Anticholinergic drugs use and risk of hip fracture in geriatric patients

Deprescribing psychotropic medications is associated with improvements in activities of daily living in post-stroke patients

AIMS

To examine the effect of deprescribing psychotropic medications on activities of daily living (ADLs) and swallowing function in patients undergoing convalescent rehabilitation following a stroke.

METHODS

In this retrospective cohort study, patients who underwent convalescent rehabilitation after a stroke were divided into two groups: deprescribing (number of psychotropic medications decreased during hospitalization) and non-deprescribing (number of psychotropic medications increased or remained unchanged). The primary outcome measure was ADLs assessed using the Functional Independence-Measured Motor Activity (FIM-motor) score at discharge. A multiple linear regression analysis was conducted to determine the independent association between deprescribing psychotropic medications and rehabilitation outcomes.

RESULTS

Of the 586 patients enrolled, 128 with a mean age of 74.1 ± 12.7 years were included in the final analysis after being prescribed psychotropic medications, with 36 of them (28.1%) in the deprescribing group. Multiple linear regression analysis revealed that deprescribing psychotropic medications was independently associated with FIM-motor function at discharge.

CONCLUSIONS

Deprescribing psychotropic medications is positively associated with improvements in ADLs among patients undergoing convalescent rehabilitation after a stroke. Geriatr Gerontol Int 2024; 24: 275-282.

Anticholinergic Load Is Associated with Swallowing Dysfunction in Convalescent Older Patients after a Stroke

This study aimed to establish whether anticholinergic load affects the swallowing function of geriatric stroke patients in convalescent stages, as no proven association between the anticholinergic load-based Anticholinergic Risk Scale and the swallowing dysfunction in Japanese patients was known. A retrospective cohort study was conducted on hospitalized older patients undergoing rehabilitation after stroke. The study outcomes included evaluating the patients at hospital discharge using the Functional Oral Intake Scale. To evaluate the effects of an increased anticholinergic load, we used a multivariate analysis to examine whether the change in the Anticholinergic Risk Scale during hospitalization was associated with the outcome. Of 542 enrolled patients, 345 (63.7%) presented with cerebral infarction, 148 (27.3%) with intracerebral hemorrhage, and 49 (9%) with subarachnoid hemorrhage. The change in the Anticholinergic Risk Scale was independently associated with the Functional Oral Intake Scale (β = −0.118, p = 0.0164) at discharge. Among anticholinergics, the use of chlorpromazine, hydroxyzine, haloperidol, metoclopramide, risperidone, etc., increased significantly from admission to discharge. An increased anticholinergic load was associated with swallowing dysfunction in older patients undergoing stroke rehabilitation.

A meta-analysis of observational studies on anticholinergic burden and fracture risk: evaluation of conventional burden scales

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.

The extent of polypharmacy and use of 'fall risk increasing drugs' in the oldest old admitted to a regional New South Wales hospital

OBJECTIVE(S)

Polypharmacy is associated with significant morbidity including cognitive decline and falls. We sought to quantify the extent of polypharmacy and use of medications associated with fall risk in the very old admitted to a regional NSW hospital.

METHODS

Cross-sectional study of patients aged over 80 years admitted to a regional NSW hospital from September to October 2019. Demographic data and medication usage on admission were collected. Polypharmacy was defined as regular use of five or more medications.

RESULTS

A total of 401 patients were included: mean age was 87.2 (±4.6) years and 56.9% were female. Of the participations, 82.9% experienced polypharmacy, and the mean number of medications was 8.2 (±4.2). Of the patients, 91.6% utilised medications associated with risk of falls. There was no association between age and number of preadmission regular medications.

CONCLUSION

Polypharmacy is extremely common prior to acute hospitalisation for regional older individuals. This highlights the importance of medication rationalisation to reduce medication-related harm.

Quality of anticholinergic burden scales and their impact on clinical outcomes: a systematic review

PURPOSE

Older people are at risk of anticholinergic side effects due to changes affecting drug elimination and higher sensitivity to drug's side effects. Anticholinergic burden scales (ABS) were developed to quantify the anticholinergic drug burden (ADB). We aim to identify all published ABS, to compare them systematically and to evaluate their associations with clinical outcomes.

METHODS

We conducted a literature search in MEDLINE and EMBASE to identify all published ABS and a Web of Science citation (WoS) analysis to track validation studies implying clinical outcomes. Quality of the ABS was assessed using an adapted AGREE II tool. For the validation studies, we used the Newcastle-Ottawa Scale and the Cochrane tool Rob2.0. The validation studies were categorized into six evidence levels based on the propositions of the Oxford Center for Evidence-Based Medicine with respect to their quality. At least two researchers independently performed screening and quality assessments.

RESULTS

Out of 1297 records, we identified 19 ABS and 104 validations studies. Despite differences in quality, all ABS were recommended for use. The anticholinergic cognitive burden (ACB) scale and the German anticholinergic burden scale (GABS) achieved the highest percentage in quality. Most ABS are validated, yet validation studies for newer scales are lacking. Only two studies compared eight ABS simultaneously. The four most investigated clinical outcomes delirium, cognition, mortality and falls showed contradicting results.

CONCLUSION

There is need for good quality validation studies comparing multiple scales to define the best scale and to conduct a meta-analysis for the assessment of their clinical impact.

Anticholinergic Burden and Fractures: A Systematic Review with Methodological Appraisal

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.

Quality of anticholinergic burden scales and their impact on clinical outcomes: a systematic review

Purpose

Older people are at risk of anticholinergic side effects due to changes affecting drug elimination and higher sensitivity to drug’s side effects. Anticholinergic burden scales (ABS) were developed to quantify the anticholinergic drug burden (ADB). We aim to identify all published ABS, to compare them systematically and to evaluate their associations with clinical outcomes.

Methods

We conducted a literature search in MEDLINE and EMBASE to identify all published ABS and a Web of Science citation (WoS) analysis to track validation studies implying clinical outcomes. Quality of the ABS was assessed using an adapted AGREE II tool. For the validation studies, we used the Newcastle-Ottawa Scale and the Cochrane tool Rob2.0. The validation studies were categorized into six evidence levels based on the propositions of the Oxford Center for Evidence-Based Medicine with respect to their quality. At least two researchers independently performed screening and quality assessments.

Results

Out of 1297 records, we identified 19 ABS and 104 validations studies. Despite differences in quality, all ABS were recommended for use. The anticholinergic cognitive burden (ACB) scale and the German anticholinergic burden scale (GABS) achieved the highest percentage in quality. Most ABS are validated, yet validation studies for newer scales are lacking. Only two studies compared eight ABS simultaneously. The four most investigated clinical outcomes delirium, cognition, mortality and falls showed contradicting results.

Conclusion

There is need for good quality validation studies comparing multiple scales to define the best scale and to conduct a meta-analysis for the assessment of their clinical impact.

Electronic supplementary material

The online version of this article (10.1007/s00228-020-02994-x) contains supplementary material, which is available to authorized users.

Rehabilitation pharmacotherapy: A scoping review

Many patients in rehabilitation facilities are affected by polypharmacy. Polypharmacy is associated with rehabilitation outcomes and functional recovery. Consequently, a combination of rehabilitation and pharmacotherapy may improve the outcomes of older people undergoing rehabilitation. A recent report described the concept of rehabilitation pharmacotherapy. The concept envisages helping frail older people and people with disabilities to achieve the highest possible body function, activity level and quality of life. There are two key tenets of rehabilitation pharmacotherapy: "pharmacotherapy in consideration of rehabilitation" and "rehabilitation in consideration of pharmacotherapy." "Pharmacotherapy in consideration of rehabilitation" includes use of drugs to treat impairment, activity limitation and participation restriction based on the International Classification of Functioning, Disability, and Health. "Rehabilitation in consideration of pharmacotherapy" refers to tailoring of rehabilitation considering the content of pharmacotherapy. With respect to drugs and motor dysfunction, anticholinergic drugs are associated with dysphagia and fractures. Increased use of potentially inappropriate medications may adversely affect the nutritional status. With respect to activities of daily living, polypharmacy and use of potentially inappropriate medications negatively affect the improvement in motor function during rehabilitation. Potent anticholinergic drugs are more likely to impede the improvement in cognitive function. In this review, we address the concept of rehabilitation pharmacotherapy and discuss its importance from the perspective of polypharmacy, the effect of drugs on disability and disease, nutritional status and activities of daily living. Geriatr Gerontol Int 2020; 20: -.

Use of a Bioinformatics-Based Toxicity Scoring System to Assess Serotonin Burden and Predict Population-Level Adverse Drug Events from Concomitant Serotonergic Drug Therapy

STUDY OBJECTIVE

Numerous medications interact at serotonin (5-hydroxytryptamine [5-HT]) receptors directly or through off-target interactions, causing mild to severe serotonergic adverse drug events (ADEs), particularly among older adults. Our objective was to develop a novel molecular-based toxicity scoring system to assess serotonergic burden resulting from concurrently administered drugs. Quantitative methods to assess serotonergic burden may provide a useful clinical tool for improving pharmacotherapy.

DESIGN

Retrospective cohort study.

DATA SOURCES

PharMetrics Legacy health claims database (January 2001-December 2013) and ChEMBL bioactivity database.

PATIENTS

A 2-serotonergic drug exposure cohort (78,172 patients) and a 3-serotonergic drug exposure cohort (19,900 patients) were generated, and population-level statistics were collected. Nonexposure cohorts were created for each drug exposure cohort and matched in a 4:1 ratio for age, sex, and length of enrollment.

MEASUREMENTS AND MAIN RESULTS

Eight 5-HT medications were screened against multiple bioactivity databases to identify their off-target interactions at 5-HT receptors and serotonin reuptake transporter protein. A computational serotonin burden score (SBS) was derived from the receptor-specific interaction propensities reported from the comprehensive bioactivity screen. Linear regression was used to characterize associations between SBSs and combined total ADE incidence rate detected by International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis codes. A significantly greater incidence of 17 potential 5-HT-related ADEs was seen in exposed serotonergic drug cohorts (p<0.05). A positive correlation between SBS and overall ADE incidence rate in the 2-serotonergic drug exposure cohort (R²  = 0.69, p<0.34) and 3-drug cohort (R²  = 0.85, p<0.01) was observed. When both drug cohorts were combined, total drug SBSs strongly correlated with the composite 5-HT adverse event rate (R²  = 0.92, p<0.0001). Despite an increasing burden of illness, these data suggest that drug combinations with higher SBSs are associated with a higher rate of potential serotonergic ADEs.

CONCLUSION

In this test of concept, positive associations between SBSs and serotonin-related ADEs suggest that it may offer a pharmacologic-based foundation for developing risk assessment tools to assist in optimizing pharmacotherapy.

Influence of Antipsychotics on Functional Prognosis after Geriatric Hip Fracture

OBJECTIVE

To investigated the effects of antipsychotics on rehabilitation outcomes for geriatric hip fracture inpatients.

DESIGN

Retrospective cohort study.

SETTING

The registry data from the Japan Rehabilitation Nutrition Database for analysis.

PARTICIPANTS

Of the 234 patients in the Japan Rehabilitation Nutrition Database admitted between November 2015 and March 2018, 214 met the eligibility criteria.

MEASUREMENTS

The antipsychotics were phenothiazine, butyrophenone, benzamide, and atypical antipsychotics. For hip fracture patients, the following information was registered: (a) admission data: age, sex, Charlson Comorbidity Index, Functional Independence Measure (FIM) at admission, medications, height, body weight, and Mini Nutritional Assessment-Short Form score (MNA-SF) and (b) discharge data: discharge destination, FIM at discharge, MNA-SF, and total units of provided rehabilitation therapy (one unit = 20 minutes based on the national healthcare insurance policy).

RESULTS

Thirteen patients (6.1%) were prescribed antipsychotics. According to the multiple linear regression analysis, antipsychotics negatively affected FIM efficiency (β=-0.190, 95% confidence interval, -0.652 to -0.104, p=0.007). Furthermore, on logistic regression analysis, fall during hospitalization was correlated with the use of antipsychotics (odds ratio=4.376, 95% confidence interval: 1.153 to 16.612, p=0.030).

CONCLUSION

The use of antipsychotics impaired the improvement of the activities of daily living (ADL) and increased the incidence of fall during hospitalization. Reviewing medication therapies at admission may further improve ADL.