Simultaneous usage of dementia medications and anticholinergics among Asians and Pacific Islanders

Mapping racial and ethnic healthcare disparities for persons living with dementia: A scoping review

INTRODUCTION

We set out to map evidence of disparities in Alzheimer's disease and Alzheimer's disease related dementias healthcare, including issues of access, quality, and outcomes for racial/ethnic minoritized persons living with dementia (PLWD) and family caregivers.

METHODS

We conducted a scoping review of the literature published from 2000 to 2022 in PubMed, PsycINFO, and CINAHL. The inclusion criteria were: (1) focused on PLWD and/or family caregivers, (2) examined disparities or differences in healthcare, (3) were conducted in the United States, (4) compared two or more racial/ethnic groups, and (5) reported quantitative or qualitative findings.

RESULTS

Key findings include accumulating evidence that minoritized populations are less likely to receive an accurate and timely diagnosis, be prescribed anti-dementia medications, and use hospice care, and more likely to have a higher risk of hospitalization and receive more aggressive life-sustaining treatment at the end-of-life.

DISCUSSION

Future studies need to examine underlying processes and develop interventions to reduce disparities while also being more broadly inclusive of diverse populations.

Pharmacogenetic considerations when prescribing cholinesterase inhibitors for the treatment of Alzheimer's disease

INTRODUCTION

Cholinergic dysfunction, demonstrated in the late 1970s and early 1980s, led to the introduction of acetylcholinesterase inhibitors (AChEIs) in 1993 (Tacrine) to enhance cholinergic neurotransmission as the first line of treatment against Alzheimer's disease (AD). The new generation of AChEIs, represented by Donepezil (1996), Galantamine (2001) and Rivastigmine (2002), is the only treatment for AD to date, together with Memantine (2003). AChEIs are not devoid of side-effects and their cost-effectiveness is limited. An option to optimize the correct use of AChEIs is the implementation of pharmacogenetics (PGx) in the clinical practice.

AREAS COVERED

(i) The cholinergic system in AD, (ii) principles of AD PGx, (iii) PGx of Donepezil, Galantamine, Rivastigmine, Huperzine and other treatments, and (iv) practical recommendations.

EXPERT OPINION

The most relevant genes influencing AChEI efficacy and safety are APOE and CYPs. APOE-4 carriers are the worst responders to AChEIs. With the exception of Rivastigmine (UGT2B7, BCHE-K), the other AChEIs are primarily metabolized via CYP2D6, CYP3A4, and UGT enzymes, with involvement of ABC transporters and cholinergic genes (CHAT, ACHE, BCHE, SLC5A7, SLC18A3, CHRNA7) in most ethnic groups. Defective variants may affect the clinical response to AChEIs. PGx geno-phenotyping is highly recommended prior to treatment.

Polypharmacy in an Elderly Population: Enhancing Medication Management Through the Use of Clinical Decision Support Software Platforms

INTRODUCTION

Polypharmacy is a growing problem in the United States. The use of multiple medications increases the likelihood that a patient will experience potential drug interactions and adverse drug reactions (ADRs). Those individuals with dementia or Alzheimer's disease (AD) are at greater risk, due to age, comorbidities, and an increased likelihood of being on a greater number of neuroactive medications.

METHODS

uMETHOD Health (uMH) has developed a precision medicine platform to address dementia and mild AD through the creation of personalized, multidomain treatment plans. Many interactions and ADRs may be observed, such as drug-drug interactions (DDIs), drug-gene interactions (DGIs), anticholinergic cognitive burden (ACB), and depression-inducing drugs (DIDs). uMH's algorithms can parse these interactions, rate them based on input from open-source databases, and then record all these interactions in a generated treatment plan. A total of 295 individuals aged 65 and older were included in this analysis.

RESULTS

Of 295 individuals, 97.59% were on at least one medication, with an overall mean of 11.5 medications per person; 83.66% were on five or more medications. A total of 102 DGIs, 3642 DDIs, and one high-priority DDI were found in this population. There was a significant increase in the number of DDIs as medications per person increased (P value < 0.0001). Of the population, 65.86% were on one or more anticholinergic drugs. There was a significant difference in the ACB score between individuals with cognitive decline and those without. In total, 60.98% of the overall population were on DIDs, with a mean of 1.19 medications per person.

CONCLUSIONS

The results of this work show that older populations have a high medication burden. With the growing elderly and AD populations, medication management for polypharmacy is a need that grows direr every year. uMH's platform was able to identify a multitude of polypharmacy problems that individuals are currently facing.

FUNDING

uMETHOD Health.

Anticholinergic burden of patients with dementia attending a Psychiatry of Later Life service

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 (&gt;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.