adjusted using multivariate linear regression. Secondary outcomes included 30-day readmission rate adjusted using logistic regression and use of injectable antipsychotics or benzodiazepines. A sub-analysis evaluated the impact of the institution's implementation of a geriatric prescribing context (GEM-CON) on cyclobenzaprine dose selection. Results The adjusted LOS was 32.7% longer (95% CI 25.9%-39.9%) for patients exposed to higher-dose cyclobenzaprine. Use of injectable antipsychotics or benzodiazepines was also significantly greater in the higher-dose group (P < 0.001; P = 0.025). Cyclobenzaprine dose was not significantly associated with readmission on multivariate analysis (OR = 0.93, 95% CI 0.45-1.93). After GEM-CON implementation, there was a significant increase in use of the recommended lower cyclobenzaprine dose (P < 0.001). Conclusion Use of lower cyclobenzaprine dosing in older inpatients is associated with reduced hospital LOS and need for injectable antipsychotics and benzodiazepines.

Drugs with a negative impact on cognitive functions (Part 2): drug classes to consider while prescribing in CKD patients

There is growing evidence that chronic kidney disease (CKD) is an independent risk factor for cognitive impairment, especially due to vascular damage, blood-brain barrier disruption and uremic toxins. Given the presence of multiple comorbidities, the medication regimen of CKD patients often becomes very complex. Several medications such as psychotropic agents, drugs with anticholinergic properties, GABAergic drugs, opioids, corticosteroids, antibiotics and others have been linked to negative effects on cognition. These drugs are frequently included in the treatment regimen of CKD patients. The first review of this series described how CKD could represent a risk factor for adverse drug reactions affecting the central nervous system. This second review will describe some of the most common medications associated with cognitive impairment (in the general population and in CKD) and describe their effects.

Potential Risk Factors for, and Clinical Implications of, Delirium during Inpatient Rehabilitation: A Matched Case-Control Study

OBJECTIVES

To investigate the association between a wide set of baseline characteristics (age, sex, rehabilitation discipline), functional scores [Functional Independence Measure (FIM), cumulative Illness Rating Scale (CIRS)], diseases, and administered drugs and incident delirium in rehabilitation inpatients and, furthermore, to assess clinical implications of developing delirium during rehabilitation.

DESIGN

Matched case-control study based on electronic health record data.

SETTING AND PARTICIPANTS

We studied rehabilitation stays of inpatients admitted between January 1, 2015, and December 31, 2018, to ZURZACH Care, Rehaklinik Bad Zurzach, an inpatient rehabilitation clinic in Switzerland.

METHODS

We conducted unconditional logistic regression analyses to estimate adjusted odds ratios (AORs) with 95% CIs of exposures that were recorded in ≥5 cases and controls.

RESULTS

Among a total of 10,503 rehabilitation stays, we identified 125 validated cases. Older age, undergoing neurologic rehabilitation, a low FIM, and a high CIRS were associated with an increased risk of incident delirium. Being diagnosed with a bacterial infection (AOR 2.62, 95% CI 1.06-6.49), a disorder of fluid, electrolyte, or acid-base balance (AOR 2.76, 95% CI 1.19-6.38), Parkinson's disease (AOR 5.68, 95% CI 2.54-12.68), and administration of antipsychotic drugs (AOR 8.06, 95% CI 4.26-15.22), antiparkinson drugs (AOR 2.86, 95% CI 1.42-5.77), drugs for constipation (AOR 2.11, 95% CI 1.25-3.58), heparins (AOR 2.04, 95% CI 1.29-3.24), or antidepressant drugs (AOR 1.88, 95% CI 1.14-3.10) during rehabilitation, or an increased anticholinergic burden (ACB ≥ 3) (AOR 2.59, 95% CI 1.41-4.73) were also associated with an increased risk of incident delirium.

CONCLUSIONS AND IMPLICATIONS

We identified a set of factors associated with an increased risk of incident delirium during inpatient rehabilitation. Our findings contribute to detect patients at risk of delirium during inpatient rehabilitation.

Chronic kidney disease and neurological disorders: are uraemic toxins the missing piece of the puzzle?

Chronic kidney disease (CKD) perturbs the crosstalk with others organs, with the interaction between the kidneys and the heart having been studied most intensively. However, a growing body of data indicates that there is an association between kidney dysfunction and disorders of the central nervous system. In epidemiological studies, CKD is associated with a high prevalence of neurological complications, such as cerebrovascular disorders, movement disorders, cognitive impairment and depression. Along with traditional cardiovascular risk factors (such as diabetes, inflammation, hypertension and dyslipidaemia), non-traditional risk factors related to kidney damage (such as uraemic toxins) may predispose patients with CKD to neurological disorders. There is increasing evidence to show that uraemic toxins, for example indoxyl sulphate, have a neurotoxic effect. A better understanding of factors responsible for the elevated prevalence of neurological disorders among patients with CKD might facilitate the development of novel treatments. Here, we review (i) the potential clinical impact of CKD on cerebrovascular and neurological complications, (ii) the mechanisms underlying the uraemic toxins' putative action (based on pre-clinical and clinical research) and (iii) the potential impact of these findings on patient care.

The effect of the anticholinergic burden on duration and severity of delirium in older hip-surgery patients with and without haloperidol prophylaxis: A post hoc analysis

BACKGROUND

Anticholinergic acting drugs have been associated with delirium in older patients.

OBJECTIVE

To examine the association between the anticholinergic burden (ACB) and the duration and severity of delirium in older hip-surgery patients with or without haloperidol prophylaxis.

METHODS

Older patients with a postoperative delirium following hip surgery from a randomized controlled trial investigating the effects of haloperidol prophylaxis on delirium incidence were included in this study. The ACB was quantified using two different tools, the Anticholinergic Drug Scale and an Expert Panel. Using linear regression, the association between the ACB and delirium was analyzed.

RESULTS

Overall delirium duration and severity were not significantly associated with the ACB. Also, no statistically significant differences were found in delirium duration or severity between the placebo and haloperidol treatment groups for the ACB groups. The protective effect of haloperidol on delirium duration and severity however tended to be present in patients with no or a low ACB but not or to a lesser extent in patients with an intermediate to high ACB.

CONCLUSIONS

The ACB was not significantly associated with delirium duration or severity. Haloperidol prophylaxis tended to shorten delirium duration and decrease delirium severity in patients with no or a low ACB. To further explore the influence of anticholinergic acting drugs on delirium duration and severity and the effect of concomitant haloperidol use, additional research with a higher haloperidol dose, a larger study population, and ACB quantification taking drug exposure into account is warranted.

The Interplay between Anticholinergic Burden and Anemia in Relation to 1-Year Mortality among Older Patients Discharged from Acute Care Hospitals

Anticholinergic burden (ACB) and anemia were found associated with an increased risk of death among older patients. Additionally, anticholinergic medications may contribute to the development of anemia. Therefore, we aimed at investigating the prognostic interplay of ACB and anemia among older patients discharged from hospital. Our series consisted of 783 patients enrolled in a multicenter observational study. The outcome of the study was 1 year mortality. ACB was assessed by an Anticholinergic Cognitive Burden score. Anemia was defined as hemoglobin < 13 g/dL in men and <12 g/dL in women. The association between study variables and mortality was investigated by Cox regression analysis. After adjusting for several potential confounders, ACB score = 2 or more was significantly associated with the outcome in anemic patients (HR = 1.93, 95%CI = 1.13–3.40), but not non anemic patients (HR = 1.51, 95%CI = 0.65–3.48). An additive prognostic interaction between ACB and anemia was observed (p = 0.02). Anemia may represent a relevant effect modifier in the association between ACB and mortality.

Association of Histamine-2 Blockers and Proton-Pump Inhibitors With Delirium Development in Critically Ill Adults: A Retrospective Cohort Study

Supplemental Digital Content is available in the text.

OBJECTIVES:

Histamine-2 receptor antagonists are commonly administered for stress ulcer prophylaxis in critically ill adults and may be associated with delirium development. We aimed to determine differential associations of histamine-2 receptor antagonist or proton-pump inhibitor administration with delirium development in patients admitted to a medical ICU.

DESIGN:

Retrospective observational study using a deidentified database sourced from the University of North Carolina Health Care system. Participants were identified as having delirium utilizing an International Classification of Diseases-based algorithm. Associations among histamine-2 receptor antagonist, proton-pump inhibitor, or no medication administration and delirium were identified using relative risk. Multiple logistic regression was used to control for potential confounders including mechanical ventilation and age.

SETTING:

Academic tertiary care medical ICU in the United States.

PATIENTS:

Adults admitted to the University of North Carolina medical ICU from January 2015 to December 2019, excluding those on concurrent histamine-2 receptor antagonists and proton-pump inhibitors in the same encounter.

INTERVENTIONS:

None.

MEASUREMENTS AND MAIN RESULTS:

We identified 6,645 critically ill patients, of whom 29% (n = 1,899) received mechanical ventilation, 45% (n = 3,022) were 65 or older, and 22% (n = 1,487) died during their medical ICU encounter. Of the 6,645 patients, 31% (n = 2,057) received an histamine-2 receptor antagonist and no proton-pump inhibitors, 40% (n = 2,648) received a proton-pump inhibitor and no histamine-2 receptor antagonists, and 46% (n = 3,076) had delirium. The histamine-2 receptor antagonist group had a greater association with delirium than the proton-pump inhibitor group compared with controls receiving neither medication, after controlling for mechanical ventilation and age (risk ratio, 1.36; 1.25–1.47; p < 0.001) and (risk ratio, 1.15; 1.07–1.24; p < 0.001, respectively).

CONCLUSIONS:

Histamine-2 receptor antagonists are more strongly associated with increased delirium than proton-pump inhibitors. Prospective studies are necessary to further elucidate this association and to determine if replacement of histamine-2 receptor antagonists with proton-pump inhibitors in ICUs decreases the burden of delirium in critically ill patients.

Anticholinergic load and delirium in end-of-life patients

BACKGROUND

Delirium is a neuropsychiatric syndrome associated with negative outcomes, including worsening of cognitive and functional status and an increased burden on patients and caregivers. Medications with anticholinergic effect have been associated with delirium symptoms, but the relationship is still debated.

OBJECTIVE

To assess the relation between delirium and anticholinergic load according to the hypothesis that the cumulative anticholinergic burden increases the risk of delirium.

METHODS

This retrospective cross-sectional study was conducted in a sample of end-of-life patients in a hospice or living at home between February and August 2019. Delirium was diagnosed on admission using the 4 'A's Test (4AT) and each patient's anticholinergic burden was measured with the Anticholinergic Cognitive Burden (ACB) scale.

RESULTS

Of the 461 eligible for analysis, 124 (26.9%) had delirium. Anticholinergic medications were associated with an increased risk of delirium in univariate (OR (95% CI) 1.26 (1.16-1.38), p < 0.0001) and multivariate models adjusted for age, sex, dementia, tumors, Karnofsky Performance Status (KPS) score, days of palliative assistance, and setting (OR (95% CI) 1.16 (1.05-1.28), p < 0.0001). Patients with delirium had a greater anticholinergic burden than those without, with a dose-effect relationship between total ACB score and delirium. Patients who scored 4 or more had 2 or 3 times the risk of delirium than those not taking anticholinergic drugs. The dose-response relationship was maintained in the multivariate model.

CONCLUSIONS

Anticholinergic drugs may influence the development of delirium due to the cumulative effect of multiple medications with modest antimuscarinic activity.

Anticholinergic Burden Does Not Influence Delirium Subtype or the Delirium-Mortality Association in Hospitalized Older Adults: Results from a Prospective Cohort Study

BACKGROUND

Anticholinergic burden (ACB) is associated with an increased risk of delirium in the older population outside of the acute hospital setting. In acute settings, delirium is associated with increased mortality, and this association is greater with full syndromal delirium (FSD) than with subsyndromal delirium (SSD). Little is known about the impact of ACB on delirium prevalence or subtype in hospitalized older adults or the impact on mortality in this population.

OBJECTIVES

Our objectives were to determine whether ACB moderates associations between the subtype of delirium experienced by hospitalized older adults and to explore factors (including ACB) that might moderate consequent associations between delirium and mortality in hospital inpatients.

METHODS

We conducted a retrospective analysis of a cohort of 784 older adults with unplanned admission to a North London acute medical unit between June and December 2007. Univariate regression analyses were performed to explore associations between ACB, as represented by the Anticholinergic Burden Scale (ACBS), delirium subtype (FSD vs. SSD), and mortality.

RESULTS

The mean age of the sample was 83 ± standard deviation (SD) 7.4 years, and the majority of patients were female (59%), lived in their own homes (71%), were without dementia (75%), and died between hospital admission and the end of the 2-year follow-up period (59%). Mean length of admission was 13.2 ± 14.4 days. Prescription data revealed an ACBS score of 1 in 26% of the cohort, of 2 in 12%, and of ≥ 3 in 16%. The mean total ACBS score for the cohort was 1.1 ± 1.4 (range 0-9). Patients with high ACB on admission were more likely to have severe dementia, to have multiple comorbidities, and to live in residential care. Higher ACB was not associated with delirium of either subtype in hospitalized older adults. Delirium itself was associated with increased mortality, and greater associations were seen in FSD (hazard ratio [HR] 2.27; 95% confidence interval [CI] 1.70-3.01) than in SSD (HR 1.58; 95% CI 1.2-2.09); however, ACB had no impact on this relationship.

CONCLUSIONS

ACB was not found to be associated with increased delirium of either subtype or to have a demonstrable impact on mortality in delirium. Prior suggestions of links between ACB and mortality in similar populations may be mediated by higher levels of functional dependence, greater levels of residential home residence, or an increased prevalence of dementia in this population.

Anti-Cholinergic Drug Burden Among Ambulatory Elderly Patients in a Nigerian Tertiary Healthcare Facility

Background: The use of drugs with anticholinergic effects among elderly patients is associated with adverse clinical outcomes. There is paucity of information about anticholinergic drug burden among Nigerian elderly population. Objectives: To determine the anticholinergic drug burden among elderly Nigerian patients. Methods: This was a retrospective cross-sectional study conducted among elderly patients (aged 65 and above) who visited the Family Medicine outpatients' clinics of the Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria between July 1 and October 31, 2018. Information extracted from the case files included patient's age, sex, diagnoses, and list of prescribed medications. Medicines with anticholinergic effects were identified and scored using the anticholinergic drug burden calculator (http://www.acbcalc.com). Results: The medical records of 400 patients were analyzed with females accounting for 60.5% of the study population. The mean age of participants was 73 ± 7.4 years with only 28 (7%) of patients having more than two co-morbid conditions. Polypharmacy was identified in 152 (38%) of the patients while 147 (36.7%) had drugs with anticholinergic effects prescribed. The anticholinergic burden was high in 60 (15%) patients. Polypharmacy was significantly associated with having more than two diagnosed conditions and high anticholinergic burden (p value of < 0 .001 and 0.013 respectively). There was significant correlation between total number of prescribed drugs and count of diagnoses (r = 0.598; p < 0 .000) and between total number of prescribed drugs and number of drugs with anticholinergic effects (r = 0 .196; p < 0 .000). Conclusion: The anticholinergic burden in this group of elderly Nigerian patients was low; majority (67%) had no exposure to drugs with anticholinergic effects with only 15% having high anticholinergic burden. Polypharmacy and multiple diagnosed conditions were positively associated with high anticholinergic burden. Based on the positive and significant correlations found in this study, a reduction in the number of prescribed medicines especially those with significant anticholinergic effects used for secondary indications may lessen the anticholinergic burden among the elderly.

Association between anticholinergic burden and hospital readmission in older patients: a prospective analysis

OBJECTIVE

Despite known adverse effects of anticholinergic (AC) medication, little work has been devoted to the impact of high anticholinergic burden on the rate of hospital readmission. The purpose of this study was to analyze prospectively the link between high AC burden and the rate of all-cause thirty-day hospital readmission in older people.

STUDY DESIGN

This was a prospective non-interventional study conducted from January to August 2019 in one acute-care geriatric ward. All hospital stays of patients aged at least 75 years who were discharged to their home were included in the analysis. AC burden was determined from discharge prescriptions using the Anticholinergic Drug Scale (ADS) and the Anticholinergic Risk Scale (ARS), and defined as high if ≥3.

RESULTS

The analysis concerned 350 hospital stays. Median patient age was 88 years (interquartile interval 84-91). In a multivariate analysis, the risk of hospital readmission within 30 days was not increased for patients with high AC burden (ADS≥3): odds ratio 1.16 [95% confidence interval 0.56-2.37], compared to a patient whose anticholinergic burden was not high.

CONCLUSION

Unlike retrospective studies on this issue, the findings of our prospective analysis do not support a higher risk of hospital admission within 30 days for older people with high AC burden as assessed from their discharge prescriptions.

Decrease of Anticholinergic Drug Use in Nursing Home Residents in the United States, 2009 to 2017

OBJECTIVE

To investigate the time course of anticholinergic drug use in nursing home residents and assess if any temporal change in anticholinergic use varied by nursing home quality rating.

DESIGN

Retrospective repeated cross-sectional analysis of Medicare enrollment, Parts A, B, and D, claims data linked to the Minimum Data Set from 2009 to 2017.

SETTING

Medicare-certified nursing homes.

PARTICIPANTS

Long-term residents 65 years or older with nursing home stay of at least 100 consecutive days within a given calendar year.

MEASUREMENTS

Estimates of anticholinergic drug prescription rates between 2009 and 2017 were based on a binary variable indicating whether a resident received a drug with high anticholinergic activity, as defined by the Anticholinergic Cognitive Burden scale, for at least 1 day during the initial 100 consecutive days of nursing home stay in a given calendar year. We used mixed effects logistic regression models to determine adjusted rates of anticholinergic use each year and test the interaction between nursing home quality rating and year, while adjusting for patient and nursing home characteristics.

RESULTS

The cohort included 786,858 100-day nursing home stays (299,354 unique residents) in 6,703 nursing homes for the years 2009 to 2017. Prescription rates were stable at approximately 34% to 35% between 2009 and 2011, then gradually decreased to 24.3% in 2017 (P < .0001), with the decline being more pronounced in nursing homes having high quality ratings (P < .0001). Rates for anticholinergic drugs in nursing homes with 4 to 5 star quality rating (33.7% in 2011 to 23.3% in 2017) showed a steeper decline over time relative to nursing homes with 1 to 2 star quality rating (34.2% in 2011 to 25.2% in 2017) (P < .0001).

CONCLUSIONS

The use of drugs with high anticholinergic activity has declined from 2009 to 2017, with a greater decline in higher-quality nursing homes.

Hand Grip Strength May Affect the Association Between Anticholinergic Burden and Mortality Among Older Patients Discharged from Hospital

BACKGROUND AND OBJECTIVE

The relationship between anticholinergic burden and mortality is unclear, and the impact of anticholinergic burden on prognosis may vary in the presence of other conditions common in old age. We aimed to investigate the role of hand grip strength as a potential effect modifier in the association between anticholinergic burden and 1-year mortality in older patients discharged from hospital.

METHODS

Our series consisted of 620 older patients consecutively admitted to seven geriatric and internal medicine acute care wards in the context of a prospective multicenter observational study. Overall anticholinergic burden was assessed by Anticholinergic Cognitive Burden (ACB) score. Hand grip strength was assessed by the use of a North Coast medical hand dynamometer and categorized by using sex-specific cut-offs (women < 15 kg, men < 20 kg). The study outcome was 1-year mortality. Statistical analysis was performed by Cox regression analysis.

RESULTS

After adjusting for potential confounders, the co-occurrence of an ACB score of 2 or more and low hand grip strength was significantly associated with mortality (hazard ratio [HR] = 2.30, 95% confidence interval [CI] 1.07-6.01). Stratified analysis confirmed that an ACB score of 2 or more was associated with mortality among patients with low (HR = 2.15, 95% CI 1.08-5.02), but not normal hand grip strength (HR = 0.88, 95% CI 0.13-3.52). The association was confirmed among patients with low hand grip strength after adjusting for the ACB score at the 3-month follow-up (HR = 2.20; 95% CI 1.09-4.87), as well as when considering the ACB score as a continuous variable (HR = 1.24, 95% CI 1.03-1.48).

CONCLUSIONS

The ACB score at discharge may predict mortality among older patients discharged from an acute care hospital with low hand grip strength. Hospital physicians should be aware that prescribing anticholinergic medications in such a vulnerable population may have negative prognostic implications.

The Association Between Drug Burden Index (DBI) and Health-Related Outcomes: A Longitudinal Study of the 'Oldest Old' (LiLACS NZ)

BACKGROUND

The prescribing of medications with anticholinergic and/or sedative properties is considered potentially inappropriate in older people (due to their side-effect profile), and the Drug Burden Index (DBI) is an evidence-based tool which measures exposure to these medications. Life and Living in Advanced Age: a Cohort Study in New Zealand (LiLACS NZ) is an ongoing longitudinal study investigating the determinants of healthy ageing. Using data from LiLACS NZ, this study aimed to determine whether a higher DBI was associated with poorer outcomes (hospitalisation, falls, mortality and cognitive function and functional status) over 36 months follow-up.

METHODS

LiLACS NZ consists of two cohorts: Māori (the indigenous population of New Zealand) aged ≥ 80 years and non-Māori aged 85 years at the time of enrolment. Data relating to regularly prescribed medications at baseline, 12 months and 24 months were used in this study. Medications with anticholinergic and/or sedative properties (i.e. medications with a DBI > 0) were identified using the Monthly Index of Medical Specialities (MIMS) medication formulary, New Zealand. DBI was calculated for everyone enrolled at each time point. The association between DBI at baseline and outcomes was evaluated throughout a series of 12-month follow-ups using negative binomial (hospitalisations and falls), Cox (mortality) and linear (cognitive function and functional status) regression analyses (significance p < 0.05). Regression models were adjusted for age, gender, general practitioner (GP) visits, socioeconomic deprivation, number of medicines prescribed and one of the following: prior hospitalisation, history of falls, baseline cognitive function [Modified Mini-Mental State Examination (3MS)] or baseline functional status [Nottingham Extended Activities of Daily Living (NEADL)].

RESULTS

Full demographic data were obtained for 671, 510 and 403 individuals at baseline, 12 months and 24 months, respectively. Overall, 31%, 30% and 34% of individuals were prescribed a medication with a DBI > 0 at baseline, 12 months and 24 months, respectively. At baseline and 12 months, non-Māori had a greater mean DBI (0.28 ± 0.5 and 0.27 ± 0.5, respectively) compared to Māori (0.16 ± 0.3 and 0.18 ± 0.5, respectively). At baseline, the most commonly prescribed medicines with a DBI > 0 were zopiclone, doxazosin, amitriptyline and codeine. In Māori, a higher DBI was significantly associated with a greater risk of mortality: at 36 months follow-up, adjusted hazard ratio [95% confidence interval (CI)] 1.89 (1.11-3.20), p = 0.02. In non-Māori, a higher DBI was significantly associated with a greater risk of mortality [at 12 months follow-up, adjusted hazard ratio (95% CIs) 2.26 (1.09-4.70), p = 0.03] and impaired cognitive function [at 24 months follow-up, adjusted mean difference in 3MS score (95% CIs) 0.89 (- 3.89 to - 0.41), p = 0.02).

CONCLUSIONS

Using data from LiLACS NZ, a higher DBI was significantly associated with a greater risk of mortality (in Māori and non-Māori) and impaired cognitive function (in non-Māori). This highlights the importance of employing strategies to manage the prescribing of medications with a DBI > 0 in older adults.

Prevalence and Risk Factors for Delirium in Elderly Patients With Severe Burns: A Retrospective Cohort Study

Little is known about delirium in elderly burn center patients. The aim of this study is to provide information on the prevalence of delirium and risk factors contributing to the onset of delirium. All patients aged 70 years or older admitted with burn injuries to the Burn Center, Maasstad Hospital, in 2011 to 2017 were eligible for inclusion. We retrospectively collected data regarding the presence of delirium, potential risk factors contributing to the onset of delirium and outcome after delirium. We included elderly 90 patients in this study. The prevalence of delirium in our population was 13% (N = 12). Risk factors for delirium were advanced age, increased American Society for Anesthesiologists score, physical impairment and the use of anticholinergic drugs during admission. Patients with delirium had a poorer outcome, with prolonged hospital stay and increased mortality 6 and 12 months after discharge. Delirium is diagnosed in 13% of the elderly patients admitted to our burn center. Risk factors for delirium found in this study are advanced age, poor physical health status, physical impairment, and the use of anticholinergic drugs. Delirium is related to poor outcomes, including prolonged hospital stay and mortality after discharge.

Cholinesterase alterations in delirium after cardiosurgery: a German monocentric prospective study

OBJECTIVES

Postoperative delirium (POD) is a common complication after elective cardiac surgery. Recent evidence indicates that a disruption in the normal activity of the cholinergic system may be associated with delirium.

DESIGN

Prospective observational study.

SETTING

Single-centre at a European academic hospital.

PRIMARY AND SECONDARY OUTCOME MEASURES

In our study the enzyme activities of acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) were determined preoperatively as well as on the first and second postoperative day. The confusion assessment method for the intensive care unit was used to screen patients for the presence of POD.

RESULTS

A total of 114 patients were included in the study. POD was associated with a decrease in BChE activity on postoperative day 1 (p=0.03). In addition, patients who developed POD, had significantly lower preoperative AChE activity than patients without POD (p<0.01). Multivariate analysis identified a preoperatively decreased AChE activity (OR 3.1; 95% CI 1.14 to 8.46), anticholinergic treatment (OR 5.09; 95% CI 1.51 to 17.23), elevated European System for Cardiac Operative Risk Evaluation (OR 3.68; 95% CI 1.04 to 12.99) and age (OR 3.02; 95% CI 1.06 to 8.62) to be independently associated with the development of POD.

CONCLUSIONS

We conclude that a reduction in the acetylcholine hydrolysing enzyme activity in patients undergoing cardiac surgery may correlate with the development of POD.

Association between anticholinergic drug burden and mortality in older people: a systematic review

PURPOSE

The purpose of the study is to conduct a systematic review of studies examining the association between anticholinergic burden and mortality in older individuals.

METHODS

A literature search was performed to identify relevant studies, using MEDLINE, EMBASE, PsycINFO and CENTRAL, from January 1990 to December 2018. We included studies of patients with a mean age of 65 years or older where the anticholinergic burden was estimated using anticholinergic risk assessment tools, and associations between anticholinergic load and mortality were investigated. The primary outcome of interest was the association between anticholinergic burden and mortality.

RESULTS

Twenty-seven studies were included. These were three cross-sectional, one nested case-control and 23 prospective or retrospective cohort studies. Most studies were determined to be of good quality. A total of 15 studies reported a positive correlation between anticholinergic burden and mortality, while the remaining 10 studies did not report a significant association. Eighteen out of 27 studies (80%) had a short follow-up period of 1 year or less. Among the five high-quality studies that met all the domains of the quality assessment criteria, four showed a positive association.

CONCLUSION

The variation in results could relate to the quality of the studies, follow-up period, anticholinergic risk assessment tool used and the study setting. Sixty-three percent (n = 17) of all the included studies, but almost all of the high-quality studies with an extended follow-up, reported a positive correlation between anticholinergic burden and mortality. Further high-quality research, using standardized measures and with adequate follow-up periods, is required to confirm the relationship between anticholinergic burden and mortality.

Anticholinergic Medication Burden in Pediatric Prolonged Critical Illness: A Potentially Modifiable Risk Factor for Delirium

OBJECTIVES

It is important to describe and understand the prevalence and risk factors for the syndrome of delirium in critical illness. Since anticholinergic medication may contribute to the development of delirium in the PICU, we have sought to quantify anticholinergic medication exposure in patients with prolonged admission. We have used Anticholinergic Drug Scale scores to quantify the magnitude or extent of this burden.

DESIGN

Retrospective cohort study, January 2011 to December 2015.

SETTING

Single academic medical center PICU.

PATIENTS

Children under 18 years old with a PICU admission of 15 days or longer, requiring mechanical ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Daily Anticholinergic Drug Scale scores for the first 15 days of admission, in each of 88 subjects (total of 1,320 PICU days), were collected and assessed in relation to demographic data, severity of illness, and medication use. Median (interquartile range) of daily Anticholinergic Drug Scale score was 5 (interquartile range, 3-7). Anticholinergic Drug Scale score was not associated with age, sex, medical history, presenting Severity of Illness score, PICU length of stay, ventilator hours, or hospital mortality. Medications most frequently associated with high Anticholinergic Drug Scale score were low potency anticholinergic drugs such as morphine, midazolam, vancomycin, steroids, and furosemide, with the exception of ranitidine (Anticholinergic Drug Scale score 2). Patients receiving high doses of midazolam infusion had significantly higher Anticholinergic Drug Scale scores compared with those receiving lower or no midazolam dosing.

CONCLUSIONS

A high number of medications with anticholinergic effects are administered to PICU patients receiving prolonged mechanical ventilation. These exposures are much higher than those reported in adult intensive care patients. Since anticholinergic drug exposure is associated with delirium, further study of this exposure in PICU patients is needed.

Interactions between drugs and geriatric syndromes in nursing home and home care: results from Shelter and IBenC projects

AIM

Drugs may interact with geriatric syndromes by playing a role in the continuation, recurrence or worsening of these conditions. Aim of this study is to assess the prevalence of interactions between drugs and three common geriatric syndromes (delirium, falls and urinary incontinence) among older adults in nursing home and home care in Europe.

METHODS

We performed a cross-sectional multicenter study among 4023 nursing home residents participating in the Services and Health for Elderly in Long-TERm care (Shelter) project and 1469 home care patients participating in the Identifying best practices for care-dependent elderly by Benchmarking Costs and outcomes of community care (IBenC) project. Exposure to interactions between drugs and geriatric syndromes was assessed by 2015 Beers criteria.

RESULTS

790/4023 (19.6%) residents in the Shelter Project and 179/1469 (12.2%) home care patients in the IBenC Project presented with one or more drug interactions with geriatric syndromes. In the Shelter project, 288/373 (77.2%) residents experiencing a fall, 429/659 (65.1%) presenting with delirium and 180/2765 (6.5%) with urinary incontinence were on one or more interacting drugs. In the IBenC project, 78/172 (45.3%) participants experiencing a fall, 80/182 (44.0%) presenting with delirium and 36/504 (7.1%) with urinary incontinence were on one or more interacting drugs.

CONCLUSION

Drug-geriatric syndromes interactions are common in long-term care patients. Future studies and interventions aimed at improving pharmacological prescription in the long-term care setting should assess not only drug-drug and drug-disease interactions, but also interactions involving geriatric syndromes.

Anticholinergic Prescribing in Medicare Part D Beneficiaries Residing in Nursing Homes: Results from a Retrospective Cross-Sectional Analysis of Medicare Data

BACKGROUND

Prescribing of medications with anticholinergic properties in older nursing home residents is relatively common, despite an association with an increased risk for falls, delirium, and other outcomes. Few studies have investigated what factors influence different levels of prescribing of these agents.

OBJECTIVES

The primary objective was to identify factors associated with low- and high-level anticholinergic burden in nursing home residents. A secondary objective was to examine in detail the contribution of different medications to low versus high burden to aid in determining which drugs to target in interventions.

METHODS

This was a retrospective, cross-sectional analysis of a national sample of 2009-2010 Medicare Part A and B claims, Part D prescription drug events, and Minimum Data Set (MDS) v2.0 assessments. The cohort included 4730 Medicare beneficiaries aged ≥ 65 years with continuous Medicare Parts A, B, and D enrollment, admitted for non-skilled stays of ≥ 14 days between 1 January 2010 and 30 September 2010. Anticholinergic burden was defined using the Anticholinergic Cognitive Burden (ACB) scale. Medication scores were summed at the patient level and categorized as high (score ≥ 3), low (score 1-2), or none. Baseline predisposing factors (age, sex, race/ethnicity), enabling factors (prior year hospitalization, emergency department, primary care, specialist visits; region; Medicaid/low-income subsidy), and medical need factors (dementia severity, anti-dementia medication, Charlson co-morbidity index [CCI], select comorbidities) were evaluated for association with anticholinergic burden using multinomial logistic regression.

RESULTS

Overall, 29.6% of subjects had a high anticholinergic burden and 35.2% had a low burden. High burden was most often (72%) due to one highly anticholinergic medication rather than a cumulative effect. In adjusted analyses, factors associated with increased risk of both low and high anticholinergic burden included comorbidity, antidementia medication, depression, hypertension, and prior year hospitalization. Older age was associated with decreased odds of high anticholinergic burden. Urinary incontinence and prior year specialist visit were associated with increased odds of high anticholinergic burden. Severe and nonsevere dementia were associated with decreased odds of low burden but increased odds of high burden.

CONCLUSION

Almost two-thirds of nursing home patients have some degree of anticholinergic burden. Several medical need variables are significantly associated with increased risk for low and high anticholinergic burden. Interventions should be developed to optimize prescribing for residents at increased risk of receiving medications with anticholinergic properties. Future study is needed to evaluate the difference in the risk of adverse outcomes associated with various levels of anticholinergic burden.

Differentiating Delirium From Sedative/Hypnotic-Related Iatrogenic Withdrawal Syndrome: Lack of Specificity in Pediatric Critical Care Assessment Tools

OBJECTIVES

To identify available assessment tools for sedative/hypnotic iatrogenic withdrawal syndrome and delirium in PICU patients, the evidence supporting their use, and describe areas of overlap between the components of these tools and the symptoms of anticholinergic burden in children.

DATA SOURCES

Studies were identified using PubMed and EMBASE from the earliest available date until July 3, 2016, using a combination of MeSH terms "delirium," "substance withdrawal syndrome," and key words "opioids," "benzodiazepines," "critical illness," "ICU," and "intensive care." Review article references were also searched.

STUDY SELECTION

Human studies reporting assessment of delirium or iatrogenic withdrawal syndrome in children 0-18 years undergoing critical care. Non-English language, exclusively adult, and neonatal intensive care studies were excluded.

DATA EXTRACTION

References cataloged by study type, population, and screening process.

DATA SYNTHESIS

Iatrogenic withdrawal syndrome and delirium are both prevalent in the PICU population. Commonly used scales for delirium and iatrogenic withdrawal syndrome assess signs and symptoms in the motor, behavior, and state domains, and exhibit considerable overlap. In addition, signs and symptoms of an anticholinergic toxidrome (a risk associated with some common PICU medications) overlap with components of these scales, specifically in motor, cardiovascular, and psychiatric domains.

CONCLUSIONS

Although important studies have demonstrated apparent high prevalence of iatrogenic withdrawal syndrome and delirium in the PICU population, the overlap in these scoring systems presents potential difficulty in distinguishing syndromes, both clinically and for research purposes.

Factors predicting incidence of post-operative delirium in older people following hip fracture surgery: a systematic review and meta-analysis

OBJECTIVE

Delirium is one of the most common complications following hip fracture surgery in older people. This study identified pre- and peri-operative factors associated with the development of post-operative delirium following hip fracture surgery.

METHODS

Published and unpublished literature were searched to identify all evidence reporting variables on patient characteristics, on-admission, intra-operative and post-operative management assessing incident delirium in older people following hip fracture surgery. Pooled odds ratio (OR) and mean difference of those who experienced delirium compared to those who did not were calculated for each variable. Evidence was assessed using the Downs and Black appraisal tool and interpreted using the GRADE approach.

RESULTS

A total of 6704 people (2090 people with post-operative delirium) from 32 studies were analysed. There was moderate evidence of nearly a two-times greater probability of post-operative delirium for those aged 80 years and over (OR: 1.77; 95% CI: 1.09, 2.87), whether patients lived in a care institution pre-admission (OR: 2.65; 95% CI: 1.79, 3.92), and a six-times greater probability of developing post-operative delirium with a pre-admission diagnosis of dementia (OR: 6.07, 95% CI: 4.84, 7.62). There was no association with intra-operative variables and probability of delirium.

CONCLUSION

Clinicians treating people with a hip fracture should be vigilant towards post-operative delirium if their patients are older, have pre-existing cognitive impairment and poorer overall general health. This is also the case for those who experience post-operative complications such as pneumonia or a urinary tract infection. Copyright © 2017 John Wiley & Sons, Ltd.

The anticholinergic impregnation scale: Towards the elaboration of a scale adapted to prescriptions in French psychiatric settings

PURPOSE

Some drugs have anticholinergic activity and can cause peripheral or central side effects. Several scales exist to evaluate the potential anticholinergic effect of prescribed drugs but: (i) they are validated in the elderly and mainly assess the cognitive side effect of treatments; (ii) they do not concern some of the drugs frequently used in clinical psychiatry in France. The aim of our study is to develop a new scale, the anticholinergic impregnation scale (AIS), with drugs used in France and based on an assessment of the drugs used against peripheral anticholinergic adverse effects.

METHODS

We assigned a score, ranging from 1 to 3, to a list of 128 drugs with a consensus approach obtained via literature data and expert opinions. We collected data from 7278 prescriptions in 34 French psychiatric facilities: age, sex, atropinic drugs, laxatives and treatments of xerophthalmia and xerostomia, in order to evaluate the association between AIS score and the prescription of drugs aiming to reduce peripheral anticholinergic side effects.

RESULTS

The most frequently prescribed drugs were cyamemazine (n=1429; 20%) and tropatepine (n=1403; 19%), two drugs marketed almost exclusively in France and with a score of 3. The frequency of patients with a high AIS score, greater than 5, was significantly higher in patients who received laxatives and treatments of xerostomia. AIS score represents the first validated solution to evaluate anticholinergic load in psychiatry settings in France.

CONCLUSION

The anticholinergic problem remains underevaluated in mental health settings. In order to rule out the confounding factor of mental disease, assessment of peripheral side effects can be considered more objective than the evaluation of cognitive function in psychiatric patients. Building scales appropriate for each state also appear essential to obtain an useful and effective tool in clinical practice.

Associations between Anticholinergic Burden and Adverse Health Outcomes in Parkinson Disease

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.