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Tsang CCS, Wang J, Shih YCT. Cost-effectiveness of medication therapy management among Medicare population and across racial/ethnic groups. Medicine (Baltimore) 2024; 103:e37935. [PMID: 38701304 PMCID: PMC11062681 DOI: 10.1097/md.0000000000037935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 03/28/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Inappropriate medication utilization among older adults is a pressing concern in the United States, owing to its high prevalence and the consequential detrimental impact it engenders. The adverse effects stemming from the inappropriate use of medication may be unequally borne by racial/ethnic minority populations, calling for greater efforts towards promoting equity in healthcare. The study objective was to assess the cost-effectiveness of Medication Therapy Management (MTM) services among Medicare beneficiaries and across racial/ethnic groups. METHODS Medicare administrative data from 2016 to 2017 linked to Area Health Resources Files were used to analyze Medicare fee-for-service patients aged 65 or above with continuous Parts A/B/D coverage. The intervention group included new MTM enrollees in 2017; the control group referred to patients who met the general MTM eligible criteria but did not enroll in 2016 or 2017. The 2 groups were matched using a propensity score method. Effectiveness was evaluated as the proportion of appropriate medication utilization based on performance measures developed by the Pharmacy Quality Alliance. Costs were computed as total healthcare costs from Medicare perspective. A multivariable net benefit regressions with a classic linear model and Bayesian analysis were utilized. Net benefit was calculated based on willingness-to-pay thresholds at various multiples of the gross domestic product in 2017. Three-way interaction terms among dummy variables for MTM enrollment, 2017, and racial/ethnic minority groups were incorporated in a difference-in-differences study design. RESULTS After adjusting for patient characteristics, the findings indicate that MTM receipt was associated with incremental net benefit among each race and ethnicity. For instance, the net benefit of MTM among the non-Hispanic White patients was $2498 (95% confidence interval = $1609, $3386) at a willingness-to-pay value of $59,908. The study found no significant difference in net benefits for MTM services between minority and White patients. CONCLUSION The study provides evidence that MTM is a cost-effective tool for managing medication utilization among the Medicare population. However, MTM may not be cost-effective in reducing racial/ethnic disparities in medication utilization in the short term. Further research is needed to understand the long-term cost-effectiveness of MTM on racial/ethnic disparities.
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Affiliation(s)
- Chi Chun Steve Tsang
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, TN
| | - Junling Wang
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, TN
| | - Ya-Chen Tina Shih
- University of California, Los Angeles, School of Medicine, Los Angeles, CA
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Aldridge Z, Dening KH. Incontinence in people living with dementia. Br J Community Nurs 2024; 29:S8-S14. [PMID: 38728161 DOI: 10.12968/bjcn.2024.29.sup5.s8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
Dementia and incontinence are both prevalent in older age; yet, neither are an inevitable or normal part of ageing. It has been recognised that there is a skills and knowledge gap in professionals assessing and managing incontinence for people living with dementia. All too often, assumptions are made that incontinence is a symptom of dementia and that nothing can be done if a person living with dementia experiences episodes of incontinence. While dementia may impact on a person's ability to remain continent, it may not be the sole cause, and there may be treatments and strategies that can reduce the incidence in those affected. Therefore, a person-centred continence assessment should be undertaken to promote continence and reduce the impact of incontinence for people living with dementia and those who care for them. This paper will highlight some of the issues that are important for health and social care professionals to explore and identify, assess and manage incontinence to improve outcomes for families affected by dementia.
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Affiliation(s)
- Zena Aldridge
- Registered Mental Health Nurse; Independent Dementia Nurse Consultant
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Talwar A, Chatterjee S, Sherer J, Abughosh S, Johnson M, Aparasu RR. Cumulative Anticholinergic Burden and its Predictors among Older Adults with Alzheimer's Disease Initiating Cholinesterase Inhibitors. Drugs Aging 2024; 41:339-355. [PMID: 38467994 DOI: 10.1007/s40266-024-01103-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Cumulative anticholinergic burden refers to the cumulative effect of multiple medications with anticholinergic properties. However, concomitant use of cholinesterase inhibitors (ChEIs) and anticholinergic burden can nullify the benefit of the treatment and worsen Alzheimer's disease (AD). A literature gap exists regarding the extent of the cumulative anticholinergic burden and associated risk factors in AD. Therefore, this study evaluated the prevalence and predictors of cumulative anticholinergic burden among patients with AD initiating ChEIs. METHODS A retrospective longitudinal cohort study was conducted using the Medicare claims data involving parts A, B, and D from 2013 to 2017. The study sample included older adults (65 years and older) diagnosed with AD and initiating ChEIs (donepezil, rivastigmine, or galantamine). The cumulative anticholinergic burden was calculated based on the Anticholinergic Cognitive Burden scale and patient-specific dosing using the defined daily dose over the 1 year follow-up period after ChEI initiation. Incremental anticholinergic burden levels were dichotomized into moderate-high (sum of standardized daily anticholinergic exposure over a year (TSDD) score ≥ 90) versus low-no (score 0-89). The Andersen Behavioral Model was used as the conceptual framework for selecting the predictors under the predisposing, enabling, and need categories. A multivariable logistic regression model was used to evaluate the predictors of high-moderate versus low-no cumulative anticholinergic burden. A multinomial logistic regression model was also used to determine the factors associated with patients having moderate and high burdens compared to low/no burdens. RESULTS The study included 222,064 older adults with AD with incident ChEI use (mean age 82.24 ± 7.29, 68.9% females, 83.6% White). Overall, 80.48% had some anticholinergic burden during the follow-up, with 36.26% patients with moderate (TSDD scores 90-499), followed by 24.76% high (TSDD score > 500), and 19.46% with low (TSDD score 1-89) burden categories. Predisposing factors such as age; African American, Asian, or Hispanic race; and need factors included comorbidities such as dyslipidemia, syncope, delirium, fracture, pneumonia, epilepsy, and claims-based frailty index were less likely to be associated with the moderate-high anticholinergic burden. The factors that increased the odds of moderate-high burden were predisposing factors such as female sex; enabling factors such as dual eligibility and diagnosis year; and need factors such as baseline burden, behavioral and psychological symptoms of dementia, depression, insomnia, urinary incontinence, irritable bowel syndrome, anxiety, muscle spasm, gastroesophageal reflux disease, heart failure, and dysrhythmia. Most of these findings remained consistent with multinomial logistic regression. CONCLUSION: Four out of five older adults with AD had some level of anticholinergic burden, with over 60% having moderate-high anticholinergic burden. Several predisposing, enabling, and need factors were associated with the cumulative anticholinergic burden. The study findings suggest a critical need to minimize the cumulative anticholinergic burden to improve AD care.
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Affiliation(s)
- Ashna Talwar
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX, USA
| | | | - Jeffrey Sherer
- Department of Pharmacy Practice and Translational Research, College of Pharmacy, University of Houston, Houston, TX, USA
| | - Susan Abughosh
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX, USA
| | - Michael Johnson
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX, USA
| | - Rajender R Aparasu
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Houston, TX, USA.
- Department of Pharmaceutical Health Outcomes and Policy, Adjunct Professor of Geriatrics, UTHealth McGovern Medical School, Health and Biomedical Sciences Building 2 - Office 4052, College of Pharmacy, University of Houston, 4349 Martin Luther King Boulevard, Houston, TX, 77204-5047, USA.
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Bhatkhande G, Choudhry NK, Mahesri M, Haff N, Lauffenburger JC. Disentangling drug contributions: anticholinergic burden in older adults linked to individual medications: a cross-sectional population-based study. BMC Geriatr 2024; 24:44. [PMID: 38200457 PMCID: PMC10782746 DOI: 10.1186/s12877-023-04640-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/26/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Medications with potent anticholinergic properties have well-documented adverse effects. A high cumulative anticholinergic burden may arise from the concurrent use of multiple medications with weaker anticholinergic effects. We sought to identify patterns of high anticholinergic burden and associated patient characteristics. METHODS We identified patients aged ≥ 65 who filled ≥ 1 medication with anticholinergic adverse effects in 2019 and had a cumulative Anticholinergic Burden score (ACB) ≥ 4 (i.e., high anticholinergic burden) in a large US health insurer. We classified patients based on how they attained high burden, as follows: 1) only filling strong or moderate anticholinergic medications (i.e., ACB = 2 or 3, "moderate/strong"), 2) only filling lightly anticholinergic medications (i.e., ACB = 1, "light/possible"), and 3) filling any combination ("mix"). We used multinomial logistic regression to assess the association between measured patient characteristics and membership in the three anticholinergic burden classifications, using the moderate/strong group as the referent. RESULTS In total, 83,286 eligible patients with high anticholinergic burden were identified (mean age: 74.3 years (SD:7.1), 72.9% female). Of these, 4.5% filled only strong/moderate anticholinergics, 4.3% filled only light/possible anticholinergics, and the rest filled a mix (91.2%). Within patients in the mixed group, 64.3% of medication fills were for light/possible anticholinergics, while 35.7% were for moderate/strong anticholinergics. Compared with patients in the moderate/strong anticholinergics group, patients filling only light/possible anticholinergics were more likely to be older (adjusted Odds Ratio [aOR] per 1-unit of age: 1.06, 95%CI: 1.05-1.07), less likely to be female (aOR: 0.56, 95%CI: 0.50-0.62 vs. male), more likely to have comorbidities (e.g., heart failure aOR: 3.18, 95%CI: 2.70-3.74 or depression aOR: 1.20, 95%CI: 1.09-1.33 vs. no comorbidity), and visited fewer physicians (aOR per 1-unit of change: 0.98, 95%CI: 0.97-0.98). Patients in the mixed group were older (aOR per 1-unit of age: 1.02, 95%CI: 1.02-1.03) and less likely to be female (aOR: 0.89, 95%CI: 0.82-0.97 vs. male) compared with those filling moderate/strong anticholinergics. CONCLUSION Most older adults accumulated high anticholinergic burden through a combination of light/possible and moderate/strong anticholinergics rather than moderate/strong anticholinergics, with light/possible anticholinergics being the major drivers of overall anticholinergic burden. These insights may inform interventions to improve prescribing in older adults.
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Affiliation(s)
- Gauri Bhatkhande
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Niteesh K Choudhry
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Mufaddal Mahesri
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
| | - Nancy Haff
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Julie C Lauffenburger
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA, 02120, USA.
- Center for Healthcare Delivery Sciences (C4HDS), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.
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Saz HG, Yalçın N, Demirkan K, Halil MG. Clinical pharmacist-led assessment and management of anticholinergic burden and fall risk in geriatric patients. BMC Geriatr 2023; 23:863. [PMID: 38102545 PMCID: PMC10724986 DOI: 10.1186/s12877-023-04599-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/14/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND The aim of this study was to examine the risk of fall with the surrogate outcome of the Aachen Falls Prevention Scale and to assess the clinical pharmacist interventions in order to minimize anticholinergic drug burden and associated risk of fall according to a fall risk assessment scale in the older adults. METHODS Patients who admitted to the geriatric outpatient clinic of a university hospital and taking at least one anticholinergic drug were evaluated both retrospectively and prospectively as groups of different patients by the clinical pharmacist. Patients' anticholinergic burden was assessed using the Anticholinergic Cognitive Burden Scale. For fall risk assessment, the Aachen Falls Prevention Scale was also administered to each patient whose anticholinergic burden was determined in the prospective phase of the study. RESULTS A total of 601 patients were included. Risk of falls increased 2.50 times in patients with high anticholinergic burden (OR (95% CI) = 2.503 (1.071-5.852); p = 0.034), and the existing history of falls increased the risk of high anticholinergic burden 2.02 times (OR (95%CI) = 2.026 (1.059-3.876); p = 0.033). In addition, each unit increase in the fall scale score in the prospective phase increased the risk of high anticholinergic burden by 22% (p = 0.028). Anticholinergic burden was significantly reduced as a result of interventions by the clinical pharmacist in the prospective phase (p = 0.010). CONCLUSION Our study revealed that incorporating a clinical pharmacist in the handling of geriatric patients aids in the detection, reduction, and prevention of anticholinergic adverse effects.
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Affiliation(s)
- Hilal Gökçay Saz
- Department of Clinical Pharmacy, Faculty of Pharmacy, Hacettepe University, Ankara, 06230, Turkey
| | - Nadir Yalçın
- Department of Clinical Pharmacy, Faculty of Pharmacy, Hacettepe University, Ankara, 06230, Turkey.
| | - Kutay Demirkan
- Department of Clinical Pharmacy, Faculty of Pharmacy, Hacettepe University, Ankara, 06230, Turkey
| | - Meltem Gülhan Halil
- Division of Geriatric Medicine, Department of Internal Medine, Faculty of Medicine, Hacettepe University, Ankara, 06230, Turkey
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Gruneir A, Youngson E, Dobbs B, Wagg A, Williamson T, Duerksen K, Garies S, Soos B, Forst B, Bakal J, Manca DP, Drummond N. Older persons living with dementia and their use of acute care services over 2 years in Alberta. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2023; 69:114-124. [PMID: 36813522 PMCID: PMC9945888 DOI: 10.46747/cfp.6902114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVE To characterize transitions to acute and residential care and identify variables associated with specific transitions among community-based persons living with dementia (PLWD). DESIGN Retrospective cohort study using primary care electronic medical record data linked with health administrative data. SETTING Alberta. PARTICIPANTS Adults aged 65 years or older living in the community who had been diagnosed with dementia and who saw a Canadian Primary Care Sentinel Surveillance Network contributor between January 1, 2013, and February 28, 2015. MAIN OUTCOME MEASURES All emergency department visits, hospitalizations, residential care (supportive living and long-term care) admissions, and deaths within a 2-year follow-up period. RESULTS In total, 576 PLWD were identified who had a mean (SD) age of 80.4 (7.7) years; 55% were female. In 2 years, 423 (73.4%) had at least 1 transition and, of these, 111 (26.2%) had 6 or more. Emergency department visits, including multiple visits, were common (71.4% had ≥1, 12.1% had ≥4). Of those hospitalized (43.8%), nearly all were admitted from the emergency department; the average (SD) length of stay was 23.6 (35.8) days, and 32.9% had at least 1 alternate level of care day. In total, 19.3% entered residential care, most admitted from hospital. Those admitted to hospital and those admitted to residential care were older and had greater historical health system use, including home care. One-quarter of the sample did not have any transitions (or die) during follow-up; they were typically younger and had limited historical health system use. CONCLUSION Older PLWD experienced frequent, and frequently compound, transitions that have implications for them, their family members, and the health system. There was also a large proportion without transitions suggesting that appropriate supports enable PLWD to do well in their own communities. The identification of PLWD who are at risk of or who make frequent transitions may allow for more proactive implementation of community-based supports and smoother transitions to residential care.
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Affiliation(s)
- Andrea Gruneir
- Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton.
| | - Erik Youngson
- Biostatistician in the Data Platform of the Alberta SPOR (Strategy for Patient-Oriented Research) SUPPORT (Support for People and Patient-Oriented Research and Trials) Unit at the University of Alberta
| | - Bonnie Dobbs
- Professor in the Department of Family Medicine at the University of Alberta
| | - Adrian Wagg
- Professor in the Department of Medicine at the University of Alberta
| | - Tyler Williamson
- Associate Professor of Biostatistics in the Department of Community Health Sciences at the University of Calgary in Alberta
| | - Kim Duerksen
- Research Coordinator in the Department of Family Medicine at the University of Alberta
| | - Stephanie Garies
- Postdoctoral fellow at the MAP Centre for Urban Health Solutions in Toronto, Ont
| | - Boglarka Soos
- Doctoral student and Data Administrator in the Department of Family Medicine and the Department of Community Health Sciences at the University of Calgary
| | - Brian Forst
- Data Manager in the Department of Family Medicine at the University of Alberta
| | - Jeff Bakal
- Program Director for Provincial Research Data Services at Alberta Health Services
| | - Donna P Manca
- Professor in the Department of Family Medicine at the University of Alberta
| | - Neil Drummond
- Professor and Research Chair in Primary Care in the Department of Family Medicine at the University of Alberta
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Maltais A, Simard M, Vedel I, Sirois C. Changes in Polypharmacy and Psychotropic Medication Use After Diagnosis of Major Neurocognitive Disorders: A Population-based Study in Québec, Canada. Alzheimer Dis Assoc Disord 2022; 36:222-229. [PMID: 35661072 DOI: 10.1097/wad.0000000000000513] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 04/30/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Older adults with major neurocognitive disorder (MNCD) are often exposed to polypharmacy. We aimed to assess the prescribing and discontinuation patterns of medications following diagnosis of MNCD among community-dwelling older adults. METHODS Using the Quebec Integrated Chronic Disease Surveillance System, we conducted a population-based cohort study comparing 1-year prediagnosis and postdiagnosis use of medications between a group of individuals older than 65 years newly diagnosed with MNCD in 2016-2017 and a control group without MNCD. The difference-in-difference method was used to estimate the prediagnosis and postdiagnosis variation in the number of medications prescribed and in the proportion of psychotropic and anticholinergic medication users. RESULTS In the MNCD group, the mean number of medications used (excluding Alzheimer disease treatments) increased by 1.25 in the year after the diagnosis. The respective increase was 0.45 in the control group, yielding an adjusted difference-in-differences of 0.81 (95% confidence interval: 0.74; 0.87) between groups. The adjusted difference-in-differences in the proportions of antipsychotic, antidepressant, and anticholinergic medication users was 13.2% (12.5; 13.9), 7.1% (6.5; 7.7), and 3.8% (3.1; 4.6), respectively. CONCLUSIONS The medication burden among older adults tends to increase in the year following a diagnosis of MNCD. The use of antipsychotics and antidepressants may explain a part of the observed increase.
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Affiliation(s)
- Annie Maltais
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University
- Quebec Center of Excellence on Aging, Research Center of the CHU of Quebec
| | - Marc Simard
- Department of Social and Preventive Medicine, Faculty of Medicine, Laval University
- Quebec Center of Excellence on Aging, Research Center of the CHU of Quebec
- Quebec National Institute of Public Health, Québec
| | - Isabelle Vedel
- Quebec National Institute of Public Health, Québec
- Lady Davis Institute of the Jewish General Hospital
- Department of Family Medicine, McGill University, Montreal, QC, Canada
| | - Caroline Sirois
- Faculty of Pharmacy, Laval University
- Quebec Center of Excellence on Aging, Research Center of the CHU of Quebec
- Quebec National Institute of Public Health, Québec
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Khong TK, Threapleton CJD. Prescribing of anticholinergic medicines to patients initiating dementia medicines. Drug Ther Bull 2020; 58:83-84. [PMID: 32385044 DOI: 10.1136/dtb.2020.000020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Commentary on: Narayan SW, Pearson SA, Litchfield M, et al Anticholinergic medicines use among older adults before and after initiating dementia medicines. BJCP 2019;85:1957-1963.Commentary by: Dr Christopher JD Threapleton and Dr Teck Khong, Clinical Pharmacology, St George's, University of London, UKSeries Editor: Dr Teck Khong, DTB Associate Editor, Clinical Pharmacology, St George's, University of London, London, UK.
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Affiliation(s)
- Teck K Khong
- Clinical Pharmacology, St George's, University of London, London, UK
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Temporal Trends in the Use of Anticholinergic Drugs Among Older People Living in Long-Term Care Facilities in Helsinki. Drugs Aging 2020; 37:27-34. [PMID: 31705445 PMCID: PMC6965041 DOI: 10.1007/s40266-019-00720-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background The use of drugs with anticholinergic properties (DAPs) is common among older adults despite their known adverse effects, such as cognitive decline. Professionals should pay attention to DAPs, since evidence on their adverse effects has been accumulating during the last decade. However, to our knowledge previous studies exploring temporal trends in the use of DAPs are scarce. Objective The aim of this study was to assess temporal trends in the use of DAPs from 2003 to 2017 in long-term care facilities in Helsinki. Methods Four cross-sectional studies were conducted in 2003, 2007, 2011, and 2017. Participants included older people (≥ 65 years) living in nursing homes (NHs) in 2003 (n = 1979), 2011 (n = 1568), and 2017 (n = 750), and in assisted living facilities (ALFs) in 2007 (n = 1336), 2011 (n = 1556), and 2017 (n = 1673) in Helsinki, Finland. Data on demographics, medication use, and diagnoses were collected by structured questionnaires. The assessments were conducted as a point prevalence over 1 day. The use of DAPs and the total anticholinergic burden were defined by the Anticholinergic Risk Scale (ARS). Results In ALFs, there has been an increasing trend in the use of DAPs over a 10-year period (41.2% in 2007 and 53.7% in 2017). In NHs, by contrast, the use of DAPs remained quite stable (52.3% in 2003 and 52.4% in 2017). The burden of DAPs measured by ARS score decreased in NHs and remained stable in ALFs. Marked changes occurred in the DAPs used; antidepressants, especially mirtazapine, increased in both settings, whereas the use of hydroxyzine and urinary antispasmodics nearly disappeared. The proportion of users of DAP antipsychotics increased in ALFs. Participants with dementia had a lower anticholinergic burden than those without dementia, in both settings. Conclusions Despite increased knowledge of the harms of DAPs, they remain widely used. Physicians seem to be aware of the harms of DAPs among people with dementia, and some other favorable trends in prescribing were also observed. Clinicians should especially consider the indications behind the use of DAP antidepressants and antipsychotics, and carefully weigh their potential benefits and harms.
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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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Zhu L, Rochon PA, Gruneir A, Wu W, Giannakeas V, Austin PC, Stall NM, McCarthy L, Alberga A, Herrmann N, Gill SS, Bronskill SE. Sex Differences in the Prevalent Use of Oral Formulations of Cholinesterase Inhibitors in Older Adults with Dementia. Drugs Aging 2019; 36:875-884. [PMID: 31309528 DOI: 10.1007/s40266-019-00690-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cholinesterase inhibitors (ChEIs) are one of only two drug therapies available to manage cognitive decline in dementia. Given sex-specific differences in medication access and effects, it is important to understand how ChEIs are used by women and men. OBJECTIVE The objective of this study was to provide contemporary sex-stratified evidence on patterns of ChEI use by community-dwelling older adults with dementia to inform opportunities to optimize drug prescribing. METHODS We conducted a population-based cross-sectional study examining ChEI use in older adults with dementia in Ontario, Canada. We identified all community-dwelling individuals aged 66 years and older with a pre-existing diagnosis of dementia as of 1 April, 2016. We examined the prevalence of ChEI use among women and men separately, and explored the association between ChEI use and age, sex, income status, geographic location of residence, use of palliative care services, comorbidity, and polypharmacy. Concurrent use of drugs known to impair cognition (including antipsychotics, benzodiazepines, and medications with strong anticholinergic properties) was separately assessed among women and men using multivariable analyses and prevalence risk ratios. RESULTS Of 74,799 women and 52,231 men living with dementia in the community, nearly 30% currently were using a ChEI (29.3% women, 28.6% men). Close to 70% of users were receiving the target therapeutic dose. Compared to men, women were less often taking the target therapeutic dose (67.8% women vs. 71.6% men, p < 0.001). Over 20% of users also were using drugs known to impair cognition, while being treated for cognitive decline using ChEIs. Compared to men, women were more often concurrently using drugs known to impair cognition (23.9% women vs. 21.8% men, p < 0.001). CONCLUSIONS This is one of the first studies of ChEI use to account for important sex differences. The results remind clinicians and researchers that patterns of ChEI therapy use differ by sex, as women were less likely to receive target therapeutic doses and more vulnerable to potentially problematic polypharmacy than men.
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Affiliation(s)
- Lynn Zhu
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
| | - Paula A Rochon
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.,Department of Medicine, University of Toronto, Room 2109, 1 King's College Circle, Medical Sciences Building, Toronto, ON, M5S 1A8, Canada.,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, 4th Floor, 155 College Street, Toronto, ON, M5T 3M6, Canada.,ICES, G1 06, G-Wing, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Andrea Gruneir
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.,ICES, G1 06, G-Wing, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, AB, T6G 2T4, Canada
| | - Wei Wu
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada
| | - Vasily Giannakeas
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.,ICES, G1 06, G-Wing, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Peter C Austin
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, 4th Floor, 155 College Street, Toronto, ON, M5T 3M6, Canada.,ICES, G1 06, G-Wing, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Nathan M Stall
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.,Department of Medicine, University of Toronto, Room 2109, 1 King's College Circle, Medical Sciences Building, Toronto, ON, M5S 1A8, Canada.,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, 4th Floor, 155 College Street, Toronto, ON, M5T 3M6, Canada
| | - Lisa McCarthy
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, M5S 3M2, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, ON, M5G 1V7, Canada
| | - Amanda Alberga
- ICES, G1 06, G-Wing, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Nathan Herrmann
- Department of Psychiatry, University of Toronto, 8th Floor, 250 College Street, Toronto, ON, M5T 1R8, Canada
| | - Sudeep S Gill
- ICES, G1 06, G-Wing, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Department of Medicine, Queen's University, Etherington Hall, Rooms 3032-3043, 94 Stuart Street, Kingston, ON, K7L 3N6, Canada
| | - Susan E Bronskill
- Women's College Research Institute, Women's College Hospital, 76 Grenville Street, Toronto, ON, M5S 1B2, Canada. .,Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, 4th Floor, 155 College Street, Toronto, ON, M5T 3M6, Canada. .,ICES, G1 06, G-Wing, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
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13
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Phan SV, Osae S, Morgan JC, Inyang M, Fagan SC. Neuropsychiatric Symptoms in Dementia: Considerations for Pharmacotherapy in the USA. Drugs R D 2019; 19:93-115. [PMID: 31098864 PMCID: PMC6544588 DOI: 10.1007/s40268-019-0272-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Dementia affects all domains of cognition. The relentless progression of the disease after diagnosis is associated with a 98% incidence of neuropsychiatric symptoms (NPS) at some point in the disease, including depression, psychosis, agitation, aggression, apathy, sleep disturbances, and disinhibition. These symptoms can be severe and lead to excess morbidity and mortality. The purpose of this article was to describe current literature on the medication management of NPS of dementia and highlight approaches to and concerns about the pharmacological treatment of NPS in the USA. Guidelines and expert opinion favor nonpharmacologic management of NPS as first-line management. Unfortunately, lack of adequate caregiver training and a high failure rate eventually result in the use of psychotropic agents in patients with dementia. Various psychotropic medications have been studied, although how they should be used in the management of NPS remains unclear. A systematic approach to evaluation, treatment, and monitoring, along with careful documentation and evidenced-based agent and dose selection, is likely to reduce risk and improve patient outcomes. Considerations should be given to the NPS presentation, including type, frequency, and severity, when weighing the risks and benefits of initiating, continuing, or discontinuing psychotropic management. Use of antidepressants, sedative/hypnotics, antipsychotics, and antiepileptic agents should include a clear and documented analysis of risk and benefit in a given patient with dementia.
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Affiliation(s)
- Stephanie V Phan
- Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Southwest Georgia Clinical Campus, Albany, GA, USA.
| | - Sharmon Osae
- Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Southwest Georgia Clinical Campus, Albany, GA, USA
| | - John C Morgan
- Memory Disorders Program, Department of Neurology, Augusta University, Augusta, GA, USA
| | - Mfon Inyang
- Phoebe Putney Memorial Hospital, Albany, GA, USA
| | - Susan C Fagan
- Memory Disorders Program, Department of Neurology, Augusta University, Augusta, GA, USA.,Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Augusta, GA, USA.,Program in Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, Augusta, GA, USA
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14
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Impact of anticholinergic burden on emergency department visits among older adults in Korea: A national population cohort study. Arch Gerontol Geriatr 2019; 85:103912. [DOI: 10.1016/j.archger.2019.103912] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 06/20/2019] [Accepted: 07/09/2019] [Indexed: 11/19/2022]
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15
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Eshetie TC, Nguyen TA, Gillam MH, Kalisch Ellett LM. Potentially inappropriate prescribing in people with dementia: An Australian population-based study. Int J Geriatr Psychiatry 2019; 34:1498-1505. [PMID: 31173395 DOI: 10.1002/gps.5160] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 06/01/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To investigate the prevalence of potentially inappropriate prescribing (PIP) using the Screening Tool of Older Person's Prescriptions (STOPP) criteria in people with dementia compared with people without dementia. METHODS A retrospective cohort study was conducted using the Pharmaceutical Benefits Scheme 10% sample of pharmacy claims. People with dementia were defined as those dispensed a medicine for dementia (cholinesterase inhibitors, memantine, or risperidone for behavioural and psychological symptoms of dementia) between 1 January 2005 and 31 December 2015, aged 65 years or older at 1 January 2016 and alive at the end of 2016. An age- and gender-matched comparison cohort of people not dispensed medicines for dementia was identified. PIP prevalence was determined between 1 January 2016 and 31 December 2016. RESULTS In total, 8280 people dispensed medicines for dementia and 41 400 comparisons not dispensed medicines for dementia were included: 63% were female and the median age was 82 years. PIP prevalence was 79% among people with dementia compared with 70% among the comparison group (P < .0001). Use of anticholinergics, long-term use of high-dose proton pump inhibitors, and use of benzodiazepines were the most common instances of PIP in people with dementia. After adjustments for age, gender, comorbidity, and number of prescribers, people with dementia were more likely to be exposed to PIP than comparisons (adjusted OR 1.44, 95% CI, 1.35-1.53, P < .0001). CONCLUSIONS PIP was more common in people dispensed medicines for dementia than comparisons. These results highlight the need for effective interventions to optimize prescribing in people with dementia.
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Affiliation(s)
- Tesfahun C Eshetie
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Tuan A Nguyen
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Marianne H Gillam
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Lisa M Kalisch Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
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16
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Reinold J, Palese F, Romanese F, Logroscino G, Riedel O, Pisa FE. Anticholinergic burden before and after hospitalization in older adults with dementia: Increase due to antipsychotic medications. Int J Geriatr Psychiatry 2019; 34:868-880. [PMID: 30761624 DOI: 10.1002/gps.5084] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 02/03/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To evaluate changes in the use of antipsychotics and medications with anticholinergic activity (MACs) during hospitalization in older adults with dementia and factors associated with antipsychotic prescriptions and increased anticholinergic burden (ACB). METHODS AND DESIGN This retrospective cohort study included all patients aged 65 years or older with a discharge diagnosis of dementia hospitalized at the university hospital of Udine, Italy, from 2012 to 2014. Medications dispensed within 3 months before and after hospitalization were identified in community-pharmacy dispensations while those prescribed at discharge were collected from Hospital Electronic Medical Records (EMR). ACB was assessed using the Anticholinergic Cognitive Burden score. RESULTS Among 1908 patients included, at discharge, 37.0% used one or more antipsychotic (9.4% before and 12.6% after hospitalization), 68.6% used one or more MAC (49.1% and 45.7%, respectively), and ACB of 38.4% of patients increased at discharge mainly because of a higher use of antipsychotics with anticholinergic activity (33% at discharge vs 12% before hospitalization). Prescription of antipsychotics at discharge was associated with prior treatment with antipsychotics (adjusted odds ratio [aOR] 4.85; 95%CI, 3.37-6.97), psychiatric conditions, (4.39; 3.47-5.54) and discharge from surgical department (2.17; 1.32-3.55). An increased ACB was associated with psychiatric conditions (1.91; 1.52-2.39), discharge from surgical (1.75; 1.09-2.80) or medical department (1.50; 1.04-2.17), and with cardiac insufficiency (1.41; 1.00-1.99). CONCLUSIONS ACB was higher at discharge, and antipsychotics were the main drivers of this increase. Clinicians treating older adults with dementia should be aware of the risks associated with antipsychotics and that some of these medications may increase the risk of anticholinergic effects.
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Affiliation(s)
- Jonas Reinold
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology BIPS, Bremen, Germany
| | | | | | - Giancarlo Logroscino
- Neurodegenerative Diseases Unit, Department of Basic Medicine Neuroscience and Sense Organs, Department of Clinical Research in Neurology of the University of Bari at "Pia Fondazione Card. G.Panico" Hospital Tricase, University of Bari, Lecce, Italy
| | - Oliver Riedel
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology BIPS, Bremen, Germany
| | - Federica E Pisa
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology BIPS, Bremen, Germany
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17
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Abstract
OBJECTIVES Older adults with dementia are particularly vulnerable to adverse outcomes resulting from anticholinergic use. We aimed to: (i) Examine the anticholinergic burden of patients with dementia attending a Psychiatry of Later Life (PLL) service (ii) Examine concomitant prescription of acetylcholinesterase inhibitors (AChEIs) and anticholinergics and (iii) Compare the Anticholinergic Cognitive Burden (ACB) scale with a recently published composite list of anticholinergics. METHODS Retrospective chart review of new referrals with a diagnosis of dementia (n = 66) seen by the PLL service, Tallaght University Hospital, Dublin, Ireland, over a consecutive period of 4 months. RESULTS The mean ACB score was 2.2 (range = 0-9, SD = 2.1). 37.9% (n = 25) had a clinically significant ACB score (>3) and 42.1% (n = 8) of those taking AChEIs had a clinically significant ACB score. A significantly greater number of medications with anticholinergic activity were identified using the composite list versus the traditional ACB scale (2.3 v.1.5, p = 0.001). CONCLUSIONS We demonstrated a significant anticholinergic burden amongst patients with dementia attending a specialist PLL service. There was no difference in anticholinergic burden between groups prescribed and not prescribed AChEIs, indicating that these medications are being prescribed without discontinuation of potentially inappropriate medications with anticholinergic activity. The true anticholinergic burden experienced by patients may be underestimated by the use of the ACB score alone, although the clinical significance of this finding is unclear. Calculation of true clinical anticholinergic burden load and its translation to a specific rating scale remains a challenge.
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18
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Ah Y, Suh Y, Jun K, Hwang S, Lee J. Effect of anticholinergic burden on treatment modification, delirium and mortality in newly diagnosed dementia patients starting a cholinesterase inhibitor: A population‐based study. Basic Clin Pharmacol Toxicol 2019; 124:741-748. [DOI: 10.1111/bcpt.13184] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/28/2018] [Indexed: 01/07/2023]
Affiliation(s)
- Young‐Mi Ah
- College of Pharmacy Yeungnam University Gyeongsangbuk‐do Korea
| | - Yewon Suh
- College of Pharmacy and Research Institute of Pharmaceutical Sciences Seoul National University Seoul Korea
| | - Kwanghee Jun
- College of Pharmacy and Research Institute of Pharmaceutical Sciences Seoul National University Seoul Korea
| | - Sunghee Hwang
- College of Pharmacy and Institute of Pharmaceutical Science and Technology Hanyang University Ansan Korea
| | - Ju‐Yeun Lee
- College of Pharmacy and Research Institute of Pharmaceutical Sciences Seoul National University Seoul Korea
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19
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Moore A, Frank C, Chambers LW. [Not Available]. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2018; 64:e418-e421. [PMID: 30315030 PMCID: PMC6184956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Ainsley Moore
- Professeure clinicienne agrégée au Département de médecine familiale de l'Université McMaster à Hamilton (Ontario).
| | - Christopher Frank
- Professeur au Département de médecine de l'Université Queen's à Kingston (Ontario)
| | - Larry W Chambers
- Professeur émérite en méthodes de recherche, données probantes et impacts à l'Université McMaster, et directeur de la recherche au Campus régional de Niagara de la Faculté de médecine Michael G. DeGroote à l'Université McMaster
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20
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Moore A, Frank C, Chambers LW. Role of the family physician in dementia care. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2018; 64:717-719. [PMID: 30315013 PMCID: PMC6184977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Ainsley Moore
- Associate Clinical Professor in the Department of Family Medicine at McMaster University in Hamilton, Ont.
| | - Christopher Frank
- Professor in the Department of Medicine at Queen's University in Kingston, Ont
| | - Larry W Chambers
- Professor Emeritus of Research Methods, Evidence and Impact at McMaster University and Research Director of the Niagara Regional Campus of the Michael G. DeGroote School of Medicine at McMaster University
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21
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Triantafylidis LK, Clemons JS, Peron EP, Roefaro J, Zimmerman KM. Brain Over Bladder: A Systematic Review of Dual Cholinesterase Inhibitor and Urinary Anticholinergic Use. Drugs Aging 2018; 35:27-41. [PMID: 29350336 DOI: 10.1007/s40266-017-0510-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Case reports have demonstrated that dual use of cholinesterase inhibitors (ChIs) and urinary anticholinergics (UAChs) in older adults may be associated with delusions, aggression, changes in cognition, and anxiety, which typically resolve on drug discontinuation. Despite opposing mechanisms of action, these drugs continue to be co-prescribed. OBJECTIVE This systematic review evaluates cognitive and functional outcomes of dual use of ChIs and UAChs and describes its prevalence. PATIENTS AND METHODS A literature search using terms related to ChIs and UAChs was conducted. Observational or interventional studies evaluating cognitive or functional outcomes in subjects receiving dual therapy were included for the primary aim. Articles describing prevalence of dual use were included for the secondary aim. RESULTS Of 1340 unique results, five studies met the inclusion criteria for the primary aim. Four of the studies assessed cognitive outcomes-three failed to identify a significant difference in cognitive function with dual use and the fourth study observed a statistically significant improvement in cognition with dual use of high-dose donepezil and solifenacin when compared with baseline. Three studies assessed functional outcomes-one revealed a 50% greater quarterly decline in activities of daily living (p = 0.01) among dual users functioning in the top quartile, another revealed significant functional improvement in dual users, and the final study did not demonstrate a significant difference. Seventeen articles were included for the secondary aim. Prevalence of dual use ranged from 1.2 to 40.5%. CONCLUSION This systematic review revealed a high prevalence of dual use of ChIs and UAChs; however, there are mixed results for cognitive and functional outcomes. Results were limited by methodological flaws. Observational or interventional studies assessing dual users are lacking and further study of cognitive and functional risks of dual ChI and UACh use is needed.
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Affiliation(s)
- Laura K Triantafylidis
- Department of Pharmacy, VA Boston Healthcare System, 150 S Huntington Avenue, Jamaica Plain, MA, 02130, USA.
| | - Jenna S Clemons
- Clinical Pharmacy Services, Kaiser Permanente Mid-Atlantic, 6501 Loisdale Ct, Springfield, VA, 22150, USA
| | - Emily P Peron
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, 410 N. 12th Street, PO Box 980533, Richmond, VA, 23298-0533, USA
| | - John Roefaro
- Department of Pharmacy, VA Boston Healthcare System, 150 S Huntington Avenue, Jamaica Plain, MA, 02130, USA
| | - Kristin M Zimmerman
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, 410 N. 12th Street, PO Box 980533, Richmond, VA, 23298-0533, USA
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22
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Green AR, Reifler LM, Boyd CM, Weffald LA, Bayliss EA. Medication Profiles of Patients with Cognitive Impairment and High Anticholinergic Burden. Drugs Aging 2018; 35:223-232. [PMID: 29404965 DOI: 10.1007/s40266-018-0522-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Drugs with anticholinergic properties are considered potentially inappropriate in patients with cognitive impairment because harms-including delirium, falls, and fractures-may outweigh benefits. OBJECTIVE To highlight opportunities to improve clinical decision making and care for patients with cognitive impairment and multiple chronic conditions, we identified distinct subgroups of patients with mild cognitive impairment (MCI) and dementia who had high cumulative anticholinergic burden and specific patterns of anticholinergic use. PATIENTS AND METHODS We conducted a retrospective cohort study in a not-for-profit, integrated delivery system. Participants included community-dwelling adults aged 65 years and older (n = 13,627) with MCI or dementia and at least two other chronic diseases. We calculated the Anticholinergic Cognitive Burden (ACB) score for each participant from pharmacy and electronic health record (EHR) data. Among individuals with a mean 12-month ACB score ≥ 2, we used agglomerative hierarchical clustering to identify groups or clusters of individuals with similar anticholinergic prescription patterns. RESULTS Twenty-four percent (3257 participants) had high anticholinergic burden, defined as an ACB score ≥ 2. Clinically meaningful clusters based upon anchoring medications or drug classes included a cluster of cardiovascular medications (n = 1497; 46%); two clusters of antidepressant medications (n = 633; 20%); and a cluster based on use of bladder antimuscarinics (n = 431; 13%). Several clusters comprised multiple central nervous system (CNS)-active drugs. CONCLUSIONS Cardiovascular and CNS-active medications comprise a substantial portion of anticholinergic burden in people with cognitive impairment and multiple chronic conditions. Antidepressants were highly prevalent. Clinical profiles elucidated by these clusters of anticholinergic medications can inform targeted approaches to care.
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Affiliation(s)
- Ariel R Green
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th Floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA.
| | - Liza M Reifler
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Ave. Suite 300, Denver, CO, 80207, USA
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Mason F. Lord Center Tower, 7th Floor, 5200 Eastern Avenue, Baltimore, MD, 21224, USA
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Linda A Weffald
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Ave. Suite 300, Denver, CO, 80207, USA
- University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Elizabeth A Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E. Harvard Ave. Suite 300, Denver, CO, 80207, USA.
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
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23
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Niznik J, Zhao X, Jiang T, Hanlon JT, Aspinall SL, Thorpe J, Thorpe C. Anticholinergic Prescribing in Medicare Part D Beneficiaries Residing in Nursing Homes: Results from a Retrospective Cross-Sectional Analysis of Medicare Data. Drugs Aging 2018; 34:925-939. [PMID: 29214512 DOI: 10.1007/s40266-017-0502-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
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.
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Affiliation(s)
- Joshua Niznik
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA. .,VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA. .,Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, USA.
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.,University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, USA
| | - Tao Jiang
- University of Pittsburgh, Pittsburgh, USA
| | - Joseph T Hanlon
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.,Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, USA.,Geriatric Research Education and Clinical Center, Pittsburgh, USA
| | - Sherrie L Aspinall
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.,VA Center for Medication Safety, Pittsburgh, USA.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, USA
| | - Joshua Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, USA
| | - Carolyn Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, USA
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Cossette B, Bagna M, Sene M, Sirois C, Lefebvre GP, Germain O, Morais JA, Gaudreau P, Payette H. Association Between Anticholinergic Drug Use and Health-Related Quality of Life in Community-Dwelling Older Adults. Drugs Aging 2018; 34:785-792. [PMID: 28801707 DOI: 10.1007/s40266-017-0486-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The use of drugs with anticholinergic properties (AC drugs) has been associated with decreased functioning and impaired cognition in older adults. Studies assessing the association between AC-drug use and health-related quality of life (HRQoL) show conflicting results. OBJECTIVE The aim was to evaluate the association between AC-drug use and HRQoL in community-dwelling older adults. METHODS The NuAge cohort study enrolled 1793 men and women aged 68-82 years. The participants were free of disabilities in activities of daily living, not cognitively impaired at recruitment and followed annually for 3 years (December 2003-May 2005). AC-drug exposure was assessed using the Anticholinergic Cognitive Burden Scale (ACBS). HRQoL was assessed using the physical (PCS) and mental (MCS) component summaries of the 36-item Short Form Survey (SF-36) questionnaire. The association between AC drug and HRQoL was determined by a mixed model analysis using four annual time points. RESULTS At recruitment the mean age was 74.4 ± 4.2 years, 52% were female and 33% of participants were prescribed at least one AC drug. The mean PCS and MCS (/100) scores were 49.0 ± 8.2 and 54.9 ± 8.1, respectively. In the mixed model analysis, an increase of 1 on the ACBS was associated with a decrease of -0.50 (95% CI -0.68 to -0.31) in the PCS and an increase of 0.19 (95% CI 0.01-0.37) in the MCS. CONCLUSIONS In a cohort of generally healthy community-dwelling older adults, AC-drug exposure was associated with a statistically significant decrease in the PCS and increase in the MCS throughout the entire follow-up period. However, the effects on the PCS and MCS were small and likely not clinically relevant.
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Affiliation(s)
- Benoit Cossette
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada. .,Research Centre on Aging, Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Canada. .,Department of Pharmacy, Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Canada.
| | - Maimouna Bagna
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada.,Research Centre on Aging, Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Canada
| | - Modou Sene
- Research Centre on Aging, Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Canada
| | - Caroline Sirois
- Département de médecine sociale et préventive, Université Laval, Quebec City, Québec, Canada.,Centre d'excellence sur le vieillissement de Québec, Quebec City, Québec, Canada.,Institut national de santé publique du Québec, Quebec City, Québec, Canada
| | - Gabrielle P Lefebvre
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Olivier Germain
- Department of Mathematics, Université de Sherbrooke, Sherbrooke, Canada
| | - José A Morais
- Division of Geriatric Medicine, McGill University, Montréal, Canada
| | - Pierrette Gaudreau
- Centre Hospitalier de l'Université de Montréal Research Center, Montréal, Canada.,Department of Medicine, University of Montréal, Montréal, Canada
| | - Hélène Payette
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada.,Research Centre on Aging, Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Canada
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25
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Cross AJ, George J, Woodward MC, Ames D, Brodaty H, Wolfe R, Connors MH, Elliott RA. Potentially Inappropriate Medication, Anticholinergic Burden, and Mortality in People Attending Memory Clinics. J Alzheimers Dis 2017; 60:349-358. [DOI: 10.3233/jad-170265] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Amanda J. Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Michael C. Woodward
- Medical and Cognitive Research Unit, Austin Health, Heidelberg, VIC, Australia
| | - David Ames
- National Ageing Research Institute, Parkville, VIC, Australia
- University of Melbourne Academic Unit for Psychiatry of Old Age, St George’s Hospital, Kew, VIC, Australia
| | - Henry Brodaty
- Dementia Collaborative Research Centre, School of Psychiatry, UNSW Australia, Sydney, NSW, Australia
- Center for Healthy Brain Ageing, School of Psychiatry, UNSW Australia, Sydney, NSW, Australia
| | - Rory Wolfe
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Michael H. Connors
- Dementia Collaborative Research Centre, School of Psychiatry, UNSW Australia, Sydney, NSW, Australia
- Center for Healthy Brain Ageing, School of Psychiatry, UNSW Australia, Sydney, NSW, Australia
| | - Rohan A. Elliott
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
- Pharmacy Department, Austin Health, Heidelberg, VIC, Australia
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26
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Is Dementia Screening of Apparently Healthy Individuals Justified? Adv Prev Med 2017; 2017:9708413. [PMID: 28932605 PMCID: PMC5591898 DOI: 10.1155/2017/9708413] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 06/01/2017] [Accepted: 06/14/2017] [Indexed: 01/10/2023] Open
Abstract
Despite efforts to raise awareness and develop guidelines for care of individuals with dementia, reports of poor detection and inadequate management persist. This has led to a call for more identification of people with dementia, that is, screening individuals who may or may not complain of symptoms of dementia in both acute settings and primary care. The following should be considered before recommending screening for dementia among individuals in the general population. Dementia Tests. Low prevalence reduces positive predictive value of tests and screening tests will miss people who have dementia and identify people who do not have dementia in substantial numbers. Clinical Issues. The clinical course of dementia has not yet been shown to be amenable to intervention. Misdiagnosis and overdiagnosis can have significant long-term effects including stigmatization, loss of employment, and autonomy. Economic Issues. Health systems do not have the capacity to respond to increased demand resulting from screening. In conclusion, at present attention to life-course risk reduction and support in the community for frail and cognitively impaired older adults is a better use of limited healthcare resources than introduction of unevaluated dementia screening programs.
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27
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Naharci MI, Cintosun U, Ozturk A, Oztin H, Turker T, Bozoglu E, Doruk H. Effect of anticholinergic burden on the development of dementia in older adults with subjective cognitive decline. PSYCHIAT CLIN PSYCH 2017. [DOI: 10.1080/24750573.2017.1358130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Mehmet Ilkin Naharci
- Gulhane Medical Faculty, Department of Internal Medicine, Division of Geriatrics, University of Health Sciences, Kecioren, Turkey
| | - Umit Cintosun
- Gulhane Training and Research Hospital, Geriatrics Clinic, Kecioren, Turkey
| | - Ahmet Ozturk
- Gulhane Training and Research Hospital, Geriatrics Clinic, Kecioren, Turkey
| | - Hasan Oztin
- Gulhane Medical Faculty, Department of Internal Medicine, Division of Geriatrics, University of Health Sciences, Kecioren, Turkey
| | - Turker Turker
- Gulhane Medical Faculty, Department of Public Health, University of Health Sciences, Kecioren, Ankara, Turkey
| | - Ergun Bozoglu
- Gulhane Medical Faculty, Department of Internal Medicine, Division of Geriatrics, University of Health Sciences, Kecioren, Turkey
| | - Huseyin Doruk
- Gulhane Medical Faculty, Department of Internal Medicine, Division of Geriatrics, University of Health Sciences, Kecioren, Turkey
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28
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Wu YH, Wang CJ, Hung CH, Chen LY, Lin MH, Wang PN, Chen LK. Association between using medications with anticholinergic properties and short-term cognitive decline among older men: A retrospective cohort study in Taiwan. Geriatr Gerontol Int 2017; 17 Suppl 1:57-64. [DOI: 10.1111/ggi.13032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2017] [Indexed: 12/16/2022]
Affiliation(s)
- Yi-Hui Wu
- Center for Geriatrics and Gerontology; Taipei Veterans General Hospital; Taipei Taiwan
- Department of Neurology; Taipei Veterans General Hospital; Taipei Taiwan
- Aging and Health Research Center; National Yang Ming University; Taipei Taiwan
| | - Chih-Jen Wang
- Department of Medicine; Changhua Christian Hospital; Changhua Taiwan
| | - Cheng-Hao Hung
- Center for Geriatrics and Gerontology; Taipei Veterans General Hospital; Taipei Taiwan
- Aging and Health Research Center; National Yang Ming University; Taipei Taiwan
| | - Liang-Yu Chen
- Center for Geriatrics and Gerontology; Taipei Veterans General Hospital; Taipei Taiwan
- Aging and Health Research Center; National Yang Ming University; Taipei Taiwan
| | - Ming-Hsien Lin
- Center for Geriatrics and Gerontology; Taipei Veterans General Hospital; Taipei Taiwan
- Aging and Health Research Center; National Yang Ming University; Taipei Taiwan
| | - Pei-Ning Wang
- Department of Neurology; Taipei Veterans General Hospital; Taipei Taiwan
- Aging and Health Research Center; National Yang Ming University; Taipei Taiwan
| | - Liang-Kung Chen
- Center for Geriatrics and Gerontology; Taipei Veterans General Hospital; Taipei Taiwan
- Aging and Health Research Center; National Yang Ming University; Taipei Taiwan
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29
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Matlow JN, Bronskill SE, Gruneir A, Bell CM, Stall NM, Herrmann N, Seitz DP, Gill SS, Austin PC, Fischer HD, Fung K, Wu W, Rochon PA. Use of Medications of Questionable Benefit at the End of Life in Nursing Home Residents with Advanced Dementia. J Am Geriatr Soc 2017; 65:1535-1542. [DOI: 10.1111/jgs.14844] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jeremy N. Matlow
- Women's College Research Institute Women's College HospitalToronto Ontario Canada
- Faculty of Medicine University of TorontoUniversity of Toronto Toronto Ontario Canada
| | - Susan E. Bronskill
- Women's College Research Institute Women's College HospitalToronto Ontario Canada
- Institute of Health Policy, Management and Evaluation University of TorontoToronto Ontario Canada
- Institute for Clinical Evaluative Sciences TorontoOntario Canada
| | - Andrea Gruneir
- Women's College Research Institute Women's College HospitalToronto Ontario Canada
- Institute of Health Policy, Management and Evaluation University of TorontoToronto Ontario Canada
- Institute for Clinical Evaluative Sciences TorontoOntario Canada
- Department of Family Medicine University of Alberta Edmonton, AlbertaOntario Canada
| | - Chaim M. Bell
- Institute of Health Policy, Management and Evaluation University of TorontoToronto Ontario Canada
- Institute for Clinical Evaluative Sciences TorontoOntario Canada
- Department of Medicine University of Toronto Toronto Ontario Canada
| | - Nathan M. Stall
- Department of Medicine University of Toronto Toronto Ontario Canada
| | - Nathan Herrmann
- Department of Psychiatry University of Toronto TorontoOntario Canada
| | - Dallas P. Seitz
- Institute for Clinical Evaluative Sciences Kingston Ontario
- Division of Geriatric Psychiatry Department of Psychiatry, Queen's UniversityQueen's University Kingston Ontario Canada
| | - Sudeep S. Gill
- Institute for Clinical Evaluative Sciences Kingston Ontario
- Department of Medicine Queen's University Kingston Ontario Canada
| | - Peter C. Austin
- Institute of Health Policy, Management and Evaluation University of TorontoToronto Ontario Canada
- Institute for Clinical Evaluative Sciences TorontoOntario Canada
| | - Hadas D. Fischer
- Institute for Clinical Evaluative Sciences TorontoOntario Canada
| | - Kinwah Fung
- Institute for Clinical Evaluative Sciences TorontoOntario Canada
| | - Wei Wu
- Women's College Research Institute Women's College HospitalToronto Ontario Canada
| | - Paula A. Rochon
- Women's College Research Institute Women's College HospitalToronto Ontario Canada
- Institute of Health Policy, Management and Evaluation University of TorontoToronto Ontario Canada
- Institute for Clinical Evaluative Sciences TorontoOntario Canada
- Department of Medicine University of Toronto Toronto Ontario Canada
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30
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Mondor L, Maxwell CJ, Hogan DB, Bronskill SE, Gruneir A, Lane NE, Wodchis WP. Multimorbidity and healthcare utilization among home care clients with dementia in Ontario, Canada: A retrospective analysis of a population-based cohort. PLoS Med 2017; 14:e1002249. [PMID: 28267802 PMCID: PMC5340355 DOI: 10.1371/journal.pmed.1002249] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 02/02/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND For community-dwelling older persons with dementia, the presence of multimorbidity can create complex clinical challenges for both individuals and their physicians, and can contribute to poor outcomes. We quantified the associations between level of multimorbidity (chronic disease burden) and risk of hospitalization and risk of emergency department (ED) visit in a home care cohort with dementia and explored the role of continuity of physician care (COC) in modifying these relationships. METHODS AND FINDINGS A retrospective cohort study using linked administrative and clinical data from Ontario, Canada, was conducted among 30,112 long-stay home care clients (mean age 83.0 ± 7.7 y) with dementia in 2012. Multivariable Fine-Gray regression models were used to determine associations between level of multimorbidity and 1-y risk of hospitalization and 1-y risk of ED visit, accounting for multiple competing risks (death and long-term care placement). Interaction terms were used to assess potential effect modification by COC. Multimorbidity was highly prevalent, with 35% (n = 10,568) of the cohort having five or more chronic conditions. In multivariable analyses, risk of hospitalization and risk of ED visit increased monotonically with level of multimorbidity: sub-hazards were 88% greater (sub-hazard ratio [sHR] = 1.88, 95% CI: 1.72-2.05, p < 0.001) and 63% greater (sHR = 1.63; 95% CI: 1.51-1.77, p < 0.001), respectively, among those with five or more conditions, relative to those with dementia alone or with dementia and one other condition. Low (versus high) COC was associated with an increased risk of both hospitalization and ED visit in age- and sex-adjusted analyses only (sHR = 1.11, 95% CI: 1.07-1.16, p < 0.001, for hospitalization; sHR = 1.07, 95% CI: 1.03-1.11, p = 0.001, for ED visit) but did not modify associations between multimorbidity and outcomes (Wald test for interaction, p = 0.566 for hospitalization and p = 0.637 for ED visit). The main limitations of this study include use of fixed (versus time-varying) covariates and focus on all-cause rather than cause-specific hospitalizations and ED visits, which could potentially inform interventions. CONCLUSIONS Older adults with dementia and multimorbidity pose a particular challenge for health systems. Findings from this study highlight the need to reshape models of care for this complex population, and to further investigate health system and other factors that may modify patients' risk of health outcomes.
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Affiliation(s)
- Luke Mondor
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Health System Performance Research Network, Toronto, Ontario, Canada
| | - Colleen J Maxwell
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Health System Performance Research Network, Toronto, Ontario, Canada.,School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada.,School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - David B Hogan
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Division of Geriatric Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Susan E Bronskill
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Health System Performance Research Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Gruneir
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Natasha E Lane
- Health System Performance Research Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Walter P Wodchis
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Health System Performance Research Network, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Toronto Rehabilitation Institute, Toronto, Ontario, Canada
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31
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Cognitive Effects of Anticholinergics in the Geriatric Patient Population: Safety and Treatment Considerations. CURRENT BLADDER DYSFUNCTION REPORTS 2017. [DOI: 10.1007/s11884-017-0413-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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32
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Reppas-Rindlisbacher CE, Fischer HD, Fung K, Gill SS, Seitz D, Tannenbaum C, Austin PC, Rochon PA. Anticholinergic Drug Burden in Persons with Dementia Taking a Cholinesterase Inhibitor: The Effect of Multiple Physicians. J Am Geriatr Soc 2016; 64:492-500. [PMID: 27000323 PMCID: PMC4819524 DOI: 10.1111/jgs.14034] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objectives To explore the association between the number of physicians providing care and anticholinergic drug burden in older persons newly initiated on cholinesterase inhibitor therapy for the management of dementia. Design Population‐based cross‐sectional study. Setting Community and long‐term care, Ontario, Canada. Participants Community‐dwelling (n = 79,067, mean age 81.0, 60.8% female) and long‐term care residing (n = 12,113, mean age 84.3, 67.2% female) older adults (≥66) newly dispensed cholinesterase inhibitor drug therapy. Measurements Anticholinergic drug burden in the prior year measured using the Anticholinergic Risk Scale. Results Community‐dwelling participants had seen an average of eight different physicians in the prior year. The odds of high anticholinergic drug burden (Anticholinergic Risk Scale score ≥ 2) were 24% higher for every five additional physicians providing care to individuals in the prior year (adjusted odds ratio = 1.24, 95% confidence interval = 1.21–1.26). Female sex, low‐income status, previous hospitalization, and higher comorbidity score were also associated with high anticholinergic drug burden. Long‐term care facility residents had seen an average of 10 different physicians in the prior year. After a sensitivity analysis, the association between high anticholinergic burden and number of physicians was no longer statistically significant in the long‐term care group. Conclusion In older adults newly started on cholinesterase inhibitor drug therapy, greater number of physicians providing care was associated with higher anticholinergic drug burden scores. Given the potential risks of anticholinergic drug use, improved communication among physicians and an anticholinergic medication review before prescribing a new drug are important strategies to improve prescribing quality.
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Affiliation(s)
- Christina E Reppas-Rindlisbacher
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hadas D Fischer
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Kinwah Fung
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Sudeep S Gill
- Institute for Clinical Evaluative Sciences Queen's, Kingston, Ontario, Canada.,Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Dallas Seitz
- Institute for Clinical Evaluative Sciences Queen's, Kingston, Ontario, Canada.,Division of Geriatric Psychiatry, Department of Psychiatry, Queen's University, Kingston, Ontario, Canada
| | - Cara Tannenbaum
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada
| | - Peter C Austin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Paula A Rochon
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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