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Rodrigues DA, Herdeiro MT, Mateos-Campos R, Figueiras A, Roque F. Potentially inappropriate anticholinergic drug use among older adults in primary healthcare: prevalence and determinants. Expert Opin Drug Saf 2024:1-7. [PMID: 39105534 DOI: 10.1080/14740338.2024.2385479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 05/22/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Considering the vulnerability of older adults to adverse drug reactions, medications with strong anticholinergic properties are considered potentially inappropriate for this population. This study aims to characterize older adults' profile of anticholinergics use and to identify the factors associated with their potentially inappropriate use. RESEARCH DESIGN AND METHODS A retrospective study was conducted on 1200 older adults in primary health care centers of Portugal between April 2021 and August 2022. Potentially inappropriate use was assessed according to the 2023 Beers criteria. Logistic regression analyses were performed to determine associations between independent variables and potentially inappropriate use. RESULTS A 8.9% (95% CI 0.074-0.107) of the older adults were exposed to one or more potentially inappropriate anticholinergics, and amitriptyline was the most used (2.0%). Multivariate analysis revealed that use was associated with a higher mean number of medications (OR 1.173, 95% CI 1.115-1.234), diagnoses of depression (OR 2.889, 95% CI 1.785-4.674) and psychiatric disorders (OR 1.654, 95% CI 1.003-2.729). CONCLUSIONS This study underscores the importance of vigilance in prescribing anticholinergic medications to older adults, particularly those with higher medication burdens and mental health diagnoses. By identifying factors associated with potentially inappropriate use, healthcare providers can better tailor medication regimens to mitigate risks and optimize the well-being of older adults.
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Affiliation(s)
- Daniela A Rodrigues
- Biotechnology Research, Innovation and Design for Health Products (BRIDGES) - Research Laboratory on Epidemiology and Population Health, Polytechnic of Guarda (IPG), Guarda, Portugal
- Health Sciences Research Centre, University of Beira Interior (CICS-UBI), Covilhã, Portugal
- PhD Student, University of Salamanca, Salamanca, Spain
| | - Maria Teresa Herdeiro
- Department of Medical Sciences, Institute of Biomedicine (iBiMED), University of Aveiro, Aveiro, Portugal
| | - Ramona Mateos-Campos
- Area of Preventive Medicine and Public Health, Department of Biomedical and Diagnostic Sciences, University of Salamanca, Salamanca, Spain
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela/IDIS), A Coruña, Spain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública/CIBERESP), Carlos III Institute of Health, Madrid, Spain
| | - Fátima Roque
- Biotechnology Research, Innovation and Design for Health Products (BRIDGES) - Research Laboratory on Epidemiology and Population Health, Polytechnic of Guarda (IPG), Guarda, Portugal
- Health Sciences Research Centre, University of Beira Interior (CICS-UBI), Covilhã, Portugal
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2
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Taylor-Rowan M, Kraia O, Kolliopoulou C, Noel-Storr AH, Alharthi AA, Cross AJ, Stewart C, Myint PK, McCleery J, Quinn TJ. Anticholinergic burden for prediction of cognitive decline or neuropsychiatric symptoms in older adults with mild cognitive impairment or dementia. Cochrane Database Syst Rev 2022; 8:CD015196. [PMID: 35994403 PMCID: PMC9394684 DOI: 10.1002/14651858.cd015196.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Medications with anticholinergic properties are commonly prescribed to older adults with a pre-existing diagnosis of dementia or cognitive impairment. The cumulative anticholinergic effect of all the medications a person takes is referred to as the anticholinergic burden because of its potential to cause adverse effects. It is possible that a high anticholinergic burden may be a risk factor for further cognitive decline or neuropsychiatric disturbances in people with dementia. Neuropsychiatric disturbances are the most frequent complication of dementia that require hospitalisation, accounting for almost half of admissions; hence, identification of modifiable prognostic factors for these outcomes is crucial. There are various scales available to measure anticholinergic burden but agreement between them is often poor. OBJECTIVES Our primary objective was to assess whether anticholinergic burden, as defined at the level of each individual scale, was a prognostic factor for further cognitive decline or neuropsychiatric disturbances in older adults with pre-existing diagnoses of dementia or cognitive impairment. Our secondary objective was to investigate whether anticholinergic burden was a prognostic factor for other adverse clinical outcomes, including mortality, impaired physical function, and institutionalisation. SEARCH METHODS We searched these databases from inception to 29 November 2021: MEDLINE OvidSP, Embase OvidSP, PsycINFO OvidSP, CINAHL EBSCOhost, and ISI Web of Science Core Collection on ISI Web of Science. SELECTION CRITERIA We included prospective and retrospective longitudinal cohort and case-control observational studies, with a minimum of one-month follow-up, which examined the association between an anticholinergic burden measurement scale and the above stated adverse clinical outcomes, in older adults with pre-existing diagnoses of dementia or cognitive impairment. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, and undertook data extraction, risk of bias assessment, and GRADE assessment. We summarised risk associations between anticholinergic burden and all clinical outcomes in a narrative fashion. We also evaluated the risk association between anticholinergic burden and mortality using a random-effects meta-analysis. We established adjusted pooled rates for the anticholinergic cognitive burden (ACB) scale; then, as an exploratory analysis, established pooled rates on the prespecified association across scales. MAIN RESULTS: We identified 18 studies that met our inclusion criteria (102,684 older adults). Anticholinergic burden was measured using five distinct measurement scales: 12 studies used the ACB scale; 3 studies used the Anticholinergic Risk Scale (ARS); 1 study used the Anticholinergic Drug Scale (ADS); 1 study used the Anticholinergic Effect on Cognition (AEC) Scale; and 2 studies used a list developed by Tune and Egeli. Risk associations between anticholinergic burden and adverse clinical outcomes were highly heterogenous. Four out of 10 (40%) studies reported a significantly increased risk of greater long-term cognitive decline for participants with an anticholinergic burden compared to participants with no or minimal anticholinergic burden. No studies investigated neuropsychiatric disturbance outcomes. One out of four studies (25%) reported a significant association with reduced physical function for participants with an anticholinergic burden versus participants with no or minimal anticholinergic burden. No study (out of one investigating study) reported a significant association between anticholinergic burden and risk of institutionalisation. Six out of 10 studies (60%) found a significantly increased risk of mortality for those with an anticholinergic burden compared to those with no or minimal anticholinergic burden. Pooled analysis of adjusted mortality hazard ratios (HR) measured anticholinergic burden with the ACB scale, and suggested a significantly increased risk of death for those with a high ACB score relative to those with no or minimal ACB scores (HR 1.153, 95% confidence interval (CI) 1.030 to 1.292; 4 studies, 48,663 participants). An exploratory pooled analysis of adjusted mortality HRs across anticholinergic burden scales also suggested a significantly increased risk of death for those with a high anticholinergic burden (HR 1.102, 95% CI 1.044 to 1.163; 6 studies, 68,381 participants). Overall GRADE evaluation of results found low- or very low-certainty evidence for all outcomes. AUTHORS' CONCLUSIONS: There is low-certainty evidence that older adults with dementia or cognitive impairment who have a significant anticholinergic burden may be at increased risk of death. No firm conclusions can be drawn for risk of accelerated cognitive decline, neuropsychiatric disturbances, decline in physical function, or institutionalisation.
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Affiliation(s)
- Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Olga Kraia
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | | | - Ahmed A Alharthi
- Department of Clinical Pharmacy, Umm Al Qura University, Makkah, Saudi Arabia
| | - Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Australia
| | | | - Phyo K Myint
- Division of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | | | - Terry J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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3
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Nawaz H, Sargent L, Quilon H, Cloud LJ, Testa CM, Snider JD, Lageman SK, Baron MS, Berman BD, Zimmerman K, Price ET, Mukhopadhyay ND, Barrett MJ. Anticholinergic Medication Burden in Parkinson's Disease Outpatients. JOURNAL OF PARKINSON'S DISEASE 2022; 12:599-606. [PMID: 34806617 DOI: 10.3233/jpd-212769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Individuals with Parkinson's disease (PD) may be especially vulnerable to future cognitive decline from anticholinergic medications. OBJECTIVE To characterize anticholinergic medication burden, determine the co-occurrence of anticholinergic and cholinesterase inhibitors, and to assess the correlations among anticholinergic burden scales in PD outpatients. METHODS We studied 670 PD outpatients enrolled in a clinic registry between 2012 and 2020. Anticholinergic burden was measured with the Anticholinergic Cognitive Burden Scale (ACB), Anticholinergic Drug Scale (ADS), Anticholinergic Risk Scale (ARS), and Drug Burden Index-Anticholinergic component (DBI-Ach). Correlations between scales were assessed with weighted kappa coefficients. RESULTS Between 31.5 to 46.3% of PD patients were taking medications with anticholinergic properties. Among the scales applied, the ACB produced the highest prevalence of medications with anticholinergic properties (46.3%). Considering only medications with definite anticholinergic activity (scores of 2 or 3 on ACB, ADS, or ARS), the most common anticholinergic drug classes were antiparkinsonian (8.2%), antipsychotic (6.4%), and urological (3.3%) medications. Cholinesterase inhibitors and medications with anticholinergic properties were co-prescribed to 5.4% of the total cohort. The most highly correlated scales were ACB and ADS (κ= 0.71), ACB and ARS (κ= 0.67), and ADS and ARS (κ= 0.55). CONCLUSION A high proportion of PD patients (20%) were either taking antiparkinsonian, urological, or antipsychotic anticholinergic medications or were co-prescribed anticholinergic medications and cholinesterase inhibitors. By virtue of its detection of a high prevalence of anticholinergic medication usage and its high correlation with other scales, our data support use of the ACB scale to assess anticholinergic burden in PD patients.
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Affiliation(s)
- Huma Nawaz
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Lana Sargent
- School of Nursing, Virginia Commonwealth University, Richmond, VA, USA.,Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA.,Geriatric Pharmacotherapy Program, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA.,Institute for Inclusion, Inquiry & Innovation (iCubed): Health & Wellness in Aging Populations Core, Richmond, VA, USA
| | | | - Leslie J Cloud
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Claudia M Testa
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Jon D Snider
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Sarah K Lageman
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA.,Department of Psychology, Virginia Commonwealth University, Richmond, VA, USA
| | - Mark S Baron
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA.,Southeast Veterans Affairs Parkinson's Disease Research, Education and Clinical Center (PADRECC), Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Brian D Berman
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | - Kristin Zimmerman
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA
| | - Elvin T Price
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA.,Geriatric Pharmacotherapy Program, School of Pharmacy, Virginia Commonwealth University, Richmond, VA, USA.,Institute for Inclusion, Inquiry & Innovation (iCubed): Health & Wellness in Aging Populations Core, Richmond, VA, USA
| | - Nitai D Mukhopadhyay
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Matthew J Barrett
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
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4
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Abstract
INTRODUCTION The use of medications with anticholinergic (ACh) properties is associated with numerous adverse effects especially in older adults. Emerging evidence suggests the presence of long-term effects with ACh use. AREAS COVERED Our article presents an overview of ACh effects and falls in older individuals including examination of emerging evidence on ACh use and cumulative exposure on short-term and long-term falls risk. The databases CINAHL, MEDLINE, EMBASE, and Web of Science were searched for articles published from January 2002 to December 2021. EXPERT OPINION Anticholinergic side effects include muscle weakness, blurred vision, and mental confusion which are likely to lead to increased falls risk. Many commonly used medications such as beta-blockers, calcium-channel blockers, and antihistamines are now known to have mild ACh properties. With polypharmacy now considered unavoidable in older patients, the cumulative effects of the use of multiple drugs with mild ACh properties may also lead to increased falls risk. The relationship between ACh drugs and falls may also be irreversible as ACh effects may extend beyond the period of drug use, due to cognitive and physical deconditioning following the initial exposure to ACh drugs. Future long-term studies with accurate quantification of cumulative ACh exposure and measurement of actual falls outcomes are urgently required.
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Affiliation(s)
- Xiang Jiang Xu
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Maw Pin Tan
- Ageing and Age-Associated Disorders Research Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Medical Sciences, Faculty of Healthcare and Medical Sciences, Sunway University, Selangor, Malaysia
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5
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Choi JY, Kim H, Jung YI, Chun S, Yoo S, Lim JY, Ko JY, Park K, Kim KI. Factors associated with anticholinergic burden among older patients in long-term care hospitals in Korea. Korean J Intern Med 2022; 37:468-477. [PMID: 35176208 PMCID: PMC8925946 DOI: 10.3904/kjim.2021.457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/10/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Drugs with anticholinergic properties (DAPs) are associated with adverse health outcomes in older patients. The objective of this study was to evaluate the factors that determine the prescribing of more DAPs in long-term care hospitals (LTCHs) in Korea. In addition, the current patterns of DAP prescription were explored using a novel platform, which can collect data from LTCHs. METHODS This was a Health-RESPECT (integrated caRE Systems for elderly PatiEnts using iCT) sub-study, which is a pragmatic, cluster-randomized, controlled trial. The Health-RESPECT platform was used to collect prescribed medication data of 466 patients (aged ≥ 65 years) from seven LTCHs. DAPs were identified using the Korean Anticholinergic Burden Scale (KABS). Physical frailty, cognitive function, functional status, and quality of life were evaluated. RESULTS Among 466 LTCH patients, 88.8% (n = 414) were prescribed DAPs, and the prevalence of high KABS (≥ 3) was 70.4% (n = 328). The drugs that contributed most to the total KABS were quetiapine (20.7%), chlorpheniramine (19.5%), tramadol (9.8%), cimetidine (5.8%), and furosemide (3.6%). Polypharmacy, higher body mass index, less dependence, better communication and cognitive functions, and poorer quality of life were associated with high KABS. CONCLUSION Although the patients with a high burden of DAPs were less dependent and had better cognitive and communication functions, they had poorer quality of life. DAP use in LTCH patients should be monitored carefully, and the risk/ benefit relationship for their use should be considered.
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Affiliation(s)
- Jung-Yeon Choi
- Division of Geriatrics, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam,
Korea
| | - Hongsoo Kim
- Department of Public Health Sciences, Graduate School of Public Health, Seoul, Korea
- Institute of Health and Environment, Seoul National University, Seoul, Korea
- Institute on Aging, Seoul National University, Seoul, Korea
| | - Young-il Jung
- Department of Environmental Health, Korea National Open University, Seoul, Korea
| | - Seungyeon Chun
- Department of Public Health Sciences, Graduate School of Public Health, Seoul, Korea
| | - Sooyoung Yoo
- Office of eHealth Research and Businesses, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae-Young Lim
- Institute on Aging, Seoul National University, Seoul, Korea
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Young Ko
- Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kayoung Park
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Kwang-il Kim
- Division of Geriatrics, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam,
Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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6
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Lisibach A, Gallucci G, Beeler PE, Csajka C, Lutters M. High anticholinergic burden at admission associated with in-hospital mortality in older patients: A comparison of 19 different anticholinergic burden scales. Basic Clin Pharmacol Toxicol 2021; 130:288-300. [PMID: 34837340 PMCID: PMC9299782 DOI: 10.1111/bcpt.13692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/10/2021] [Accepted: 11/18/2021] [Indexed: 01/16/2023]
Abstract
Although no gold standard exists to assess a patient's anticholinergic burden, a review identified 19 anticholinergic burden scales (ABSs). No study has yet evaluated whether a high anticholinergic burden measured with all 19 ABSs is associated with in‐hospital mortality and length of stay (LOS). We conducted a cohort study at a Swiss tertiary teaching hospital using patients' electronic health record data from 2015–2018. Included were patients aged ≥65 years, hospitalised ≥48 h without stays and >24 h in intensive care. Patients' cumulative anticholinergic burden score was classified using a binary (<3: low, ≥3: high) and categorical approach (0: no, 0.5–3: low, ≥3: high). In‐hospital mortality and LOS were analysed using multivariable logistic and linear regression, respectively. We included 27,092 patients (mean age 78.0 ± 7.5 years, median LOS 6 days). Of them, 913 died. Depending on the evaluated ABS, 1370 to 17,035 patients were exposed to anticholinergics. Patients with a high burden measured by all 19 ABSs were associated with a 1.32‐ to 3.03‐fold increase in in‐hospital mortality compared with those with no/low burden. We obtained similar results for LOS. To conclude, discontinuing drugs with anticholinergic properties (score ≥3) at admission might be a targeted intervention to decrease in‐hospital mortality and LOS.
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Affiliation(s)
- Angela Lisibach
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland.,Center for Research and Innovation in Clinical Pharmaceutical Sciences, University Hospital and University of Lausanne, Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Lausanne, Switzerland
| | - Giulia Gallucci
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
| | - Patrick E Beeler
- Division of Occupational and Environmental Medicine, Epidemiology, Biostatistics and Prevention Institute, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, University Hospital and University of Lausanne, Lausanne, Switzerland.,School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland.,Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Lausanne, Switzerland
| | - Monika Lutters
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland.,Swiss Federal Institute of Technology, Zurich, Switzerland
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7
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The evaluation of relationship between polypharmacy and anticholinergic burden scales. North Clin Istanb 2021; 8:139-144. [PMID: 33851077 PMCID: PMC8039107 DOI: 10.14744/nci.2020.17136] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 11/05/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE: Polypharmacy and anticholinergic burden are the indicators for the evaluation of the quality of pharmacotherapy in older adults. The aim of this study was to consider which anticholinergic burden scales are more related with polypharmacy among older patients. METHODS: Four hundred and twenty older adults were evaluated retrospectively in this cross-sectional study. The patient’s demographic data, comorbidities, the drugs, and number of drugs were recorded. Anticholinergic burden scales were calculated by a tool named anticholinergic burden calculator. RESULTS: The participants’ mean age was 73.08±8.71. The prevalence of polypharmacy was 32.14%. The highest relationship with polypharmacy was observed for drug burden index (DBI) (odds ratio 10.87, p<0.001). CONCLUSION: Our study demonstrated that polypharmacy and DBI scores were more related than other anticholinergic burden scales in older adults.
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8
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Lisibach A, Benelli V, Ceppi MG, Waldner-Knogler K, Csajka C, Lutters M. Quality of anticholinergic burden scales and their impact on clinical outcomes: a systematic review. Eur J Clin Pharmacol 2021; 77:147-162. [PMID: 33011824 DOI: 10.1007/s00228-020-0299x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 09/10/2020] [Indexed: 05/23/2023]
Abstract
PURPOSE Older people are at risk of anticholinergic side effects due to changes affecting drug elimination and higher sensitivity to drug's side effects. Anticholinergic burden scales (ABS) were developed to quantify the anticholinergic drug burden (ADB). We aim to identify all published ABS, to compare them systematically and to evaluate their associations with clinical outcomes. METHODS We conducted a literature search in MEDLINE and EMBASE to identify all published ABS and a Web of Science citation (WoS) analysis to track validation studies implying clinical outcomes. Quality of the ABS was assessed using an adapted AGREE II tool. For the validation studies, we used the Newcastle-Ottawa Scale and the Cochrane tool Rob2.0. The validation studies were categorized into six evidence levels based on the propositions of the Oxford Center for Evidence-Based Medicine with respect to their quality. At least two researchers independently performed screening and quality assessments. RESULTS Out of 1297 records, we identified 19 ABS and 104 validations studies. Despite differences in quality, all ABS were recommended for use. The anticholinergic cognitive burden (ACB) scale and the German anticholinergic burden scale (GABS) achieved the highest percentage in quality. Most ABS are validated, yet validation studies for newer scales are lacking. Only two studies compared eight ABS simultaneously. The four most investigated clinical outcomes delirium, cognition, mortality and falls showed contradicting results. CONCLUSION There is need for good quality validation studies comparing multiple scales to define the best scale and to conduct a meta-analysis for the assessment of their clinical impact.
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Affiliation(s)
- Angela Lisibach
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland.
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University Hospital and University of Lausanne, Lausanne, Switzerland.
- School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, University of Geneva, Geneva, Switzerland.
| | - Valérie Benelli
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
| | - Marco Giacomo Ceppi
- Department of Neurorehabilitation, RehaClinic, Bad Zurzach, Switzerland
- Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | | | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University Hospital and University of Lausanne, Lausanne, Switzerland.
- School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, University of Geneva, Geneva, Switzerland.
| | - Monika Lutters
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
- Swiss Federal Institute of Technology, Zurich, Switzerland
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9
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Stump TA, Nelson LA, Liu Y, Kriz CR, Iuppa CA, Diefenderfer LA, Lang SE, Elliot ESR, Sommi RW. The effects of concurrent oral paliperidone or risperidone use with paliperidone long-acting injection. Ment Health Clin 2021; 11:12-18. [PMID: 33505820 PMCID: PMC7800326 DOI: 10.9740/mhc.2021.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction Dosing recommendations for paliperidone long-acting injectable antipsychotic (LAIA) do not include oral antipsychotic (OAP) overlap; however, OAPs are often given concurrently despite limited evidence describing both the risks and benefits of this practice. Methods A retrospective chart review was conducted in patients initiated on paliperidone palmitate (PP) during a psychiatric hospitalization to compare patients who received OAP overlap versus those who did not. The primary outcome is the proportion of patients who receive prescription claims for benztropine, a medication commonly prescribed for extrapyramidal symptoms, at the time of LAIA discontinuation and 6 months postdischarge. Secondary outcomes include prescription claims for beta blockers and diphenhydramine, number of psychiatric emergency visits and hospitalizations, length of stay of the index hospitalization, frequency of LAIA discontinuation and the time to LAIA discontinuation. Results There is a significant difference in the proportion of benztropine prescription claims in the OAP overlap group versus the no-overlap group at the time of LAIA discontinuation (30% vs 0%, P = .046) but not at 6 months postdischarge. There are also significant differences in the number of psychiatric emergency visits (0.7 vs 0.1, P = .02) and psychiatric hospitalizations (0.6 vs 0.1, P = .029) at the time of LAIA discontinuation. No other differences are observed in defined secondary outcomes. Discussion Patients who receive OAP overlap while receiving PP receive more benztropine and have more psychiatric emergency visits and hospitalizations than those treated without OAP. Larger studies with better control for confounding variables are needed to confirm these results.
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Affiliation(s)
- Trevor A Stump
- Behavioral Health Clinical Pharmacist, Cleveland Clinic Marymount Hospital, Cleveland, Ohio
| | - Leigh Anne Nelson
- Behavioral Health Clinical Pharmacist, Cleveland Clinic Marymount Hospital, Cleveland, Ohio.,Associate Professor of Pharmacy Practice and Administration, University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri.,Clinical Research Coordinator, University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri.,Clinical Manager, Center for Behavioral Medicine, Kansas City, Missouri.,Clinical Pharmacist, Center for Behavioral Medicine, Kansas City, Missouri.,Clinical Pharmacist, Center for Behavioral Medicine, Kansas City, Missouri.,Director of Pharmacy, Center for Behavioral Medicine, Kansas City, Missouri.,Associate Dean, Vice Chair and Professor of Pharmacy Practice and Administration, University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri
| | - Yifei Liu
- Associate Professor of Pharmacy Practice and Administration, University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri
| | - Carrie R Kriz
- Clinical Research Coordinator, University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri
| | - Courtney A Iuppa
- Clinical Manager, Center for Behavioral Medicine, Kansas City, Missouri
| | | | - Shelby E Lang
- Clinical Pharmacist, Center for Behavioral Medicine, Kansas City, Missouri
| | - Ellie S R Elliot
- Director of Pharmacy, Center for Behavioral Medicine, Kansas City, Missouri
| | - Roger W Sommi
- Associate Dean, Vice Chair and Professor of Pharmacy Practice and Administration, University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri
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10
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Lavrador M, Castel-Branco MM, Cabral AC, Veríssimo MT, Figueiredo IV, Fernandez-Llimos F. Association between anticholinergic burden and anticholinergic adverse outcomes in the elderly: Pharmacological basis of their predictive value for adverse outcomes. Pharmacol Res 2020; 163:105306. [PMID: 33248197 DOI: 10.1016/j.phrs.2020.105306] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 01/25/2023]
Abstract
The use of anticholinergic drugs and other drugs with anticholinergic activity is highly prevalent in older people. Cumulative anticholinergic effects, known as anticholinergic burden, are associated with important peripheral and central adverse effects and outcomes. Several methods have been developed to quantify anticholinergic burden and to estimate the risk of adverse anticholinergic effects. Serum anticholinergic activity (SAA) and anticholinergic burden scoring systems are the most commonly used methods to predict the occurrence of important negative outcomes. These tools could guide clinicians in making more rational prescriptions to enhance patient safety, especially in older people. However, the literature has reported conflicting results about the predictive ability of these tools. The majority of these instruments ignore relevant pharmacologic aspects such as the doses used, differential muscarinic receptor subtype affinities, and blood-brain barrier permeability. To increase the clinical relevance of these tools, mechanistic and clinical pharmacology should collaborate. This narrative review describes the rational and pharmacological basis of anticholinergic burden tools and provides insight about their predictive value for adverse outcomes.
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Affiliation(s)
- Marta Lavrador
- University of Coimbra, Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal.
| | - M Margarida Castel-Branco
- University of Coimbra, Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal.
| | - Ana C Cabral
- University of Coimbra, Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal.
| | - Manuel T Veríssimo
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; University of Coimbra, Faculty of Medicine, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal.
| | - Isabel V Figueiredo
- University of Coimbra, Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal; Coimbra Institute for Clinical and Biomedical Research (iCBR), Pólo das Ciências da Saúde, Azinhaga de Santa Comba, 3000-548 Coimbra, Portugal.
| | - Fernando Fernandez-Llimos
- University of Porto, Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy. Rua Jorge Viterbo 228, 4050-313 Porto, Portugal; CINTESIS - Center for Health Technology and Services Research, University of Porto, Porto, Portugal.
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11
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Reinold J, Schäfer W, Christianson L, Barone-Adesi F, Riedel O, Pisa FE. Anticholinergic Burden and Fractures: A Systematic Review with Methodological Appraisal. Drugs Aging 2020; 37:885-897. [PMID: 33094444 PMCID: PMC7704512 DOI: 10.1007/s40266-020-00806-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2020] [Indexed: 11/28/2022]
Abstract
Introduction Medications with anticholinergic activity (MACs) are used to treat diseases common in older adults. Evidence on the association between anticholinergic burden (AB) and increased risk of fractures and osteoporosis or reduced bone mineral density (BMD) is inconsistent. Our aim was to conduct a systematic review of observational studies on AB with fractures and osteoporosis or reduced BMD and provide methodological appraisal of included studies. Methods We searched MEDLINE, EMBASE, Science Citation Index and CENTRAL as well as grey literature from database inception up to August 2020. Eligibility criteria were: observational design, AB-exposure measured through a scale, fracture of any type or osteoporosis or reduced BMD as outcome, and reported measure of association between exposure and outcome. No restrictions related to time, language or type of data were applied. Eligibility and risk of bias assessment as well as data extraction were performed independently by two reviewers. Risk of bias of the included studies was assessed using the Newcastle–Ottawa Scale and the RTI Item Bank. Results The majority of the nine included studies had low risk of bias but heterogeneous methodology. No study used a new user design. Seven studies reported an increased risk of fractures associated with AB. In four studies using the Anticholinergic Risk Scale (ARS), adjusted risk of fractures was increased by 2–61% for ARS = 1, by 0–97% for ARS = 2, by 19–84% for ARS = 3, and by 56–96% for ARS ≥ 4; in three studies the ARS was aggregated, risk increased by 39% for ARS = 1–2 and 17% for ARS = 2–3. Two studies reported increased risk of fractures of 14 and 52% in the highest AB-category and one study reported that change in ARS of ≥ 3 during hospitalization was associated with a 321% increased risk in fractures. Two studies did not find an association between AB and fractures. The association between AB and osteoporosis or reduced BMD could only be assessed in two studies, one reporting increased risk of lower BMD at Ward’s triangle, the other reporting no association between AB and BMD T-score change at the femoral neck. Discussion Our study suggests an association between AB and increased risk of fractures with possible dose-exposure gradient in studies using the ARS. The low number of studies and heterogeneity of methods calls for the conduct of more studies. Plain language summary We conducted a study investigating the risk of fractures associated with anticholinergic burden, which is the result of taking one or more medication with anticholinergic activity. The results of our study suggest that persons who experience anticholinergic burden might have a higher risk of fractures. However, since we were only able to include nine studies, more studies conducted in a similar way are needed. Electronic supplementary material The online version of this article (10.1007/s40266-020-00806-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jonas Reinold
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany.
| | - Wiebke Schäfer
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
| | - Lara Christianson
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
| | - Francesco Barone-Adesi
- Department of Translational Medicine, University of Eastern Piedmont, Via Solaroli 17, 28100, Novara, Italy
| | - Oliver Riedel
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
| | - Federica Edith Pisa
- Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology-BIPS, Achterstraße 30, 28359, Bremen, Germany
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12
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Lisibach A, Benelli V, Ceppi MG, Waldner-Knogler K, Csajka C, Lutters M. Quality of anticholinergic burden scales and their impact on clinical outcomes: a systematic review. Eur J Clin Pharmacol 2020; 77:147-162. [PMID: 33011824 PMCID: PMC7803697 DOI: 10.1007/s00228-020-02994-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 09/10/2020] [Indexed: 12/13/2022]
Abstract
Purpose Older people are at risk of anticholinergic side effects due to changes affecting drug elimination and higher sensitivity to drug’s side effects. Anticholinergic burden scales (ABS) were developed to quantify the anticholinergic drug burden (ADB). We aim to identify all published ABS, to compare them systematically and to evaluate their associations with clinical outcomes. Methods We conducted a literature search in MEDLINE and EMBASE to identify all published ABS and a Web of Science citation (WoS) analysis to track validation studies implying clinical outcomes. Quality of the ABS was assessed using an adapted AGREE II tool. For the validation studies, we used the Newcastle-Ottawa Scale and the Cochrane tool Rob2.0. The validation studies were categorized into six evidence levels based on the propositions of the Oxford Center for Evidence-Based Medicine with respect to their quality. At least two researchers independently performed screening and quality assessments. Results Out of 1297 records, we identified 19 ABS and 104 validations studies. Despite differences in quality, all ABS were recommended for use. The anticholinergic cognitive burden (ACB) scale and the German anticholinergic burden scale (GABS) achieved the highest percentage in quality. Most ABS are validated, yet validation studies for newer scales are lacking. Only two studies compared eight ABS simultaneously. The four most investigated clinical outcomes delirium, cognition, mortality and falls showed contradicting results. Conclusion There is need for good quality validation studies comparing multiple scales to define the best scale and to conduct a meta-analysis for the assessment of their clinical impact. Electronic supplementary material The online version of this article (10.1007/s00228-020-02994-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Angela Lisibach
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland. .,Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University Hospital and University of Lausanne, Lausanne, Switzerland. .,School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, University of Geneva, Geneva, Switzerland.
| | - Valérie Benelli
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland
| | - Marco Giacomo Ceppi
- Department of Neurorehabilitation, RehaClinic, Bad Zurzach, Switzerland.,Basel Pharmacoepidemiology Unit, Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | | | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University Hospital and University of Lausanne, Lausanne, Switzerland. .,School of Pharmaceutical Sciences, Institute of Pharmaceutical Sciences of Western Switzerland, University of Lausanne, University of Geneva, Geneva, Switzerland.
| | - Monika Lutters
- Clinical Pharmacy, Department Medical Services, Cantonal Hospital of Baden, Baden, Switzerland.,Swiss Federal Institute of Technology, Zurich, Switzerland
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13
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Rajan R, Saini A, Verma B, Choudhary N, Gupta A, Vishnu VY, Bhatia R, Singh MB, Srivastava AK, Srivastava MVP. Anticholinergics May Carry Significant Cognitive and Gait Burden in Parkinson's Disease. Mov Disord Clin Pract 2020; 7:803-809. [PMID: 33043076 DOI: 10.1002/mdc3.13032] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/26/2020] [Accepted: 07/13/2020] [Indexed: 12/30/2022] Open
Abstract
Background Anticholinergic drugs are associated with significant cognitive and other adverse events in older adults, including those with Parkinson's disease (PD). Anticholinergic effects are considered lesser in younger individuals and the burden and outcomes in younger patients with PD are unknown. Objectives To determine the cumulative anticholinergic burden in a cohort of younger of patients with PD and to correlate the same with cognitive impairment and freezing of gait (FOG). Methods We conducted a cross-sectional study to identify the cumulative anticholinergic burden from medications prescribed to patients with PD. Two standard scales, the Anticholinergic Cognitive Burden (ACB) scale and the ACB score, were used to calculate the anticholinergic burden from prescriptions. We identified commonly prescribed drugs contributing to anticholinergic effects and correlated the cumulative ACB score with cognitive impairment (Movement Disorder Society-Unified Parkinson's Disease Rating Scale item 1.1) and FOG (Movement Disorder Society-Unified Parkinson's Disease Rating Scale items 2.13 and 3.11). Results We recruited 287 patients with PD (68.9% male) with a mean age of 56.9 ± 11.8 years and a duration of symptoms 6.3 ± 6.9 years. Median ACB score was 4 (range 0-12). A total of 164 (58.4%) patients had total ACB score > 3. ACB score > 3 was independently associated with cognitive impairment (Odds Ratio, 2.55; 95% confidence interval, 1.43-4.53; P < 0.001) and FOG using patient-reported measures (Odds Ratio, 3.192; 95% Confidence Interval, 1.68-6.07; P < 0.001) and objective measures (odds ratio, 2.41; 95% confidence interval, 1.27-4.6, P = 0.007). Conclusion Patients with PD are exposed to significant anticholinergic burden from drugs prescribed for PD and non-PD indications. Higher anticholinergic burden is associated with cognitive impairment and FOG even in younger patients with PD.
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Affiliation(s)
- Roopa Rajan
- Department of Neurology All India Institute of Medical Sciences New Delhi India
| | - Arti Saini
- Department of Neurology All India Institute of Medical Sciences New Delhi India
| | - Bhawna Verma
- Department of Neurology All India Institute of Medical Sciences New Delhi India
| | - Nishu Choudhary
- Department of Neurology All India Institute of Medical Sciences New Delhi India
| | - Anu Gupta
- Department of Neurology All India Institute of Medical Sciences New Delhi India
| | | | - Rohit Bhatia
- Department of Neurology All India Institute of Medical Sciences New Delhi India
| | - Mamta B Singh
- Department of Neurology All India Institute of Medical Sciences New Delhi India
| | - Achal K Srivastava
- Department of Neurology All India Institute of Medical Sciences New Delhi India
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14
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Cardwell K, Kerse N, Ryan C, Teh R, Moyes SA, Menzies O, Rolleston A, Broad J, Hughes CM. The Association Between Drug Burden Index (DBI) and Health-Related Outcomes: A Longitudinal Study of the 'Oldest Old' (LiLACS NZ). Drugs Aging 2020; 37:205-213. [PMID: 31919805 DOI: 10.1007/s40266-019-00735-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The prescribing of medications with anticholinergic and/or sedative properties is considered potentially inappropriate in older people (due to their side-effect profile), and the Drug Burden Index (DBI) is an evidence-based tool which measures exposure to these medications. Life and Living in Advanced Age: a Cohort Study in New Zealand (LiLACS NZ) is an ongoing longitudinal study investigating the determinants of healthy ageing. Using data from LiLACS NZ, this study aimed to determine whether a higher DBI was associated with poorer outcomes (hospitalisation, falls, mortality and cognitive function and functional status) over 36 months follow-up. METHODS LiLACS NZ consists of two cohorts: Māori (the indigenous population of New Zealand) aged ≥ 80 years and non-Māori aged 85 years at the time of enrolment. Data relating to regularly prescribed medications at baseline, 12 months and 24 months were used in this study. Medications with anticholinergic and/or sedative properties (i.e. medications with a DBI > 0) were identified using the Monthly Index of Medical Specialities (MIMS) medication formulary, New Zealand. DBI was calculated for everyone enrolled at each time point. The association between DBI at baseline and outcomes was evaluated throughout a series of 12-month follow-ups using negative binomial (hospitalisations and falls), Cox (mortality) and linear (cognitive function and functional status) regression analyses (significance p < 0.05). Regression models were adjusted for age, gender, general practitioner (GP) visits, socioeconomic deprivation, number of medicines prescribed and one of the following: prior hospitalisation, history of falls, baseline cognitive function [Modified Mini-Mental State Examination (3MS)] or baseline functional status [Nottingham Extended Activities of Daily Living (NEADL)]. RESULTS Full demographic data were obtained for 671, 510 and 403 individuals at baseline, 12 months and 24 months, respectively. Overall, 31%, 30% and 34% of individuals were prescribed a medication with a DBI > 0 at baseline, 12 months and 24 months, respectively. At baseline and 12 months, non-Māori had a greater mean DBI (0.28 ± 0.5 and 0.27 ± 0.5, respectively) compared to Māori (0.16 ± 0.3 and 0.18 ± 0.5, respectively). At baseline, the most commonly prescribed medicines with a DBI > 0 were zopiclone, doxazosin, amitriptyline and codeine. In Māori, a higher DBI was significantly associated with a greater risk of mortality: at 36 months follow-up, adjusted hazard ratio [95% confidence interval (CI)] 1.89 (1.11-3.20), p = 0.02. In non-Māori, a higher DBI was significantly associated with a greater risk of mortality [at 12 months follow-up, adjusted hazard ratio (95% CIs) 2.26 (1.09-4.70), p = 0.03] and impaired cognitive function [at 24 months follow-up, adjusted mean difference in 3MS score (95% CIs) 0.89 (- 3.89 to - 0.41), p = 0.02). CONCLUSIONS Using data from LiLACS NZ, a higher DBI was significantly associated with a greater risk of mortality (in Māori and non-Māori) and impaired cognitive function (in non-Māori). This highlights the importance of employing strategies to manage the prescribing of medications with a DBI > 0 in older adults.
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Affiliation(s)
- Karen Cardwell
- Northern Ireland Centre for Pharmacy Learning and Development, School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK.
| | - Ngaire Kerse
- Department of General Practice and Primary Health Care, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Cristín Ryan
- School of Pharmacy and Pharmaceutical Science, Trinity College Dublin, The University of Dublin, College Green, Dublin 2, Ireland
| | - Ruth Teh
- Department of General Practice and Primary Health Care, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Simon A Moyes
- Department of General Practice and Primary Health Care, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Oliver Menzies
- Older People's Health, Auckland District Health Board, Auckland, New Zealand
| | | | - Joanna Broad
- Department of Geriatric Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Carmel M Hughes
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland, UK
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15
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Graves-Morris K, Stewart C, Soiza RL, Taylor-Rowan M, Quinn TJ, Loke YK, Myint PK. The Prognostic Value of Anticholinergic Burden Measures in Relation to Mortality in Older Individuals: A Systematic Review and Meta-Analysis. Front Pharmacol 2020; 11:570. [PMID: 32411001 PMCID: PMC7201087 DOI: 10.3389/fphar.2020.00570] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/15/2020] [Indexed: 11/13/2022] Open
Abstract
Background Greater anticholinergic burden (ACB) increases the risk of mortality in older individuals, yet the strength of this association varies between studies. One possible explanation for this variance is the use of different approaches to quantify ACB. This systematic review (PROSPERO number CRD42019115918) assessed the prognostic utility of ACB-specific measures on mortality in older individuals. Methods Multiple cross-disciplinary databases were searched from 2006-2018. Observational studies assessing the association between ACB and mortality utilizing ≥1 ACB measure, involving persons aged ≥65 years were included. Screening and data extraction were performed by two independent reviewers, with disagreements resolved by a third independent reviewer. Risk of bias and quality of evidence were assessed using Quality in Prognosis Studies (QUIPS) and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria. Meta-analysis was conducted where appropriate. Results Of 19,224 titles, 20 articles describing 18 cohort studies involving 498,056 older individuals were eligible. Eight anticholinergic-specific measures were identified; the Anticholinergic Cognitive Burden Scale (ACBS, n=9) and Anticholinergic Risk scale (ARS, n=8) were most frequently reported. The evidence base was of poor quality, with moderate to high risk of bias. Meta-analysis showed increased mortality risk. Conclusions There was a modest association between some ACB measures and mortality, with most evidence derived from the ACBS. Studies comparing different measures within the same population were lacking. Analysis was limited by poor generalizability between studies, specifically regarding heterogeneity in methodology and reporting, as well as high risk of bias for most studies in the evidence base.
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Affiliation(s)
- Katherine Graves-Morris
- Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Carrie Stewart
- Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Roy L Soiza
- Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.,Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, United Kingdom
| | - Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Phyo Kyaw Myint
- Ageing Clinical and Experimental Research (ACER) Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.,Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, United Kingdom
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16
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Rigor J, Rueff Rato I, Ferreira PM, Pereira R, Ribeiro C, Teixeira D, Mesquita Oliveira P, Silva AM, Pereira S, Costa I, Ferreira P, Sequeira M, Monteiro-Soares M, Martins-Mendes D. Prehospital Anticholinergic Burden Is Associated With Delirium but Not With Mortality in a Population of Acutely Ill Medical Patients. J Am Med Dir Assoc 2020; 21:481-485. [PMID: 31983551 DOI: 10.1016/j.jamda.2019.12.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/13/2019] [Accepted: 12/17/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Anticholinergic drugs have several side effects, and they have been associated with adverse outcomes, particularly in older patients. The aim of this study was to analyze anticholinergic burden and its relationship to delirium and mortality in older acutely ill medical patients. DESIGN Cohort study. SETTING AND PARTICIPANTS Patients 65 years of age and older who were admitted to an Internal Medicine ward between August 1 and December 31, 2016. METHODS Anticholinergic drug use, outpatient and inpatient, was assessed using the Anticholinergic Cognitive Burden Scale (ACB). Prevalent delirium was diagnosed by the Short Confusion Assessment Method (Short-CAM). RESULTS Of the 198 patients, 28.3% developed delirium. Mortality rate was 13.6% in-hospital and 45.6% at 12 months. In multivariate analysis, outpatient ACB was associated with delirium, with an odds ratio (OR) of 1.65 [95% confidence interval (CI) 1.09-2.51]. Those with delirium had longer hospital stays (median 13 vs 8 days; P = .01), received more drugs (median 18 vs 15; P = .02), and presented a higher inpatient ACB (mean 3.9 vs 3.1; P = .034). No increased risk was found for in-hospital or 12-month mortality with drug use, ACB, or delirium. DISCUSSION In the population studied, we found an association between anticholinergic burden as measured by the ACB and the presence of delirium, but not with mortality at 12 months. A very high 12-month mortality rate might have been an obstacle for association recognition. CONCLUSIONS AND IMPLICATIONS Clinician awareness of possible drug side effects, especially in older populations, is crucial. As part of medication reconciliation at the time of hospitalization, ACB of prehospitalization medications should be routinely calculated by inpatient pharmacy services and made available to medical teams.
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Affiliation(s)
- Joana Rigor
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal.
| | - Inês Rueff Rato
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Paula Marques Ferreira
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Rita Pereira
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Catarina Ribeiro
- Nephrology Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Diogo Teixeira
- Dermatology Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Pedro Mesquita Oliveira
- Intensive Care Unit, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Ana Mafalda Silva
- Internal Medicine Department, Entre Douro e Vouga Hospital Center, E.P.E., Santa Maria da Feira, Portugal
| | - Sofia Pereira
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Ingride Costa
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Paula Ferreira
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Manuela Sequeira
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal
| | - Matilde Monteiro-Soares
- MEDCIDS-Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine of the University of Porto, Porto, Portugal; CINTESIS-Center for Health Technology and Services Research, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Daniela Martins-Mendes
- Internal Medicine Department, Vila Nova de Gaia/Espinho Hospital Center, E.P.E., Vila Nova de Gaia, Portugal; Biomedicine Department, Faculty of Medicine of the University of Porto, Porto, Portugal; i3S-Instituto de Investigação e Inovação em Saúde da Universidade do Porto, Porto, Portugal
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17
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Association between anticholinergic drug burden and mortality in older people: a systematic review. Eur J Clin Pharmacol 2019; 76:319-335. [PMID: 31832732 DOI: 10.1007/s00228-019-02795-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/05/2019] [Indexed: 01/29/2023]
Abstract
PURPOSE The purpose of the study is to conduct a systematic review of studies examining the association between anticholinergic burden and mortality in older individuals. METHODS A literature search was performed to identify relevant studies, using MEDLINE, EMBASE, PsycINFO and CENTRAL, from January 1990 to December 2018. We included studies of patients with a mean age of 65 years or older where the anticholinergic burden was estimated using anticholinergic risk assessment tools, and associations between anticholinergic load and mortality were investigated. The primary outcome of interest was the association between anticholinergic burden and mortality. RESULTS Twenty-seven studies were included. These were three cross-sectional, one nested case-control and 23 prospective or retrospective cohort studies. Most studies were determined to be of good quality. A total of 15 studies reported a positive correlation between anticholinergic burden and mortality, while the remaining 10 studies did not report a significant association. Eighteen out of 27 studies (80%) had a short follow-up period of 1 year or less. Among the five high-quality studies that met all the domains of the quality assessment criteria, four showed a positive association. CONCLUSION The variation in results could relate to the quality of the studies, follow-up period, anticholinergic risk assessment tool used and the study setting. Sixty-three percent (n = 17) of all the included studies, but almost all of the high-quality studies with an extended follow-up, reported a positive correlation between anticholinergic burden and mortality. Further high-quality research, using standardized measures and with adequate follow-up periods, is required to confirm the relationship between anticholinergic burden and mortality.
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18
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Park KH, Yang YM, Yoo JC, Choi EJ. Comparative Analysis Of Anticholinergics Prescribed To Elderly Patients At A Korean Long-Term Care Facility According To Beers Criteria 2003, 2012, And 2015 And Anticholinergic-Burden Rating Scales: A Cross-Sectional Retrospective Study. Clin Interv Aging 2019; 14:1963-1974. [PMID: 31806952 PMCID: PMC6850676 DOI: 10.2147/cia.s224434] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/19/2019] [Indexed: 12/26/2022] Open
Abstract
Background The Beers Criteria is used as a reference to identify potentially inappropriate medications (PIMs) prescribed to older people, and anticholinergic risk measurement scales (ARMSs) have been continuously made for measuring the anticholinergic burden. This study aimed to evaluate the concordance between any anticholinergics among PIMs identified by the Beers Criteria and those assessed by 9 different ARMSs. Methods This study was retrospectively conducted with Korean older patients hospitalized in the long-term care facility between March 2014 and August 2015. The data were collected through the chart review of electronic medical records of the patients. The Beers Criteria 2003, 2012, and 2015 were used to detect PIMs, and the following ARMSs were also employed to assess their potential anticholinergic effects: Anticholinergic Cognitive Burden Scale (2008), Anticholinergic Risk Scale (2008), Chew’s Scale (2008), Anticholinergic Drug Scale (ADS; 2006), Anticholinergic Activity Scale (AAS; 2010), Anticholinergic Load Scale (2011), Clinician-Rated Anticholinergic Scale (2008), Duran’s Scale (2013), and Anticholinergic Burden Classification (2006). Results The eligible patients who met inclusion and exclusion criteria were 216 during the study period. Most patients were females (70.4%), and the mean age was 81.0 ± 6.7 years. Approximately 70%, 86%, and 87% of the patients included were identified as using at least one PIM according to the Beers Criteria 2003, 2012, and 2015, respectively. Compared with the Beers Criteria 2003, the versions of 2012 and 2015 showed more improved concordance associated with the ARMSs. When the Beers Criteria 2015 was compared with the ARMSs, the lowest concordance was found for AAS (κ = 0.153; 95% CI, 0.079–0.227), whereas the highest concordance was observed for ADS (κ = 0.530; 95% CI, 0.406–0.654). Conclusion The heterogeneity between the Beers Criteria and the ARMSs was observed. Compared with the Beers Criteria 2003, the versions of 2012 and 2015 showed more enhanced concordance associated with the ARMSs.
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Affiliation(s)
- Ki Hyun Park
- Department of Pharmacy, College of Pharmacy, Chosun University, Gwangju, South Korea
| | - Young-Mo Yang
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, South Korea
| | - Jin Cheol Yoo
- Department of Pharmacy, College of Pharmacy, Chosun University, Gwangju, South Korea
| | - Eun Joo Choi
- Department of Pharmacy, College of Pharmacy, Chosun University, Gwangju, South Korea
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19
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Joung K, Shin J, Cho S. Features of anticholinergic prescriptions and predictors of high use in the elderly: Population‐based study. Pharmacoepidemiol Drug Saf 2019; 28:1591-1600. [DOI: 10.1002/pds.4902] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/07/2019] [Accepted: 09/09/2019] [Indexed: 01/21/2023]
Affiliation(s)
- Kyung‐in Joung
- Division of Epidemiology, Department of Public Health Science, Graduate School of Public HealthSeoul National University Seoul South Korea
| | - Ju‐Young Shin
- School of PharmacySungkyunkwan University Suwon South Korea
| | - Sung‐il Cho
- Department of Public Health Science, Graduate School of Public Health and Institute of Health and EnvironmentSeoul National University Seoul South Korea
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20
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Aalto UL, Finne-Soveri H, Kautiainen H, Roitto HM, Öhman H, Pitkälä KH. Use of Anticholinergic Drugs According to Various Criteria and Their Association With Psychological Well-Being and Mortality in Long-Term Care Facilities. J Am Med Dir Assoc 2019; 20:1156-1162. [PMID: 30910551 DOI: 10.1016/j.jamda.2019.02.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/28/2019] [Accepted: 02/03/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To compare 3 internationally established criteria for drugs with anticholinergic properties (DAPs) and their associated factors in long-term care facilities, and to investigate the association between use of DAPs and psychological well-being (PWB) or mortality. DESIGN Cross-sectional study and 1-year follow-up of all-cause mortality. SETTING AND PARTICIPANTS Of all 4449 residents living in long-term care facilities in Helsinki in 2011, 2432 (≥65 years of age) participated after exclusion of residents with severe dementia. MEASUREMENTS Data on demographics, medication use, and active diagnoses were collected by trained staff using structured questionnaires. DAP use was defined by the following 3 international criteria: Chew's list, the Anticholinergic Risk Scale, and the Anticholinergic Drug Scale. The total number of DAPs was counted and referred to as anticholinergic burden. PWB was assessed by a questionnaire and yielded a score ranging from 0 to 1. Mortality data was retrieved from central registers. RESULTS Of all participants, 85% were DAP users according to at least 1 of the 3 criteria used. Overlap between the 3 criteria was only moderate. DAP users were younger and a larger proportion of them had better cognition. However, they suffered more often from depression and other psychiatric diagnoses than nonusers. DAP users had lower PWB scores than those not using DAPs, and PWB decreased linearly in the overlapping groups from nonusers to those using DAPs according to all 3 criteria. The total number of DAPs used predicted mortality. CONCLUSIONS AND IMPLICATIONS DAP use and PWB appear to be negatively associated. When combining several criteria of DAPs, their burden predicted mortality. Clinicians should carefully consider the potential benefits and harms when prescribing DAPs to older persons.
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Affiliation(s)
- Ulla L Aalto
- Department of General Practice, University of Helsinki, Helsinki, Finland; Department of Social Services and Health Care, Helsinki Hospital, Helsinki, Finland.
| | - Harriet Finne-Soveri
- Department of Social Services and Health Care, Helsinki Hospital, Helsinki, Finland; National Institute for Health and Welfare, Helsinki, Finland
| | - Hannu Kautiainen
- Helsinki University Hospital, Unit of Primary Health Care, Helsinki, Finland
| | - Hanna-Maria Roitto
- Department of General Practice, University of Helsinki, Helsinki, Finland; Department of Social Services and Health Care, Helsinki Hospital, Helsinki, Finland
| | - Hannareeta Öhman
- Department of General Practice, University of Helsinki, Helsinki, Finland; Department of Social Services and Health Care, Helsinki Hospital, Helsinki, Finland
| | - Kaisu H Pitkälä
- Department of General Practice, University of Helsinki, Helsinki, Finland; Helsinki University Hospital, Unit of Primary Health Care, Helsinki, Finland
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21
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Corsonello A, Cozza A, D'Alia S, Onder G, Volpato S, Ruggiero C, Cherubini A, Di Rosa M, Fabbietti P, Lattanzio F. The excess mortality risk associated with anticholinergic burden among older patients discharged from acute care hospital with depressive symptoms. Eur J Intern Med 2019; 61:69-74. [PMID: 30449478 DOI: 10.1016/j.ejim.2018.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/03/2018] [Accepted: 11/10/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND The relationship between anticholinergic burden and mortality is controversial, and the impact of anticholinergic burden on prognosis may vary in presence of other conditions common in old age. We aimed at investigating the role of depressive symptoms as potential effect modifiers in the association between anticholinergic burden and 1-year mortality in older patients discharged from hospital. METHODS Our series consisted of 576 older patients consecutively admitted to seven geriatric and internal medicine acute care wards in the context of a prospective multicenter observational study. Overall anticholinergic burden was assessed by Anticholinergic Cognitive Burden (ACB) score. Depressive symptoms were assessed by 15-item Geriatric Depression Scale (GDS). The study outcome was all-cause mortality during 12-months follow-up. Statistical analysis was carried out by Cox regression analysis. RESULTS After adjusting for potential confounders, discharge ACB score = 2 or more was significantly associated with the outcome among patients with GDS > 5 (HR = 3.70; 95%CI = 1.18-11.6), but not among those with GDS ≤ 5 (HR = 2.32; 95%CI = 0.90-6.24). The association was confirmed among depressed patients after adjusting for ACB score at 3-month follow-up (HR = 3.58; 95%CI = 1.21-10.7), as well as when considering ACB score as a continuous variable (HR = 1.42; 95%CI = 1.10-1.91). The interaction between ACB score at discharge and BADL dependency was statistically significant (p < .005). CONCLUSIONS ACB score at discharge may predict mortality among older patients discharged from acute care hospital carrying high GDS score e. Hospital physician should be aware that prescribing anticholinergic medications in such a vulnerable population may have negative prognostic implications.
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Affiliation(s)
- Andrea Corsonello
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, IRCCS INRCA, Ancona and Cosenza, Italy.
| | - Annalisa Cozza
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, IRCCS INRCA, Ancona and Cosenza, Italy
| | - Sonia D'Alia
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, IRCCS INRCA, Ancona and Cosenza, Italy
| | - Graziano Onder
- Department of Gerontology, Neuroscience and Orthopedics, Catholic University of Sacred Heart, Gemelli University Hospital, Rome, Italy
| | - Stefano Volpato
- Department of Medical Sciences, Section of Internal and Cardiorespiratory Medicine, University of Ferrara, Ferrara, Italy
| | - Carmelinda Ruggiero
- Section of Gerontology and Geriatrics, Department of Medicine, University of Perugia, Perugia, Italy
| | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro di Ricerca per l'Invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Mirko Di Rosa
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, IRCCS INRCA, Ancona and Cosenza, Italy
| | - Paolo Fabbietti
- Unit of Geriatric Pharmacoepidemiology and Biostatistics, IRCCS INRCA, Ancona and Cosenza, Italy
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22
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Inkeri NM, Karjalainen M, Haanpää M, Kautiainen H, Saltevo J, Mäntyselkä P, Tiihonen M. Anticholinergic drug use and its association with self-reported symptoms among older persons with and without diabetes. J Clin Pharm Ther 2018; 44:229-235. [DOI: 10.1111/jcpt.12772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 09/14/2018] [Indexed: 02/06/2023]
Affiliation(s)
| | - Merja Karjalainen
- Institute of Public Health and Clinical Nutrition, General Practice; University of Eastern Finland; Kuopio Finland
- Inner Savo Health Center; Suonenjoki Finland
| | - Maija Haanpää
- Ilmarinen Mutual Pension Insurance Company; Vantaa Finland
- Department of Neurosurgery; Helsinki University Hospital; Helsinki Finland
| | - Hannu Kautiainen
- Unit of Primary Health Care; Helsinki University Central Hospital; Helsinki Finland
- Primary Health Care Unit; Kuopio University Hospital; Kuopio Finland
| | - Juha Saltevo
- Central Finland Central Hospital; Jyväskylä Finland
| | - Pekka Mäntyselkä
- Institute of Public Health and Clinical Nutrition, General Practice; University of Eastern Finland; Kuopio Finland
- Primary Health Care Unit; Kuopio University Hospital; Kuopio Finland
| | - Miia Tiihonen
- School of Pharmacy; University of Eastern Finland; Kuopio Finland
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23
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Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. Tools for Assessment of the Appropriateness of Prescribing and Association with Patient-Related Outcomes: A Systematic Review. Drugs Aging 2018; 35:43-60. [PMID: 29350335 DOI: 10.1007/s40266-018-0516-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND There are tools and criteria in the literature aimed at distinguishing between appropriate and inappropriate medicines use. However, many have not been externally validated with regard to patient-related outcomes, potentially limiting their use in clinical practice. OBJECTIVES The aim of the study was to conduct a systematic review to summarise (1) available prescribing appropriateness assessment tools and criteria, and (2) their associations with patient-related outcomes (external validity). METHODS A systematic review was conducted using MEDLINE, EMBASE and Informit (Health Collection) databases to screen for articles in English that examined (1) tools to assess the appropriateness of prescribing and (2) associations of tools with patient-related outcomes, published between 2000 and 2016, without any limits placed on the study design, participant age or setting. RESULTS After screening 1710 articles, removing duplicates and shortlisting relevant articles, 42 prescribing assessment tools were identified. Out of the 42 tools, 78.6% (n = 33) provided guidance around stopping inappropriate medications, 28.6% (n = 12) around starting appropriate medications, 61.9% (n = 26) were explicit (criteria based) and 31.0% (n = 13) had been externally validated, with hospitalisation being the most commonly used patient-related outcome (n = 9, 21.4%). CONCLUSION The results of this systematic review highlight the need for evidence-based and externally validated tools, which combine the different aspects of medication management to optimise patient-related outcomes. PROSPERO registration number: CRD42017067233.
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Affiliation(s)
- Nashwa Masnoon
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, SA, Australia.
- Department of Pharmacy, Royal Adelaide Hospital, North Terrace, Adelaide, SA, Australia.
| | - Sepehr Shakib
- Department of Clinical Pharmacology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, Australia
- Discipline of Pharmacology, School of Medicine, University of Adelaide, North Terrace, Adelaide, SA, Australia
| | - Lisa Kalisch-Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, SA, Australia
| | - Gillian E Caughey
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, SA, Australia
- Department of Clinical Pharmacology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, Australia
- Discipline of Pharmacology, School of Medicine, University of Adelaide, North Terrace, Adelaide, SA, Australia
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24
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Lattanzio F, Onder G, La Fauci MM, Volpato S, Cherubini A, Fabbietti P, Ruggiero C, Garasto S, Cozza A, Crescibene L, Tarsitano A, Corsonello A. Anticholinergic Burden is Associated With Increased Mortality in Older Patients With Dependency Discharged From Hospital. J Am Med Dir Assoc 2018; 19:942-947. [PMID: 30049542 DOI: 10.1016/j.jamda.2018.06.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 06/06/2018] [Accepted: 06/11/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To determine whether anticholinergic burden may predict differently 1-year mortality in older patients discharged from acute care hospitals with or without dependency in basic activities of daily living (BADL). DESIGN Prospective observational study. SETTING AND PARTICIPANTS Our series consisted of 807 patients aged 65 years or older consecutively discharged from 7 acute care geriatric wards throughout Italy between June 2010 and May 2011. MEASURES Overall anticholinergic burden was assessed by the anticholinergic cognitive burden (ACB) score. Dependency was rated by BADL, and dependency in at least 1 BADL was considered as a potential mediator in the analysis. The study outcome was all-cause mortality during 12-months of follow-up. RESULTS Patients included in the study were aged 81.0 ± 7.4 years, and 438 (54.3%) were female. During the follow-up period, 177 out of 807 participants (21.9%) died. After adjusting for potential confounders, discharge ACB score = 2 or more was significantly associated with the outcome among patients with dependency in at least 1 BADL [hazard ratio (HR) 2.25 95% confidence (CI) 1.22‒4.14], but not among independent ones (HR 1.06 95% CI 0.50‒2.34). The association was confirmed among dependent patients after adjusting for the number of lost BADL at discharge (HR 2.20 95% CI 1.18‒4.04) or ACB score at 3-month follow-up (HR 2.18 95% CI 1.20‒3.98), as well as when considering ACB score as a continuous variable (HR 1.28 95% CI 1.11‒1.49). The interaction between ACB score at discharge and BADL dependency was highly significant (P < .001). CONCLUSIONS/IMPLICATIONS ACB score at discharge may predict mortality among older patients discharged from an acute care hospital carrying at least 1 BADL dependency. Hospital physicians should be aware that prescribing anticholinergic medications in this population may have negative prognostic implications and they should try to reduce anticholinergic burden at discharge whenever possible.
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Affiliation(s)
- Fabrizia Lattanzio
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Graziano Onder
- Department of Gerontology, Neuroscience and Orthopedics, Catholic University of Sacred Heart, Gemelli University Hospital, Rome, Italy
| | | | - Stefano Volpato
- Department of Medical Sciences, Section of Internal and Cardiorespiratory Medicine, University of Ferrara, Ferrara, Italy
| | - Antonio Cherubini
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Paolo Fabbietti
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Carmelinda Ruggiero
- Section of Gerontology and Geriatrics, Department of Medicine, University of Perugia, Perugia, Italy
| | - Sabrina Garasto
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Annalisa Cozza
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Lucia Crescibene
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Assunta Tarsitano
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Andrea Corsonello
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy.
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Aalto UL, Roitto HM, Finne-Soveri H, Kautiainen H, Pitkälä K. Use of Anticholinergic Drugs and its Relationship With Psychological Well-Being and Mortality in Long-Term Care Facilities in Helsinki. J Am Med Dir Assoc 2018; 19:511-515. [DOI: 10.1016/j.jamda.2017.11.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 11/21/2017] [Indexed: 02/01/2023]
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26
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Welsh TJ, van der Wardt V, Ojo G, Gordon AL, Gladman JRF. Anticholinergic Drug Burden Tools/Scales and Adverse Outcomes in Different Clinical Settings: A Systematic Review of Reviews. Drugs Aging 2018; 35:523-538. [DOI: 10.1007/s40266-018-0549-z] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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27
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Lattanzio F, Corica F, Schepisi R, Amantea D, Bruno F, Cozza A, Onder G, Volpato S, Cherubini A, Ruggiero C, Maggio MG, Corsonello A. Anticholinergic burden and 1-year mortality among older patients discharged from acute care hospital. Geriatr Gerontol Int 2018; 18:705-713. [PMID: 29292589 DOI: 10.1111/ggi.13234] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/13/2017] [Accepted: 11/13/2017] [Indexed: 11/27/2022]
Abstract
AIM The association between anticholinergic burden and mortality is controversial. We aimed to investigate whether the anticholinergic cognitive burden (ACB) score predicts 1-year mortality in older patients discharged from acute care hospitals. METHODS Our series consisted of 807 hospitalized patients aged ≥65 years. Patients were followed up for 12 months after discharge. All-cause mortality was the outcome of the study. The ACB score at discharge (0, 1, ≥2) and increasing ACB score from admission to discharge (no increase, +1, +2 or more) were calculated and used as exposure variables. Cox proportional hazards models adjusted for potential confounders were used for the analysis. Interactions between the ACB score and cognitive impairment or history of falls were also investigated. RESULTS During the follow-up period, 177 out of 807 participants (21.9%) died. After adjusting for potential confounders, a discharge ACB score of ≥2 (HR 1.69, 95% CI 1.09-2.65) was significantly associated with the outcome, whereas the association between increasing ACB score of +2 or more and mortality was weaker (HR 1.30, 95% CI 0.95-1.92). The interaction between the ACB score at discharge or increasing ACB score and cognitive impairment was statistically significant (P = 0.003 and P = 0.004, respectively), whereas that between the ACB score and falls was not. CONCLUSIONS The ACB score at discharge and, to a lesser extent, an increasing ACB score during hospital stay are associated with an increased risk of 1-year mortality in older patients discharged from hospital. Such an association is stronger among patients with cognitive impairment. Geriatr Gerontol Int 2018; 18: 705-713.
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Affiliation(s)
- Fabrizia Lattanzio
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Francesco Corica
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Roberto Schepisi
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Diana Amantea
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Francesco Bruno
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Annalisa Cozza
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Graziano Onder
- Department of Gerontology, Neuroscience and Orthopedics, Catholic University of Sacred Heart, Gemelli University Hospital, Rome, Italy
| | - Stefano Volpato
- Department of Medical Sciences, Section of Internal and Cardiorespiratory Medicine, University of Ferrara, Ferrara, Italy
| | - Antonio Cherubini
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
| | - Carmelinda Ruggiero
- Section of Gerontology and Geriatrics, Department of Medicine, University of Perugia, Perugia, Italy
| | - Marcello G Maggio
- Department of Clinical and Experimental Medicine and Geriatric Rehabilitation Department, University of Parma, Parma, Italy
| | - Andrea Corsonello
- Italian National Research Center on Aging (INRCA), Ancona and Cosenza, Italy
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Ferret L, Ficheur G, Delaviez E, Luyckx M, Quenton S, Beuscart R, Chazard E, Beuscart JB. Inappropriate anticholinergic drugs prescriptions in older patients: analysing a hospital database. Int J Clin Pharm 2017; 40:94-100. [PMID: 29147963 DOI: 10.1007/s11096-017-0554-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 10/26/2017] [Indexed: 01/25/2023]
Abstract
Background Although many anticholinergics are inappropriate in older patients, the prescription of these drugs in a hospital setting has not been extensively studied. Objective To describe prescriptions of anticholinergic drugs in terms of frequency, at risk situations and constipation in hospitalized, older adults. Setting Using a database from a French general hospital (period 2009-2013), we extracted information on 14,090 hospital stays by patients aged 75 and over. Methods Anticholinergic drug prescriptions were automatically detected, with a focus on prescriptions in three well-known at-risk situations: falls, dementia, and benign prostatic hyperplasia. Cases of constipation that might have been causally related to the administration of anticholinergic drugs were screened for and reviewed. Main outcome measure Prescriptions with a high associated risk of anticholinergic related adverse reactions. Results Administration of an anticholinergic drug was detected in 1412 (10.0%) of the hospital stays by older patients. At-risk situations were identified in 413 (36.5%) of these stays: 137 (9.7%) for falls, 243 (17.2%) for dementia, and 114 (8.1%) for benign prostatic hyperplasia; 78 (18.9%) of these 413 stays featured a combination of two or three at-risk situations. Cases of constipation induced by anticholinergic drug administration were identified in 188 (13.3%) patient stays by using validated adjudication rules for adverse drug reactions: 85 and 103 cases were respectively evaluated as "possible" or "probable" adverse drug reactions. Conclusions Anticholinergic drugs prescription was found in 10.0% of hospitalized, older patients. More than one third of these prescriptions occurred in at-risk situations and more than one in ten prescriptions induced constipation.
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Affiliation(s)
- Laurie Ferret
- EA 2694 - Santé publique: épidémiologie et qualité des soins, Univ. Lille, 59000, Lile, France
| | - Gregoire Ficheur
- EA 2694 - Santé publique: épidémiologie et qualité des soins, Univ. Lille, 59000, Lile, France
- Department of Medical Information and Archives, CHU Lille, 59000, Lille, France
| | - Emeline Delaviez
- EA 2694 - Santé publique: épidémiologie et qualité des soins, Univ. Lille, 59000, Lile, France
| | - Michel Luyckx
- Department of Pharmacy, Denain General Hospital, Denain, France
- EA GRITA -Laboratoire de pharmacologie, pharmacocinétique et pharmacie clinique, Univ. Lille, 59000, Lille, France
| | - Sophie Quenton
- EA 2694 - Santé publique: épidémiologie et qualité des soins, Univ. Lille, 59000, Lile, France
| | - Regis Beuscart
- EA 2694 - Santé publique: épidémiologie et qualité des soins, Univ. Lille, 59000, Lile, France
- Department of Medical Information and Archives, CHU Lille, 59000, Lille, France
| | - Emmanuel Chazard
- EA 2694 - Santé publique: épidémiologie et qualité des soins, Univ. Lille, 59000, Lile, France
- Department of Medical Information and Archives, CHU Lille, 59000, Lille, France
| | - Jean-Baptiste Beuscart
- EA 2694 - Santé publique: épidémiologie et qualité des soins, Univ. Lille, 59000, Lile, France.
- Department of Geriatrics, CHU Lille, 59000, Lille, France.
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Gutiérrez-Valencia M, Martínez-Velilla N, Vetrano DL, Corsonello A, Lattanzio F, Ladrón-Arana S, Onder G. Anticholinergic burden and health outcomes among older adults discharged from hospital: results from the CRIME study. Eur J Clin Pharmacol 2017; 73:1467-1474. [DOI: 10.1007/s00228-017-2312-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 07/25/2017] [Indexed: 11/29/2022]
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30
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Chatterjee S, Bali V, Carnahan RM, Chen H, Johnson ML, Aparasu RR. Risk of Mortality Associated with Anticholinergic Use in Elderly Nursing Home Residents with Depression. Drugs Aging 2017; 34:691-700. [DOI: 10.1007/s40266-017-0475-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Comparison of Nine Instruments to Calculate Anticholinergic Load in a Large Cohort of Older Outpatients: Association with Cognitive and Functional Decline, Falls, and Use of Laxatives. Am J Geriatr Psychiatry 2017; 25:531-540. [PMID: 28233606 DOI: 10.1016/j.jagp.2017.01.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 12/21/2016] [Accepted: 01/11/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE A patient's risk for anticholinergic adverse effects is frequently estimated by instruments evaluating the drugs included in his medication profile. It remains unknown, however, which characteristics should be included in such an assessment instrument aiming to reliably predict adverse anticholinergic outcomes. DESIGN Cross-sectional study. SETTING ESTHER cohort (Germany). PARTICIPANTS Home-dwelling participants (N = 2,761) aged between 60 and 87 years. MEASUREMENTS The association between anticholinergic load calculated with nine different instruments and four anticholinergic adverse outcomes was investigated in univariate and multivariate analyses. Therefore, linear models complemented with Kendall's tau rank correlation coefficients (ԏ) were applied for continuous outcomes and generalized linear models were used to derive odds ratios (ORs) with 95% confidence intervals (CIs) for binary endpoints. RESULTS Based on the respective identification criteria for anticholinergic drugs, the nine instruments identified between 245 (9%) and 866 (31%) anticholinergic drug users (mean age ± SD: 73 ± 6 years; Mini-Mental State Examination [MMSE] score: 28.3 ± 2.07; Barthel Index: 97.1 ± 7.5; 291 reporting falls; 29 taking laxatives [surrogate for constipation]). In the multivariate analysis, only two instruments indicated a significant association between anticholinergic load and all four outcomes. The instrument considering the prescribed dose showed the strongest association with MMSE scores (ԏ = -0.10), falls (OR: 2.30; 95% CI: 1.50-3.52), and the use of laxatives (OR: 3.11; 95% CI: 1.04-9.36). CONCLUSIONS Instruments most reliably predicted anticholinergicadverse events if they were either based on the drugs' serum anticholinergic activity and the suggestions of clinician experts or considered the actual prescribed dose.
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Wong KKL, Tang LCY, Zhou J, Ho V. Analysis of spatiotemporal pattern and quantification of gastrointestinal slow waves caused by anticholinergic drugs. Organogenesis 2017; 13:39-62. [PMID: 28277890 DOI: 10.1080/15476278.2017.1295904] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Anticholinergic drugs are well-known to cause adverse effects, such as constipation, but their effects on baseline contractile activity in the gut driven by slow waves is not well established. In a video-based gastrointestinal motility monitoring (GIMM) system, a mouse's small intestine was placed in Krebs solution and recorded using a high definition camera. Untreated controls were recorded for each specimen, then treated with a therapeutic concentration of the drug, and finally, treated with a supratherapeutic dose of the drug. Next, the video clips showing gastrointestinal motility were processed, giving us the segmentation motions of the intestine, which were then converted via Fast Fourier Transform (FFT) into their respective frequency spectrums. These contraction quantifications were analyzed from the video recordings under standardised conditions to evaluate the effect of drugs. Six experimental trials were included with benztropine and promethazine treatments. Only the supratherapeutic dose of benztropine was shown to significantly decrease the amplitude of contractions; at therapeutic doses of both drugs, neither frequency nor amplitude was significantly affected. We have demonstrated that intestinal slow waves can be analyzed based on the colonic frequency or amplitude at a supratherapeutic dose of the anticholinergic medications. More research is required on the effects of anticholinergic drugs on these slow waves to ascertain the true role of ICC in neurologic control of gastrointestinal motility.
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Affiliation(s)
- Kelvin K L Wong
- a School of Medicine, Western Sydney University , Campbelltown , NSW , Australia
| | - Lauren C Y Tang
- a School of Medicine, Western Sydney University , Campbelltown , NSW , Australia
| | - Jerry Zhou
- a School of Medicine, Western Sydney University , Campbelltown , NSW , Australia
| | - Vincent Ho
- a School of Medicine, Western Sydney University , Campbelltown , NSW , Australia
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Bali V, Chatterjee S, Johnson ML, Chen H, Carnahan RM, Aparasu RR. Risk of Mortality in Elderly Nursing Home Patients with Depression Using Paroxetine. Pharmacotherapy 2017; 37:287-296. [DOI: 10.1002/phar.1898] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Vishal Bali
- Engage2Health; Health Advocate; Westlake Village California
| | - Satabdi Chatterjee
- Department of Pharmaceutical Health Outcomes and Policy; College of Pharmacy, University of Houston; Houston Texas
| | - Michael L. Johnson
- Department of Pharmaceutical Health Outcomes and Policy; College of Pharmacy, University of Houston; Houston Texas
| | - Hua Chen
- Department of Pharmaceutical Health Outcomes and Policy; College of Pharmacy, University of Houston; Houston Texas
| | - Ryan M. Carnahan
- Department of Epidemiology; College of Public Health, University of Iowa; Iowa City Iowa
| | - Rajender R. Aparasu
- Department of Pharmaceutical Health Outcomes and Policy; College of Pharmacy, University of Houston; Houston Texas
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Gorzoni ML, Fabbri RMA. Applicability of Anticholinergic Risk Scale in hospitalized elderly persons. REVISTA BRASILEIRA DE GERIATRIA E GERONTOLOGIA 2017. [DOI: 10.1590/1981-22562017020.150191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Objective: to define the applicability of the Anticholinergic Risk Scale (ARS) as a risk indicator of delirium in hospitalized elderly persons. Method: the medical records of elderly patients hospitalized in the medical wards of a teaching hospital were analyzed with the ARS, translated and adapted for medicines used in Brazil. The version of the Confusion Assessment Method (CAM) for the clinical diagnosis of delirium translated and validated by Fabbri et al. was used. Individuals aged ≥60 years were included in the evaluation of drug use. The sample was divided by gender and age to analyze the effect of these variables on the use of anticholinergic drugs based on the ARS, and association with delirium. Results: 123 elderly persons, 47 men and 76 women, with a mean age of 72.7(±9.2) years were included. The average consumption of drugs not listed in the ARS (some with anticholinergic action as Ipratropium and Scopolamine) was 6.1(±3.0) and the average number of drugs used listed in the ARS (Metoclopramide, Ranitidine, Atropine, Haloperidol and Risperidone) was 0.9±0.6. Four elderly persons had a score ≥3 (3.3% of total cases). Delirium was observed in 27 patients (21.9% of the total), none of whom scored more than two ARS points. There was no statistical significance regarding gender, age and delirium. Conclusion: the average score of the ARS was low among this population, and did not correlate with delirium. The ARS does not cover all anticholinergics, meaning this study should be repeated in a geriatric ward for comparison.
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Anticholinergic burden: considerations for older adults. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2016. [DOI: 10.1002/jppr.1303] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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The effect of comprehensive geriatric assessment on anticholinergic exposure assessed by four ranked anticholinergic lists. Arch Gerontol Geriatr 2016; 68:195-201. [PMID: 27837709 DOI: 10.1016/j.archger.2016.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 08/30/2016] [Accepted: 10/29/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Older people often use multiple drugs, and some of them have anticholinergic activity. Anticholinergic drugs may cause adverse reactions, and therefore their use should be limited. To identify anticholinergic load, several ranked lists with different drugs and scoring systems have been developed and used widely in research. We investigated, if a comprehensive geriatric assessment (CGA) decreased the anticholinergic drug score in a 4-year period. We used four different anticholinergic ranked lists to determine the anticholinergic score and to describe how the results differ depending on the list used. METHODS We analyzed data from population-based intervention study, in which a random sample of 1000 persons aged ≥75 years were randomized to either an intervention group or a control group. Those in the intervention group underwent CGA including medication assessment annually between 2004 and 2007. Current medication use was assessed annually. The anticholinergic load was calculated by using four ranked lists of anticholinergic drugs (Boustani's, Carnahan's, Chew's and Rudolph's) for each person and for each year. RESULTS CGA had no statistically significant effect on anticholinergic exposure during the 4-year follow-up, but improvements towards more appropriate medication use were observed especially in the intervention group. However, age, gender and functional comorbidity index were associated to higher anticholinergic exposure, depending on the list used. CONCLUSIONS Repeated CGAs may result as more appropriate anticholinergic medication use. The selection of the list may affect the results and therefore the selection of the list is important.
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Sarbacker GB, Espino DV, Wood RC, Oakes SL, Anand D, Markides KA. Total anticholinergic burden and survival within a cohort of elderly Mexican Americans. Geriatr Gerontol Int 2016; 17:1515-1521. [DOI: 10.1111/ggi.12907] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 07/14/2016] [Accepted: 07/31/2016] [Indexed: 11/29/2022]
Affiliation(s)
- G Blair Sarbacker
- University of Incarnate Word Feik School of Pharmacy; San Antonio Texas USA
- University of Texas Health Science Center San Antonio; San Antonio Texas USA
| | - David V Espino
- San Antonio State Supported Living Center; San Antonio Texas USA
| | - Robert C Wood
- Primary Care Geriatric Medicine; WellMed Medical Group; San Antonio Texas USA
| | - Sandra L Oakes
- Primary Care Geriatric Medicine; WellMed Medical Group; San Antonio Texas USA
| | - Dheeraj Anand
- Geriatrics; Christus Santa Rosa Medical Center; San Antonio Texas USA
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Examination and Estimation of Anticholinergic Burden: Current Trends and Implications for Future Research. Drugs Aging 2016; 33:305-13. [DOI: 10.1007/s40266-016-0362-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Kachru N, Carnahan RM, Johnson ML, Aparasu RR. Potentially inappropriate anticholinergic medication use in community-dwelling older adults: a national cross-sectional study. Drugs Aging 2016; 32:379-89. [PMID: 25832970 DOI: 10.1007/s40266-015-0257-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Inappropriate medications are often used in older adults despite their unfavourable risk-to-benefit profile. Although many of the medications in the American Geriatrics Society (AGS) Beers list are potentially inappropriate because of their anticholinergic properties, little is known regarding the nature and extent of potentially inappropriate anticholinergic medication use in older adults. OBJECTIVES To determine the prevalence of, and factors associated with, potentially inappropriate anticholinergic medication use in the older population. METHODS A retrospective, cross-sectional study was conducted, involving older adults (aged 65 years and older), using 2009-2010 Medical Expenditure Panel Survey (MEPS) data. The 2012 AGS Beers Criteria were used to define potentially inappropriate anticholinergic medications on the basis of the list of medications to avoid using in older adults irrespective of the diagnosis. Descriptive analyses were used to examine the nature and extent of potentially inappropriate anticholinergic medication use. Multivariable logistic regression within the conceptual framework of the Andersen Behavioral Model was used to identify the factors associated with potentially inappropriate anticholinergic use in older adults. RESULTS According to the MEPS, there were 78.60 million older adults in the USA; an estimated 7.51 million (9.56 %) of these older adults used potentially inappropriate anticholinergic medications in 2009-2010. The most frequently used potentially inappropriate anticholinergics were cyclobenzaprine, promethazine, amitriptyline, hydroxyzine and dicyclomine. Multivariable regression analyses revealed that female sex, residing in the South and the presence of anxiety disorder increased the likelihood of receiving potentially inappropriate anticholinergic medications, whereas older adults aged 75-84 or ≥ 85 years, and those with over 15 years of education, had a decreased likelihood of receiving potentially inappropriate anticholinergic medications. CONCLUSION The study found that approximately one in ten older adults used potentially inappropriate anticholinergic medications. Several predisposing, enabling and need factors were associated with the use of potentially inappropriate anticholinergic medications. Concerted efforts are needed to optimize potentially inappropriate anticholinergic medication use in older adults.
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Affiliation(s)
- Nandita Kachru
- Department of Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, Texas Medical Center, 1441 Moursund Street, Houston, TX, 77030, USA
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Nishtala PS, Salahudeen MS, Hilmer SN. Anticholinergics: theoretical and clinical overview. Expert Opin Drug Saf 2016; 15:753-68. [DOI: 10.1517/14740338.2016.1165664] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | | | - Sarah N. Hilmer
- Sydney Medical School, Royal North Shore Hospital and Kolling Institute of Medical Research, University of Sydney, St Leonards, NSW, Australia
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Collamati A, Martone AM, Poscia A, Brandi V, Celi M, Marzetti E, Cherubini A, Landi F. Anticholinergic drugs and negative outcomes in the older population: from biological plausibility to clinical evidence. Aging Clin Exp Res 2016; 28:25-35. [PMID: 25930085 DOI: 10.1007/s40520-015-0359-7] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 04/01/2015] [Indexed: 11/29/2022]
Abstract
The use of medication with anticholinergic properties is widespread among older subjects. Many drugs of common use such as antispasmodics, bronchodilators, antiarrhythmics, antihistamines, anti-hypertensive drugs, antiparkinson agents, skeletal muscle relaxants, and psychotropic drugs have been demonstrated to have an anticholinergic activity. The most frequent adverse effects are dry mouth, nausea, vomiting, constipation, abdominal pain, urinary retention, blurred vision, tachycardia and neurologic impairment such as confusion, agitation and coma. A growing evidence from experimental studies and clinical observations suggests that drugs with anticholinergic properties can cause physical and mental impairment in the elderly population. However, the morbidity and management issues associated with unwanted anticholinergic activity are underestimated and frequently overlooked. Moreover, their possible relation with specific negative outcome in the elderly population is still not firmly established. The aim of the present review was to evaluate the relationship between the use of drugs with anticholinergic activity and negative outcomes in older persons. We searched PubMed and Cochrane combining the search terms "anticholinergic", "delirium", "cognitive impairment", "falls", "mortality" and "discontinuation". Medicines with anticholinergic properties may increase the risks of functional and cognitive decline, morbidity, institutionalization and mortality in older people. However, such evidences are still not conclusive probably due to possible confounding factors. In particular, more studies are needed to investigate the effects of discontinuation of drug with anticholinergic properties. Overall, minimizing anticholinergic burden should always be encouraged in clinical practice to improve short-term memory, confusion and delirium, quality of life and daily functioning.
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Affiliation(s)
- Agnese Collamati
- Department of Gerontology, Orthopedics and Neuroscience, Catholic University of Sacred Heart, Rome, Italy
| | - Anna Maria Martone
- Department of Gerontology, Orthopedics and Neuroscience, Catholic University of Sacred Heart, Rome, Italy
| | - Andrea Poscia
- Institute of Public Health, Catholic University of Sacred Heart, Rome, Italy
| | - Vincenzo Brandi
- Department of Gerontology, Orthopedics and Neuroscience, Catholic University of Sacred Heart, Rome, Italy
| | - Michela Celi
- Department of Gerontology, Orthopedics and Neuroscience, Catholic University of Sacred Heart, Rome, Italy
| | - Emanuele Marzetti
- Department of Gerontology, Orthopedics and Neuroscience, Catholic University of Sacred Heart, Rome, Italy
| | | | - Francesco Landi
- Department of Gerontology, Orthopedics and Neuroscience, Catholic University of Sacred Heart, Rome, Italy.
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Burden of Potentially Harmful Medications and the Association With Quality of Life and Mortality Among Institutionalized Older People. J Am Med Dir Assoc 2016; 17:276.e9-14. [PMID: 26805751 DOI: 10.1016/j.jamda.2015.12.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 12/08/2015] [Accepted: 12/09/2015] [Indexed: 01/03/2023]
Abstract
OBJECTIVES This study investigated the overlap among 3 different definitions of potentially harmful medication (PHM) use and the corresponding associations with resident quality of life and mortality. DESIGN Cross-sectional study with 3-year follow-up for mortality. SETTING Assisted living facilities and nursing homes in Helsinki and Kouvola, Finland. PARTICIPANTS A total of 326 residents. MEASUREMENTS PHM use was defined as (1) use of medications with anticholinergic properties, (2) use of Beers Criteria medications, and (3) concomitant use 3 or more psychotropic medications. Health-related quality of life (HRQoL) was assessed using the 15D and psychological well-being (PWB) scale. Residents self-rated their own health using a 4-point scale. Mortality data were obtained from central registers. RESULTS There were 38.0%, 28.2%, and 12.6% of residents who used PHMs according to 1 (G1), 2 (G2), and 3 definitions (G3), respectively. Overall, 21.2% of residents did not use PHMs according to any of the 3 definitions (G0). There were no significant differences in comorbidity, cognition, or functioning among groups. In adjusted analyses, there was a stepwise association between use of multiple PHMs and poorer self-rated health, poorer PWB, and poorer HRQoL. There was no association in adjusted analyses between PHM use and 3-year mortality (47.8%-63.8%). CONCLUSION PHM use is highly prevalent in institutional settings, regardless of the definition of inappropriateness. Residents who used multiple categories of PHMs were at greatest risk of poor HRQoL, poor PWB, and poor self-rated health. However, there was no apparent association with increased mortality. Given the importance of quality of life as an outcome to older people, further efforts are needed to minimize PHM use in this setting.
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McLarin PE, Peterson GM, Curtain CM, Nishtala PS, Hannan PJ, Castelino RL. Impact of residential medication management reviews on anticholinergic burden in aged care residents. Curr Med Res Opin 2016; 32:123-31. [PMID: 26455537 DOI: 10.1185/03007995.2015.1105794] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The primary objective of this study was to investigate the impact of Residential Medication Management Reviews (RMMRs) on anticholinergic burden quantified by seven anticholinergic risk scales. DESIGN Retrospective analysis. SETTING Accredited pharmacists conducted RMMRs in aged-care facilities (ACFs) in Sydney, Australia. PARTICIPANTS RMMRs pertained to 814 residents aged 65 years or older. MEASUREMENTS Anticholinergic burden was quantified using seven scales at baseline, after pharmacists' recommendations and after the actual GP uptake of pharmacists' recommendations. Change in the anticholinergic burden was measured using the Wilcoxon sign rank test. RESULTS At baseline, depending on the scale used to estimate the anticholinergic burden, between 36% and 67% of patients were prescribed at least one regular anticholinergic medication (ACM). Anticholinergic burden scores were significantly (p < 0.001) lower after pharmacists' recommendations as determined by each of the seven scales. The reduction in anticholinergic burden was also significant (p < 0.001) after GPs' acceptance of the pharmacists' recommendations according to all scales with the exception of one scale which reached borderline significance (p = 0.052). CONCLUSION Despite the limitations of the retrospective design and differences in the estimation of anticholinergic burden, this is the first study to demonstrate that RMMRs are effective in reducing ACM prescribing in ACF residents, using a range of measures of anticholinergic burden. Future studies should focus on whether a decrease in anticholinergic burden will translate into improvement in clinical outcomes.
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Affiliation(s)
- Patricia E McLarin
- a a Pharmacy, School of Medicine, University of Tasmania , Hobart , Tasmania , Australia
| | - Gregory M Peterson
- a a Pharmacy, School of Medicine, University of Tasmania , Hobart , Tasmania , Australia
| | - Colin M Curtain
- a a Pharmacy, School of Medicine, University of Tasmania , Hobart , Tasmania , Australia
| | | | | | - Ronald L Castelino
- a a Pharmacy, School of Medicine, University of Tasmania , Hobart , Tasmania , Australia
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Lampela P, Paajanen T, Hartikainen S, Huupponen R. Central Anticholinergic Adverse Effects and Their Measurement. Drugs Aging 2015; 32:963-74. [DOI: 10.1007/s40266-015-0321-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Different methods, different results--how do available methods link a patient's anticholinergic load with adverse outcomes? Eur J Clin Pharmacol 2015; 71:1299-314. [PMID: 26350641 DOI: 10.1007/s00228-015-1932-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 08/26/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Anticholinergic drugs are known to cause physical and cognitive impairment, particularly in older patients. The total of all anticholinergic influences to which a patient is exposed is referred to as anticholinergic load. Because the anticholinergic load is defined in various ways, this review aimed to describe differences in the development and evaluation of available methods calculating the anticholinergic load. METHODS From September 2014 to August 2015, two reviewers performed a literature search in PubMed considering relevant items of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. We aimed to identify articles which calculated the anticholinergic load with a scale or equation and investigated its association with patient-related outcomes. From the included studies, we descriptively analyzed the identification and scoring criteria of the scales and equations with a main emphasis on their association to the reported outcomes. RESULTS Out of 465 articles, 55 were included referring to 12 scales and one equation. Main discrepancies were located in eight different identification criteria for anticholinergic drugs, two different scoring principles, and 118 tests used for assessing outcomes. The methods most frequently detecting a significant association between the anticholinergic load and outcomes took into account the drugs' dosages and anticholinergic potencies. Interestingly, none of the methods included the patient's susceptibility for anticholinergic effects and they only rarely considered modulators of drug exposure. CONCLUSIONS Due to hugely varying tests for assessing outcomes, the methods are scarcely comparable. For a more valuable comparison, the anticholinergic load should be calculated with all scales and the equation and correlated with patient-related outcomes.
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Pont LG, Nielen JTH, McLachlan AJ, Gnjidic D, Chan L, Cumming RG, Taxis K. Measuring anticholinergic drug exposure in older community-dwelling Australian men: a comparison of four different measures. Br J Clin Pharmacol 2015; 80:1169-75. [PMID: 25923961 DOI: 10.1111/bcp.12670] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 04/08/2015] [Accepted: 04/10/2015] [Indexed: 11/28/2022] Open
Abstract
AIMS Anticholinergic drug exposure is associated with adverse outcomes in older people. While a number of tools have been developed to measure anticholinergic drug exposure, there is limited information about the agreement and overlap between the various scales. The aim of this study was to investigate the agreement and overlap between different measures of anticholinergic drug exposure in a cohort of community-dwelling older men. METHODS A cross-sectional study was used to compare anticholinergic drug exposure calculated using the Anticholinergic Risk Scale (ARS), the Anticholinergic Drug Scale (ADS), the Anticholinergic Cognitive Burden (ACB) and the Drug Burden Index anticholinergic subscale (DBI-ACH) in a cohort of community-dwelling men aged 70 years and older (n = 1696). Statistical agreement, expressed as Cohen's kappa (κ), between these measurements was calculated. RESULTS Differences were found between the tools regarding the classification of anticholinergic drug exposure for individual participants. Thirteen percent of the population used a drug listed as anticholinergic on the ARS, 39% used a drug listed on the ADS and the ACB, and 18% of the population used one or more anticholinergic drugs listed on the DBI-ACH. While agreement was good between the ACB and ADS (κ = 0.628, 95% CI 0.593, 0.664), little agreement was found between remaining tools (κ = 0.091-0.264). CONCLUSIONS With the exception of the ACB and ADS, there was poor agreement regarding anticholinergic drug exposure among the four tools compared in this study. Great care should be taken when interpreting anticholinergic drug exposure using existing scales due to the wide variability between the different scales.
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Affiliation(s)
- Lisa G Pont
- Australian Institute of Health Innovation, Macquarie University, North Ryde, Australia.,Sydney Nursing School, University of Sydney, Sydney, Australia
| | - Johannes T H Nielen
- Department of Pharmacy, University of Groningen, Groningen, The Netherlands.,Department of Clinical Pharmacology & Toxicology, Maastricht UMC+, Maastricht, The Netherlands.,Department of Epidemiology, CAPHRI School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Andrew J McLachlan
- Faculty of Pharmacy, University of Sydney, Sydney, Australia.,Centre for Education and Research on Ageing, University of Sydney and Concord Hospital, Sydney, Australia
| | - Danijela Gnjidic
- Faculty of Pharmacy, University of Sydney, Sydney, Australia.,Centre for Education and Research on Ageing, University of Sydney and Concord Hospital, Sydney, Australia
| | - Lewis Chan
- Department of Urology, Concord Repatriation General Hospital, Sydney, Australia
| | - Robert G Cumming
- Centre for Education and Research on Ageing, University of Sydney and Concord Hospital, Sydney, Australia.,School of Public Health, University of Sydney, Sydney, Australia
| | - Katja Taxis
- Department of Pharmacy, University of Groningen, Groningen, The Netherlands
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Salahudeen MS, Duffull SB, Nishtala PS. Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review. BMC Geriatr 2015; 15:31. [PMID: 25879993 PMCID: PMC4377853 DOI: 10.1186/s12877-015-0029-9] [Citation(s) in RCA: 312] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 03/06/2015] [Indexed: 11/26/2022] Open
Abstract
Background The cumulative effect of taking multiple medicines with anticholinergic properties termed as anticholinergic burden can adversely impact cognition, physical function and increase the risk of mortality. Expert opinion derived risk scales are routinely used in research and clinical practice to quantify anticholinergic burden. These scales rank the anticholinergic activity of medicines into four categories, ranging from no anticholinergic activity (= 0) to definite/high anticholinergic activity (= 3). The aim of this systematic review was to compare anticholinergic burden quantified by the anticholinergic risk scales and evaluate associations with adverse outcomes in older people. Methods We conducted a literature search in Ovid MEDLINE, EMBASE and PsycINFO from 1984-2014 to identify expert opinion derived anticholinergic risk scales. In addition to this, a citation analysis was performed in Web of Science and Google Scholar to track prospective citing of references of selected articles for assessment of individual scales for adverse anticholinergic outcomes. The primary outcomes of interest were functional and cognitive outcomes associated with anticholinergic burden in older people. The critical appraisals of the included studies were performed by two independent reviewers and the data were extracted onto standardised forms. Results The primary electronic literature search identified a total of 1250 records in the 3 different databases. On the basis of full-text analysis, we identified 7 expert-based anticholinergic rating scales that met the inclusion criteria. The rating of anticholinergic activity for medicines among these rating scales was inconsistent. For example, quetiapine was rated as having high anticholinergic activity in one scale (n = 1), moderate in another scale (n = 1) and low in two other scales (n = 2). Citation analysis of the individual scales showed that the Anticholinergic Cognitive Burden (ACB) scale was the most frequently validated expert based anticholinergic scale for adverse outcomes (N = 13). Conclusions In conclusion, there is not one standardised tool for measuring anticholinergic burden. Cohort studies have shown that higher anticholinergic burden is associated with negative brain effects, poorer cognitive and functional outcomes. Electronic supplementary material The online version of this article (doi:10.1186/s12877-015-0029-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Stephen B Duffull
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, 9054, New Zealand.
| | - Prasad S Nishtala
- School of Pharmacy, University of Otago, PO Box 56, Dunedin, 9054, New Zealand.
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Myint PK, Fox C, Kwok CS, Luben RN, Wareham NJ, Khaw KT. Total anticholinergic burden and risk of mortality and cardiovascular disease over 10 years in 21,636 middle-aged and older men and women of EPIC-Norfolk prospective population study. Age Ageing 2015; 44:219-25. [PMID: 25430550 DOI: 10.1093/ageing/afu185] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Studies have raised concerns that medications with anticholinergic property have potential adverse effects on health outcomes. OBJECTIVES The objective of this study is to examine the prospective relationships between total anticholinergic burden (ACB) from medications and mortality, and cardiovascular disease (CVD) in a general population. DESIGN Observational study. SETTING Community cohort. SUBJECTS We examined data collected from 21,636 men and women without cancer at the baseline who participated in a baseline survey 1993-97 in the European Prospective Investigation into Cancer (EPIC)-Norfolk. They were followed until 2009/11. METHODS We performed Cox-proportional hazards models to determine the associations between total ACB and the subsequent risk of all-cause mortality and incident CVD during the follow-up. RESULTS There were a total of 4,342 people died and 7,328 had an incident CVD during the study follow-up (total person years=322,321 years for mortality and 244,119 years for CVD event). Compared with people with no anticholinergic burden (ACB=0), people with total ACB≥3 from medications had hazards ratios of 1.83 (1.53, 2.20) and 2.17 (1.87, 2.52) for mortality and CVD incidence outcomes, respectively, after adjusting for potential confounders. Repeating the analyses after excluding people with prevalent illnesses, and events occurring within the first 2 years of follow-up, only slightly attenuated the results. CONCLUSION There appear to be a class effect as well as dose-response relationship between the ACB and both outcomes. Future research should focus on understanding the relationship between ACB and mortality, and cardiovascular disease and possibly minimising ACB load where feasible.
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Affiliation(s)
- Phyo Kyaw Myint
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen AB25 2ZD, UK Clinical Gerontology Unit, Department of Public Health and Primary Care, University of Cambridge, Addenbrooke's Hospital, Cambridge, Cambridgeshire CB2 0QQ, UK
| | - Chris Fox
- School of Medicine, University of East Anglia, Norwich, Norfolk NR47TJ, UK
| | - Chun Shing Kwok
- Institute of Cardiovascular Sciences, University of Manchester, Manchester, Lancashire, M13 9WL, UK
| | - Robert N Luben
- Clinical Gerontology Unit, Department of Public Health and Primary Care, University of Cambridge, Addenbrooke's Hospital, Cambridge, Cambridgeshire CB2 0QQ, UK
| | | | - Kay-Tee Khaw
- Clinical Gerontology Unit, Department of Public Health and Primary Care, Clinical Gerontology Unit, University of Cambridge, Cambridge CB2 2QQ, UK School of Clinical Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge CB2 2QQ, UK
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Salahudeen MS, Hilmer SN, Nishtala PS. Comparison of Anticholinergic Risk Scales and Associations with Adverse Health Outcomes in Older People. J Am Geriatr Soc 2015; 63:85-90. [DOI: 10.1111/jgs.13206] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Sarah N. Hilmer
- Sydney Medical School; Royal North Shore Hospital; University of Sydney; Sydney New South Wales Australia
- Kolling Institute of Medical Research; University of Sydney; Sydney New South Wales Australia
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Fox C, Smith T, Maidment I, Chan WY, Bua N, Myint PK, Boustani M, Kwok CS, Glover M, Koopmans I, Campbell N. Effect of medications with anti-cholinergic properties on cognitive function, delirium, physical function and mortality: a systematic review. Age Ageing 2014; 43:604-15. [PMID: 25038833 DOI: 10.1093/ageing/afu096] [Citation(s) in RCA: 227] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES to determine the effect of drugs with anti-cholinergic properties on relevant health outcomes. DESIGN electronic published and unpublished literature/trial registries were systematically reviewed. Studies evaluating medications with anti-cholinergic activity on cognitive function, delirium, physical function or mortality were eligible. RESULTS forty-six studies including 60,944 participants were included. Seventy-seven percent of included studies evaluating cognitive function (n = 33) reported a significant decline in cognitive ability with increasing anti-cholinergic load (P < 0.05). Four of five included studies reported no association with delirium and increasing anti-cholinergic drug load (P > 0.05). Five of the eight included studies reported a decline in physical function in users of anti-cholinergics (P < 0.05). Three of nine studies evaluating mortality reported that the use of drugs with anti-cholinergic properties was associated with a trend towards increased mortality, but this was not statistically significant. The methodological quality of the evidence-base ranged from poor to very good. CONCLUSION medicines with anti-cholinergic properties have a significant adverse effect on cognitive and physical function, but limited evidence exists for delirium or mortality outcomes.
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Affiliation(s)
- Chris Fox
- School of Medicine, University of East Anglia, Norwich, Norfolk NR47TJ, UK
| | - Toby Smith
- School of Rehabilitation Sciences, University of East Anglia, Norwich, Norfolk, NR4 7TJ, UK
| | - Ian Maidment
- Pharmacy, School of Life and Health Sciences, Medicines and Devices in Ageing, Aston Research Centre for Healthy Ageing, (ARCHA), Aston University, Birmingham, UK
| | - Wei-Yee Chan
- School of Medicine, University of East Anglia, Norwich, Norfolk NR47TJ, UK
| | - Nelson Bua
- School of Medicine, University of East Anglia, Norwich, Norfolk NR47TJ, UK
| | - Phyo Kyaw Myint
- School of Medicine & Dentistry, University of Aberdeen, Aberdeen, Scotland AB25 2ZD, UK
| | - Malaz Boustani
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Chun Shing Kwok
- Norfolk and Norwich University Hospital, Norwich, Norfolk NR4 7UY, UK
| | - Michelle Glover
- School of Medicine, University of East Anglia, Norwich, Norfolk NR47TJ, UK
| | - Imogen Koopmans
- School of Medicine, University of East Anglia, Norwich, Norfolk NR47TJ, UK
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