Anticholinergic medication use and dementia: latest evidence and clinical implications

Sarcopenia and diabetes-induced dementia risk

This study aimed to investigate whether sarcopenia independently increases the risk of diabetes-induced dementia in elderly individuals diagnosed with type 2 diabetes mellitus. The study cohort consisted of a large sample of elderly individuals aged 60 years and above, who were diagnosed with type 2 diabetes mellitus between 2008 and 2018. To minimize potential bias and achieve covariate balance between the sarcopenia and non-sarcopenia groups, we employed propensity score matching. Various statistical analyses, including Cox regression models to assess dementia risk and associations, competing risk analysis to account for mortality and Poisson regression analysis for incidence rates, were used. Before propensity score matching, the study included 406 573 elderly type 2 diabetes mellitus patients, with 20 674 in the sarcopenia group. Following propensity score matching, the analysis included a total of 41 294 individuals, with 20 647 in the sarcopenia group and 20 647 in the non-sarcopenia group. Prior to propensity score matching, elderly type 2 diabetes mellitus patients with sarcopenia exhibited a significantly higher risk of dementia (adjusted hazard ratio: 1.12, 95% confidence interval: 1.07-1.17). After propensity score matching, the risk remained significant (adjusted hazard ratio: 1.14, 95% confidence interval: 1.07-1.21). Incidence rates of dementia were notably higher in the sarcopenia group both before and after propensity score matching, underscoring the importance of sarcopenia as an independent risk factor. Our study highlights sarcopenia as an independent risk factor for diabetes-induced dementia in elderly type 2 diabetes mellitus patients. Advanced age, female gender, lower income levels, rural residency, higher adapted diabetes complication severity index and Charlson Comorbidity Index scores and various comorbidities were associated with increased dementia risk. Notably, the use of statins was linked to a reduced risk of dementia. This research underscores the need to identify and address modifiable risk factors for dementia in elderly type 2 diabetes mellitus patients, offering valuable insights for targeted interventions and healthcare policies.

Current optimal pharmacologic therapies for overactive bladder

INTRODUCTION

Overactive bladder (OAB) is a common syndrome in adults. Current pharmacologic treatment includes antimuscarinic agents and β-3 adrenoceptor agonists. For non-responders to oral medication, intravesical injection of botulinum toxin A (BoNT-A) is an effective option. However, these treatments have potential adverse events and should be cautiously selected for appropriate patients. This review presents the recently published results of clinical trials and studies for patients with OAB and the underlying pathophysiology of OAB. Appropriate medical therapy based on pathophysiology of OAB is also presented.

AREAS COVERED

Literature search from Pubmed from 2001 to 2023 including clinical background, pharmacology, and clinical studies for OAB medications.

EXPERT OPINION

Treatment of OAB syndrome with any antimuscarinic or β-3 adrenoceptor agonist is feasible as a first-line approach. For patients with suboptimal therapeutic effect to full-dose antimuscarinics or mirabegron, combination with both drugs can improve efficacy. Intravesical BoNT-A 100-U injection provides therapeutic effects for refractory OAB. Patients who are refractory to initial pharmacotherapies should be investigated for the underlying pathophysiology; then an appropriate medication can be added, such as an α1-blocker or anti-inflammatory agents. Patient education about behavioral modification and therapies should always be provided with oral medication or BoNT-A injection for OAB patients.

Association Between Regular Laxative Use and Incident Dementia in UK Biobank Participants

BACKGROUND AND OBJECTIVES

The use of over-the-counter laxatives is common in the general population. The microbiome-gut-brain axis hypothesis suggests that the use of laxatives could be associated with dementia. We aimed to examine the association between the regular use of laxatives and the incidence of dementia in UK Biobank participants.

METHODS

This prospective cohort study was based on UK Biobank participants aged 40-69 years without a history of dementia. Regular use of laxatives was defined as self-reported use in most days of the week for the last 4 weeks at baseline (2006-2010). The outcomes were all-cause dementia, Alzheimer disease (AD), and vascular dementia (VD), identified from linked hospital admissions or death registers (up to 2019). Sociodemographic characteristics, lifestyle factors, medical conditions, family history, and regular medication use were adjusted for in the multivariable Cox regression analyses.

RESULTS

Among the 502,229 participants with a mean age of 56.5 (SD 8.1) years at baseline, 273,251 (54.4%) were female, and 18,235 (3.6%) reported regular use of laxatives. Over a mean follow-up of 9.8 years, 218 (1.3%) participants with regular use of laxatives and 1,969 (0.4%) with no regular use developed all-cause dementia. Multivariable analyses showed that regular use of laxatives was associated with increased risk of all-cause dementia (hazard ratio [HR] 1.51; 95% CI 1.30-1.75) and VD (HR 1.65; 95% CI 1.21-2.27), with no significant association observed for AD (HR 1.05; 95% CI 0.79-1.40). The risk of both all-cause dementia and VD increased with the number of regularly used laxative types (p trend 0.001 and 0.04, respectively). Among the participants who clearly reported that they were using just 1 type of laxative (n = 5,800), only those using osmotic laxatives showed a statistically significantly higher risk of all-cause dementia (HR 1.64; 95% CI 1.20-2.24) and VD (HR 1.97; 95% CI 1.04-3.75). These results remained robust in various subgroup and sensitivity analyses.

DISCUSSION

Regular use of laxatives was associated with a higher risk of all-cause dementia, particularly in those who used multiple laxative types or osmotic laxative.

The Cumulative Use of Muscle Relaxants and the Risk of Alzheimer's Disease: A Nationwide Case-Control Study

BACKGROUND

Use of pharmacological treatments is one possible modifiable risk factor for cognitive disorders.

OBJECTIVE

To investigate if the use of muscle relaxants is associated with the risk of Alzheimer's disease (AD).

METHODS

The study was performed in a nested case-control design. Altogether 70,718 community-dwelling residents of Finland who received AD diagnosis in 2005-2011 were included as cases (the MEDALZ study). Each case was matched with four controls without AD by age, sex, and region of residence (N = 282,858). Data was extracted from Prescription register (1995-2012), Special Reimbursement register (1972-2012), and Hospital Discharge register (1972-2012). Drug use periods were modeled with PRE2DUP-method. Defined daily dose (DDD) was used to quantify the use. Analyses were conducted for any muscle relaxant use, and drug specific analyses were done for orphenadrine and tizanidine. A five-year lag window prior to the diagnosis was used, and results analyzed with conditional logistic regression.

RESULTS

The use of any muscle relaxant was associated with the risk of AD, aOR (95% CI) 1.04 (1.02-1.07). Stronger associations were observed with longer use (>366 days, aOR 1.12 (1.03-1.21)) than shorter use (1-365 days aOR, 1.04 (1.02-1.06)) compared to non-users. Dose-response was not observed. Tizanidine was not associated with AD, whereas cumulative exposure of orphenadrine (≥101 DDDs) was associated with the risk of AD, aOR 1.19 (1.07-1.32).

CONCLUSION

Muscle relaxant use was associated with the risk of AD and higher exposure to orphenadrine showed increased risk. Further studies on higher doses and longer durations of use are warranted.

Medication changes and potentially inappropriate prescribing in older patients with significant polypharmacy

BACKGROUND

Number of medicines and medicines appropriateness are often used as outcome measures to evaluate the effectiveness of deprescribing interventions.

AIM

The aim of this study was to evaluate changes in prescribing, potentially inappropriate prescriptions (PIP) and prescribing of low-value medicines in older people with multimorbidity and significant polypharmacy.

METHOD

This study was a retrospective secondary analysis of prescription data from a cluster randomised controlled trial involving 404 participants aged ≥ 65 years and prescribed ≥ 15 repeat medicines from 51 different general practices. For this study, repeat medications at baseline and follow-up (~ 1 year later) were assigned Anatomical Therapeutic Classification (ATC) codes. Outcomes were the most commonly prescribed and potentially inappropriately prescribed drug groups, the most frequently discontinued or initiated drug groups and the number of changes per person between baseline and follow-up.

RESULTS

There were 7051 medicines prescribed to 404 participants at baseline. There was a median of 17 medicines (IQR 15-19) at baseline and 16 (IQR 14-19) at follow-up. PIP represented 17.1% of prescriptions at baseline and 15.7% (n = 6777) at follow-up. There were reductions in the prescription of most drug groups with the largest reduction in antiplatelet prescriptions. Considering medication discontinuations, initiations and switches, there was a median of five medication changes per person (range 0-30, IQR 3-9) by follow-up. There were 95 low-value prescriptions at baseline reducing to 78 at follow-up.

CONCLUSION

The number of medication changes per person was not reflected by summarising medication count at two time points, highlighting the complexity of prescribing for patients with polypharmacy. Frequent medication changes has potentially important implications for patients in terms of adherence and medication safety.

TRIAL REGISTRY

The SPPiRE trial was registered prospectively on the ISRCTN registry (ISRCTN12752680).

Polypharmacy Interactions Impacting Methacholine Challenge Testing for Asthma Assessment in Older People

Objective To investigate potential reasons for unusually high incidence of negative Methacholine Challenge Tests (MCT), following standardized MCT medication-hold protocol, in older people with physician-diagnosed asthma. Design An analysis of a longitudinal observational parent study of asthma. Setting Community-dwelling participants were evaluated in an outpatient clinic and at home. Participants Screening inclusion criteria for the parent study included 60 years of age or older, physician diagnosis of asthma, and a positive response to at least one of six asthma screening questions. Participants were enrolled in the study if they also demonstrate either: (1) a postbronchodilator administration response showing an increase of at least 12% and 200 mL in forced expiratory volume or an increase of at least 12% and 200 mL in forced vital capacity, or (2) an MCT result of PC20 ≤ 16 mg/mL (indicating bronchial hyper-responsiveness, MCT positive). Exclusion criteria included diagnosis of cognitive impairment or dementia, residing in a long-term care facility, more than 20 pack/ year smoking history or a history of smoking within the previous five years, inability to perform pulmonary function testing maneuvers, and a Prognostic Index score of greater than 10. Interventions Analysis of participant data for non-medication- and medication-exposure factors for association with negative MCT results. Results Anticholinergic burden and statin use were positively associated with negative MCT. Conclusion Medications not accounted for in medication-hold protocols, and concurrently in use, may impact clinical tests and outcomes.

Anti-cholinergic drug burden in patients with dementia increases after hospital admission: a multicentre cross-sectional study

Background

Anticholinergic medications are drugs that block cholinergic transmission, either as their primary therapeutic action or as a secondary effect. Patients with dementia may be particularly sensitive to the central effects of anticholinergic drugs. Anticholinergics also antagonise the effects of the main dementia treatment, cholinesterase inhibitors. Our study aimed to investigate anticholinergic prescribing for dementia patients in UK acute hospitals before and after admission.

Methods

We included 352 patients with dementia from 17 UK hospital sites in 2019. They were all inpatients on surgical, medical or Care of the Elderly wards. Information about each patient’s medications were collected using a standardised form, and the anticholinergic drug burden of each patient was calculated with an evidence-based online calculator. Wilcoxon’s rank test was used to look at the correlation between two subgroups upon admission and discharge.

Results

On admission to hospital, 37.8% of patients had an anticholinergic burden score ≥ 1 and 5.68% ≥3. On discharge, 43.2% of patients with an anticholinergic burden score ≥ 1 and 9.1% ≥3. The increase in scores was statistically significant (p = 0.001). Psychotropics were the most common group of anticholinergic medications prescribed at discharge. Of those patients taking cholinesterase inhibitors, 44.9% were also prescribed anticholinergic medications.

Conclusions

Our cross-sectional, multicentre study found that people with dementia are commonly prescribed anticholinergic medications, even if concurrently taking cholinesterase inhibitors, and are significantly more likely to be discharged from hospital with a higher anticholinergic burden than on admission.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03235-9.

Benzodiazepine use and the risk of dementia

Introduction

Benzodiazepines (BZDs) are commonly prescribed for anxiety and agitations, which are early symptoms of Alzheimer's disease and related dementias (ADRD). It is unclear whether BZDs causally affect ADRD risk or are prescribed in response to early symptoms of dementia.

Methods

We replicate prior case-control studies using longitudinal Medicare claims. To mitigate bias from prodromal use, we compare rates of ADRD diagnosis for beneficiaries exposed and unexposed to BZDs for cervical/lumbar pain, stenosis, and sciatica, none of which are associated with dementia.

Results

Approximately 8% of Medicare beneficiaries used a BZD in 2007, increasing to nearly 13% by 2013. Estimates from case-control designs are sensitive to duration of look-back period, health histories, medication use, and exclusion of decedents. Incident BZD use is not associated with an increased risk of dementia in an "uncontaminated" sample of beneficiaries prescribed a BZD for pain (odds ratios (ORs) of 1.007 [95% confidence interval [CI] = 0.885, 1.146] and 0.986 [95% CI = 0.877, 1.108], respectively, in the 2013 and 2013 to 2015 pooled samples). Higher levels of BZD exposure (>365 days over a 2-year period) are associated with increased odds of a dementia diagnosis, but the results are not statistically significant at the 5% or 10% levels (1.190 [95% CI = 0.925, 1.531] and 1.167 [95% CI = 0.919, 1.483]).

Discussion

We find little evidence of a causal relation between BZD use and dementia risk. Nonetheless, providers should limit the extended use in elderly populations.

Anticholinergic burden and cognitive performance: cross-sectional results from the ELSA-Brasil study

OBJECTIVES

Using multiple drugs with anticholinergic properties is common and might lead to cumulative anticholinergic toxicity and increased risk of cognitive impairment. Therefore, we sought to investigate the association between the Anticholinergic Cognitive Burden (ACB) Scale and cognitive performance among middle-aged and older adults.

METHODS

In this cross-sectional study with 13,065 participants from the baseline visit of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), mean age was 51.7 ± 9.0 years old, 55% women, and 53% white. The ACB was calculated based on the medications in use. We investigated the association of ACB with global cognition and memory, verbal fluency (VF), and trail-making test version B (TMT-B) z-scores, using multiple linear regression models adjusted for sociodemographic and clinical variables.

RESULTS

Overall, 16% of participants had an ACB score greater than 0. ACB was associated with poor cognitive performance in all tests in crude analysis. After adjustment for sociodemographic characteristics, the association remained significant for the global cognitive score, as well as the memory and the TMT-B z-scores. However, after further adjustments for clinical variables, only trend associations of ACB with poor memory (β =  - 0.02, 95% Cl =  - 0.05, 0.00, p = 0.056) and the TMT-B z-scores (β =  - 0.02, 95% Cl =  - 0.04, 0.00, p = 0.054) were found. In stratified analyses by age groups, ACB was associated with poor cognitive performance on the TMT-B (β =  - 0.03, 95% Cl =  - 0.05, - 0.01, p = 0.005) in individuals aged less than 65 years old.

CONCLUSION

Although the ACB was associated with poor executive function only among middle-aged adults in adjusted analysis, residual confounding may partly explain our results.

Incidence of Drug-Induced Delirium During Treatment With Antidepressants or Antipsychotics: A Drug Surveillance Report of German-Speaking Countries Between 1993 and 2016

OBJECTIVES

Successful treatment of delirium depends on the detection of the reversible contributors. Drugs with delirogenic properties are the most prevalent reversible cause of delirium.

METHODS

This observational study is based on data from Arzneimittelsicherheit in der Psychiatrie, a multicenter drug surveillance program in German-speaking countries recording severe adverse drug reactions (ADRs) in psychiatric inpatients. The present study analyzes drug-induced delirium (DID) during treatment with antidepressants and antipsychotics.

RESULTS

A total of 436 565 psychiatric inpatients were treated with antidepressants and/or antipsychotics during the observation period from 1993 to 2016 in the participating 110 hospitals. Overall, 254 cases (0.06% of all patients treated with antidepressants and/or antipsychotics) of DID were detected. Implicated either in combination or alone (multiple drugs were implicated in 70.1% of DID), clomipramine (0.24%), amitriptyline (0.21%), and clozapine (0.18%) showed the highest incidence rates of DID. When implicated alone (98 cases overall), clozapine (0.11%) followed by amitriptyline (0.05%) were most likely causally associated with the occurrence of DID. Drugs with strong antimuscarinic properties generally exhibited higher risk of DID.

CONCLUSIONS

With an incidence rate of <0.1%, the use of antidepressants and antipsychotics was rarely associated with DID within the Arzneimittelsicherheit in der Psychiatrie program. Tricyclic antidepressants and clozapine were the most commonly implicated psychotropic drugs. These data support the specific role of antimuscarinic properties in DID.

How to choose appropriate medication for overactive bladder: Findings from the largest integrated clinical trial database analysis of mirabegron studies

Medical treatment of overactive bladder (OAB) includes antimuscarinic agents, beta-3 adrenoceptor agonist (mirabegron), or combination with both drugs. Recently, a meta-analysis reported the integrated clinical trial data from 10 phase 2–4, double-blind, 12-week mirabegron monotherapy studies. The results confirmed that mirabegron is as effective as the previously used antimuscarinic agent to treat OAB. The treatment-emergent adverse events were similar across subgroups. This article comments on this largest integrated clinical trial data analysis, and reviews the recently published literature and tries to reveal how to choose the appropriate medication for OAB. For OAB patients, starting from antimuscarinic agent is feasible. However, if the patients have risk of cognitive dysfunction, a history of constipation, dry mouth, and urinary retention, starting with mirabegron 50 mg might be more safe and appropriate. In the elderly patients with low detrusor contractility, with central nervous system lesion, and men with benign prostatic hyperplasia, starting from 25 mg mirabegron is recommended. If the treatment result is not satisfactory to the 25 mg mirabegron, increase dose to 50 mg mirabegron is appropriate. In patients who have failed from the first OAB medication either with antimuscarinics or mirabegron 50 mg, the exchange of the OAB medication to each other should be tried first. If the treatment result is still not satisfactory, a combination of antimuscarinics and mirabegron is recommended.

Delirium and Its Pharmacological Causes in Older People, Part 1

Delirium is a syndrome that can arise from many causes or underlying conditions, and though it has been reported in younger patients, it is more prevalent in older people, though it can occur in other age groups as well. Identifying delirium is challenging in older people because of the coexistence of underlying dementia or depression, which may further complicate the presentation. Drug-induced delirium is one of the major causes of delirium, and evaluation of this potential cause or contribution is an important component of the evaluation process, since it can lead to poor patient outcomes. This article will review the epidemiology, pathophysiology, evaluation, diagnostic process, and causes of delirium in older people, with a focus on the pharmacological causes.

Anticholinergic drug use and risk of mortality for people with dementia in Northern Ireland

OBJECTIVE

Anticholinergic burden refers to the cumulative effect of medications which contain anticholinergic properties. We assessed how anticholinergic burden and different types of anticholinergic medications influence mortality rates among people with dementia in Northern Ireland. Our secondary aim was to determine what demographic characteristics predict the anticholinergic burden of people with dementia.

METHODS

Data were extracted from the Enhanced Prescribing database for 25,418 people who were prescribed at least one dementia management medication between 2010 and 2016. Information was also extracted on the number of times each available anticholinergic drug was prescribed between 2010 and 2016, allowing the calculation of an overall anticholinergic burden. Cox proportional hazard models were used to determine how anticholinergic burden influenced mortality whilst multilevel model regression determined what demographic characteristics influence overall anticholinergic burden.

RESULTS

Of the 25,418 people with dementia, only 15% (n = 3880) had no anticholinergic burden. Diazepam (42%) and risperidone (18%) were the two most commonly prescribed drugs. Unadjusted Cox proportional hazard models indicated that higher anticholinergic burden was associated with significantly higher mortality rates in comparison to people with dementia who had no anticholinergic burden (HR = 1.59: 95% CI = 1.07-2.36). In particular, urological (HR = 1.20: 95% CI = 1.05-1.38) and respiratory (HR = 1.17: 95% CI = 1.08-1.27) drugs significantly increased mortality rates. People with dementia living in areas with low levels of deprivation had significantly lower anticholinergic burden (HR=-.39: 95% CI=-.47:-30).

CONCLUSIONS

Reducing anticholinergic burden is essential for people with dementia. Further research should address the unfavourable prognosis of people living with dementia in highly deprived areas.

The treatment of neurogenic lower urinary tract dysfunction in persons with spinal cord injury: An open label, pilot study of anticholinergic agent vs. mirabegron to evaluate cognitive impact and efficacy

STUDY DESIGN

Pre-post intervention.

OBJECTIVES

1. To test whether replacement of oral anticholinergic (AC) agents with mirabegron for neurogenic lower urinary tract dysfunction (NLUTD) yields improved cognitive function in older persons with spinal cord injury (SCI). 2. To test whether mirabegron is safe and as efficacious as AC.

SETTING

USA.

METHODS

Pilot study: Twenty older (>60 y/o) persons with SCI taking chronic (>6 months) AC medication for NLUTD were enrolled. All participants were first studied on AC at baseline then switched to mirabegron for 6 months. Primary outcomes were cognitive tests of (1) executive function (TEXAS, SDMT); (2) attention (SCWT); and (3) memory (SLUMS and WMS-IV Story A/B). Secondary outcomes assessed efficacy and safety including Neurogenic Bladder Symptom Score (NBSS), bladder diary, neurogenic bowel dysfunction (NBD) survey, heart rate (HR), electrocardiogram (EKG), and mean arterial pressure (MAP).

RESULTS

When switching from AC to mirabegron for NLUTD, older persons with SCI exhibited statistically significant improvements in immediate Story A recall (p = 0.01), delayed story A and B recall (p = 0.01, 0.004), and in TEXAS (p = 0.04). Three subscores within NBSS significantly improved (p = 0.001) and the frequency of incontinence decreased (p = 0.03) on mirabegron. NBD, HR, MAP, and EKGs were unchanged.

CONCLUSIONS

Older persons with SCI on AC for NLUTD demonstrated improved short-term and delayed memory (WMS-IV Story A/B) as well as executive function (TEXAS) when switched to mirabegron. Efficacy of mirabegron for NLUTD symptoms was superior to AC with no adverse effects on bowel or cardiovascular function.

SPONSORSHIP

Claude D. Pepper Older Americans Independence Center.

Anticholinergic drugs and the risk of dementia: A systematic review and meta-analysis

Dementia is one of the greatest global challenges for public health; however, the relationship between anticholinergic drugs and dementia remains unclear. The aim of the present study was to perform a systematic review and meta-analysis of the predictive roles of anticholinergic drugs in dementia risk. After pooling fourteen longitudinal and case-control studies with a total of 1,564,181 subjects, anticholinergic drug use was associated with an increased risk of all-cause dementia and Alzheimer's disease. Both low and high anticholinergic drug burdens were associated with dementia. Moreover, there was a dose-dependent relationship between anticholinergic drugs and risk of dementia. With respect to the categories of anticholinergic drugs, antiparkinson, urological drugs, and antidepressants increased the risk for dementia; however, cardiovascular and gastrointestinal drugs played potentially protective roles. These findings underscore the importance of anticholinergic drugs as a potential modifiable risk factor for dementia and provide treatment priorities to optimize dementia prevention.

Comparison of the safety and efficacy of the on-demand use of sertraline, dapoxetine, and daily use of sertraline in the treatment of patients with lifelong premature ejaculation: A prospective randomised study

This study compared the safety and efficacy of the on-demand (OD) use of sertraline (50 mg), sertraline (100 mg) and dapoxetine (30 mg), and the daily use of sertraline (50 mg) in the treatment of patients with premature ejaculation (PE). This prospective randomised study involved 120 lifelong PE patients (intravaginal ejaculatory latency time [IELT]: <1 min; Arabic Index of Premature Ejaculation [AIPE] score: < 30) without secondary causes of PE, identified between March 2018 and May 2020. Patients were divided into 4 groups (30 patients per group) and treated for 8 weeks. Assessments were conducted using the AIPE form as a diagnostic tool. Sertraline (50 mg, daily; 196.7 ± 115.5 s) and sertraline (100 mg, OD; 173.3 ± 97.0 s) had similar IELT and AIPE scores. The latter groups had better results in comparison with sertraline (50 mg, OD; 100.5 ± 54.4 s) and dapoxetine (93.7 ± 53.5 s; p < 0.01). Sertraline (100 mg, OD) had a similar efficacy to that of sertraline (50 mg, daily) and was more effective than sertraline (50 mg, OD) and dapoxetine (30 mg, OD). Sertraline (100 mg, OD) can be considered in the treatment of lifelong PE treatment, having tolerable side effects.

Increased risk of incident dementia following use of anticholinergic agents: A systematic literature review and meta-analysis

Background/rationale

Long‐term treatment with anticholinergic agents may increase the risk of cognitive impairment or dementia. This systematic literature review and meta‐analysis aimed to assess the impact of ≥3 months of exposure to anticholinergics as a class on the risk of dementia, mild cognitive impairment, and change in cognitive function. The impact of anticholinergic agents specifically used to treat overactive bladder was also evaluated.

Materials and Methods

A systematic literature review was conducted to identify English language articles evaluating the impact of anticholinergic use for ≥3 months on dementia or cognitive function in adult patients. Databases searched included PubMed, Embase, and the Cochrane Library. Meta‐analyses were conducted using random‐effects models; 95% confidence intervals (CIs) and 95% prediction intervals (PIs) were reported.

Results

A total of 2122 records were identified. Out of those, 21 studies underwent qualitative synthesis and 6 reported endpoints relevant for inclusion in a meta‐analysis assessing the risk of incident dementia. The overall rate ratio for incident dementia was 1.46 (95% CI: 1.17–1.81; 95% PI: 0.70–3.04; n = 6). The risk of incident dementia increased with increasing exposure (n = 3). In addition, two studies from the meta‐analysis reported an increased risk of dementia with ≥3 months of use of bladder antimuscarinics (adjusted odds ratios ranged from 1.21 to 1.65, depending on exposure category).

Conclusion

Anticholinergic use for ≥3 months increased the risk of dementia on average by an estimated 46% versus nonuse. This relationship was consistent in studies assessing overactive bladder medications. The risk of developing dementia should be carefully considered in the context of potential benefit before prescribing anticholinergics.

Association of anticholinergic medications and AD biomarkers with incidence of MCI among cognitively normal older adults

OBJECTIVE

To determine the cognitive consequences of anticholinergic medications (aCH) in cognitively normal older adults as well as interactive effects of genetic and CSF Alzheimer disease (AD) risk factors.

METHODS

A total of 688 cognitively normal participants from the Alzheimer's Disease Neuroimaging Initiative were evaluated (mean age 73.5 years, 49.6% female). Cox regression examined risk of progression to mild cognitive impairment (MCI) over a 10-year period and linear mixed effects models examined 3-year rates of decline in memory, executive function, and language as a function of aCH. Interactions with APOE ε4 genotype and CSF biomarker evidence of AD pathology were also assessed.

RESULTS

aCH+ participants had increased risk of progression to MCI (hazard ratio [HR] 1.47, p = 0.02), and there was a significant aCH × AD risk interaction such that aCH+/ε4+ individuals showed greater than 2-fold increased risk (HR 2.69, p < 0.001) for incident MCI relative to aCH-/ε4-), while aCH+/CSF+) individuals demonstrated greater than 4-fold (HR 4.89, p < 0.001) increased risk relative to aCH-/CSF-. Linear mixed effects models revealed that aCH predicted a steeper slope of decline in memory (t = -2.35, p = 0.02) and language (t = -2.35, p = 0.02), with effects exacerbated in individuals with AD risk factors.

CONCLUSIONS

aCH increased risk of incident MCI and cognitive decline, and effects were significantly enhanced among individuals with genetic risk factors and CSF-based AD pathophysiologic markers. Findings underscore the adverse impact of aCH medications on cognition and the need for deprescribing trials, particularly among individuals with elevated risk for AD.

Anticholinergic medications and risk of dementia in older adults: Where are we now?

INTRODUCTION

Anticholinergic medications are effective for a wide variety of indications, but are associated with significant central adverse effects, especially cognitive decline and dementia in older adults.

AREAS COVERED

We conducted a review of relevant literature in the past decade to address anticholinergic scales and evidence of anticholinergic-related dementia/cognitive decline in older adults. We discussed various anticholinergic scales used to classify anticholinergic medications. The review focused on the evidence from previous reviews and individual studies evaluating the anticholinergic-related risk of developing cognitive decline/dementia. This review also discussed clinical and methodological issues of studies along with recommendations for practice and research.

EXPERT OPINION

The review demonstrates moderate to strong risk of dementia with anticholinergic use in multiple studies involving older adults, irrespective of the study design, analytical approach, anticholinergic exposure and outcome definition. This risk is particularly significant with the cumulative burden and high-level anticholinergics. There also exists a dose-response relationship between anticholinergic use and increased risk for dementia. Therefore, anticholinergic agents can be considered as a modifiable risk factor for dementia and cognitive decline in older adults. Based on the current evidence, regular assessment and optimization of anticholinergic burden prior to prescribing these medications can minimize anticholinergic-related morbidity in older adults.

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

OBJECTIVE

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

DESIGN

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

SETTING

Medicare-certified nursing homes.

PARTICIPANTS

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

MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

Increasing prevalence of anticholinergic medication use in older people in England over 20 years: cognitive function and ageing study I and II

BACKGROUND

Anticholinergic medication use is linked with increased cognitive decline, dementia, falls and mortality, and their use should be limited in older people. Here we estimate the prevalence of anticholinergic use in England's older population in 1991 and 2011, and describe changes in use by participant's age, sex, cognition and disability.

METHODS

We compared data from participants aged 65+ years from the Cognitive Function and Ageing Studies (CFAS I and II), collected during 1990-1993 (N = 7635) and 2008-2011 (N = 7762). We estimated the prevalence of potent anticholinergic use (Anticholinergic Cognitive Burden [ACB] score = 3) and average anticholinergic burden (sum of ACB scores), using inverse probability weights standardised to the 2011 UK population. These were stratified by age, sex, Mini-Mental State Examination score, and activities of daily living (ADL) or instrumental ADL (IADL) disability.

RESULTS

Prevalence of potent anticholinergic use increased from 5.7% (95% Confidence Interval [CI] 5.2-6.3%) of the older population in 1990-93 to 9.9% (9.3-10.7%) in 2008-11, adjusted odds ratio of 1.90 (95% CI 1.67-2.16). People with clinically significant cognitive impairment (MMSE [Mini Mental State Examination] 21 or less) were the heaviest users of potent anticholinergics in CFAS II (16.5% [95% CI 12.0-22.3%]). Large increases in the prevalence of the use medication with 'any' anticholinergic activity were seen in older people with clinically significant cognitive impairment (53.3% in CFAS I to 71.5% in CFAS II).

CONCLUSIONS

Use of potent anticholinergic medications nearly doubled in England's older population over 20 years with some of the greatest increases amongst those particularly vulnerable to anticholinergic side-effects.

Frailty status and increased risk for falls: The role of anticholinergic burden

PURPOSE OF THE STUDY

Frailty leads to serious adverse outcomes including falls. The relationship between frailty and falls has not been evaluated in the context of the side effects of drugs with anticholinergic properties. The aim of this study was to examine the potential association of anticholinergic burden (ACB) with the risk of falls among frail older adults.

DESIGN AND METHODS

Community-dwelling older adults were consecutively selected from the geriatrics outpatient clinic. Based on a fall history in the last 12 months, the participants were grouped as fallers and non-fallers. Frailty status was assessed by Fried's phenotype method. Exposure to anticholinergic medications was estimated using the ACB scale, and the participants were classified into ACB_0 (none), ACB_1 (possible) and ACB_2+ (definite).

RESULTS

The study included 520 older adults (mean age 77.7 years, 62.7 % female), with a fall prevalence of 25.8 % 12 months past. The proportions of frailty and pre-frailty were 33.1 % and 57.4 %, respectively. After adjustment for study confounders, receiving at least 1 drug with either possible or definite anticholinergic properties was independently associated to falls in frail [OR = 3.84 (1.48-9.93), p = 0.006] and pre-frail participants [OR = 2.71 (1.25-5.89); p = 0.012], but not in robust subjects. Moreover, ACB was significantly associated with the frailty components on adjusted analysis (p's<0.05).

IMPLICATIONS

Current study showed that the use of any drugs with possible or definite anticholinergic properties was associated with an increased risk of falls in frail older adults. The results emphasize the importance of medication management with respect to fall prevention in these patients.

Polypharmacy and evaluation of anticholinergic risk in a cohort of elderly people living with HIV

: As a consequence of ageing, the number of prescribed medications for people living with HIV is increasing. Concomitant use of different drugs and their potential interactions may increase anticholinergic exposure and escalate the risk for side effects. We conducted an analysis in our cohort of people living with HIV over 50 years of age to evaluate the overall anticholinergic risk, as it is useful to identify, prevent, and manage increased side effect risks.

Medication Use Quality and Safety in Older Adults: 2018 Update

Improving the quality of medication use and medication safety is an important priority for prescribers who care for older adults. The objective of this article was to identify key articles from 2018 that address these issues. In addition, we selected four of these articles to annotate, critique, and discuss their broader implications for clinical practice. The first study highlights a cluster-randomized trial that utilized a pharmacist-led education-based intervention delivered to both patients and physicians to deprescribe four types of inappropriate medications (sedative-hypnotics, first-generation antihistamines, selective nonsteroidal anti-inflammatory drugs, and glyburide). The second study, a nested case-control study using data from within the UK Clinical Practice Research Datalink, examined the association between anticholinergic exposure, overall and by anticholinergic medication class, and dementia risk in 40 770 older adults. The third study, a longitudinal cohort study of 1028 Swedish older adults, examined the association between antihypertensive medications and incident dementia. The last study was a randomized, double-blind, placebo-controlled trial that investigated the effect of daily low-dose aspirin (100 mg) for primary prevention on cardiovascular events and major hemorrhage in 19 144 community-dwelling older adults. Collectively, this current article provides insight into the pertinent topics of medication use quality and safety in older adults and helps raise awareness about optimal prescribing in older adults. J Am Geriatr Soc 67:2458-2462, 2019.

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

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.

Distinguishing characteristics of delirium in a skilled nursing facility in Spain: Influence of baseline cognitive status

OBJECTIVE

Mild cognitive impairment (MCI) and dementia (DEM) are prevalent in skilled nursing facilities (SNFs), confounding delirium detection. We report characteristics of delirium in an SNF to ascertain distinguishing features for delirium diagnosis, despite challenges of comorbidity with MCI and DEM.

METHODS

Cross-sectional study of 200 consecutive patients from an SNF in Catalunya, Spain, assessed within the first 24 to 48 admission hours by independent experts with Spanish-Informant Questionnaire on Cognitive Decline in the Elderly (for MCI-DEM), Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) delirium criteria, and Delirium Rating Scale Revised-98 (DRS-R98) for delirium phenomenology. Delirium characteristics were modeled in successive steps, according to the presence of delirium and MCI-DEM, with analysis of variance (ANOVA), receiver operator characteristic analyses, and conditional logistic regression.

RESULTS

The final model produced symptoms that represented each of the three delirium core domains (ie, cognitive, higher order thinking, and circadian). The DRS-R98 items rated these symptoms as moderate-severe attention/vigilance, mild-severe language, and moderate-severe sleep-wake cycle alterations. The delirium discriminant accuracy of the three symptoms together was high: 84.6% in the MCI-DEM group to 92.8% in the No MCI-DEM group.

CONCLUSIONS

Impairments of attention, language, and sleep-wake cycle indicate delirium in SNF patients regardless of the underlying MCI-DEM status. Because delirium is underdetected in SNFs, where nursing staff/patient ratios are low, brief simple tools that measure these symptoms could potentially enhance delirium detection.

Anticholinergic medicines use among older adults before and after initiating dementia medicines

AIMS

We investigated anticholinergic medicines use among older adults initiating dementia medicines.

METHODS

We used Pharmaceutical Benefits Scheme dispensing claims to identify patients who initiated donepezil, rivastigmine, galantamine or memantine between 1 January 2013 and 30 June 2017 (after a period of ≥180 days with no dispensing of these medicines) and remained on therapy for ≥180 days (n = 4393), and dispensed anticholinergic medicines in the 180 days before and after initiating dementia medicines. We further examined anticholinergic medicines prescribed by a prescriber other than the one initiating dementia medicines.

RESULTS

One-third of the study cohort (1439/4393) was exposed to anticholinergic medicines up to 180 days before or after initiating dementia medicines. Among patients exposed to anticholinergic medicines, 46% (659/1439) had the same medicine dispensed before and after initiating dementia medicines. The proportion of patients dispensed anticholinergic medicines increased by 2.5% (95% confidence interval [CI]: 1.3-3.7) after initiating dementia medicines. Antipsychotics use increased by 10.1% (95% CI: 7.6-12.7) after initiating dementia medicines; driven by increased risperidone use (7.3%, 95% CI: 5.3-9.3). Nearly half of patients dispensed anticholinergic medicines in the 180 days after (537/1133), were prescribed anticholinergic medicines by a prescriber other than the one initiating dementia medicines.

CONCLUSION

Use of anticholinergic medicines is common among patients initiating dementia medicines and this occurs against a backdrop of widespread campaigns to reduce irrational medicine combinations in this vulnerable population. Decisions about deprescribing medicines with questionable benefit among patients with dementia may be complicated by conflicting recommendations in prescribing guidelines.

[Complications and side effects of conservative treatment of rhinological diseases]

BACKGROUND

The spectrum of rhinological diseases is wide, as is that of their drug-based treatment. Only 1272 compounds coded R01 (nasal preparations) are listed in the ATC group (Anatomical Therapeutic Chemical Classification). Conservative therapy of rhinological diseases additionally includes systemic (often oral) application of corticosteroids, antibiotics and immunomodulators.

OBJECTIVE

The aim of this paper is to outline possible complications of medication (subdivided into classes of ingredients) commonly used to treat rhinological diseases in hospitals. Useful therapeutic and preventive measures will be presented.

MATERIALS AND METHODS

Based on the expert information in the current pharmacological drug index (ATC) for the R01 group as well as literature research in the PubMed, Cochrane Library and MEDLINE databases, medication used for the treatment of rhinological diseases was analysed in terms of side effects and their frequency.

RESULTS

Common side effects of intranasally applied medication are local irritations, burning, dryness and epistaxis. Orally or intravenously applied rhinological medication can affect the organs and lead to side effects such as cardiac dysrhythmia or alterations of the blood count. It is recommended that the therapeutic be selected on an individual basis and that the patient be thoroughly informed about possible side effects.

CONCLUSION

Particularly when treating children or pregnant or breastfeeding women, the indications of all nasal preparations should be checked carefully. The huge variety of rhinologicals enables an optimal individual selection on the basis of consideration of known side effects.

Urinary retention as a postoperative complication associated with functional decline in elderly female patients with femoral neck and trochanteric fractures: A retrospective study of a patient cohort

Urinary retention (UR) has been recognized as one of the most common postoperative complications after hip surgery in elderly. The objective of the present study was to evaluate risk for postoperative complications of UR in elderly female patients with femoral neck fractures.We recruited 221 female patients (age 85.3 ± 7.0 years) with a history of hip surgery carried out at Toyama Municipal Hospital. UR occurred in 34 out of 221 cases (15.4%). Multiple logistic regression analysis was conducted to investigate the risk factors for UR, including age, body mass index (BMI), serum albumin, cognitive impairment, and activities of daily living (ADL).The results showed significant association of UR with cognitive impairment (P = .005, odds ratio [OR] 4.11, 95% confidence interval [CI] 1.53-11.03), and ADL (P = .029, OR 2.61, 95% CI 1.11-6.18), under adjustment with age and BMI.This study demonstrated that cognitive function and ADL were the important risk factors for UR, suggested that the postoperative management of UR is important with taking account of neurofunctional assistance and nursing care in daily living, especially in elderly female patients receiving surgery of femoral neck and trochanteric fractures.

A Korean Postmarketing Study Assessing the Effectiveness of OnabotulinumtoxinA for the Treatment of Neurogenic Detrusor Overactivity or Idiopathic Overactive Bladder Using a Validated Patient-Reported Outcome Measure

Purpose

OnabotulinumtoxinA has demonstrated efficacy and safety in the treatment of urinary incontinence (UI) associated with neurogenic detrusor overactivity (NDO) and idiopathic overactive bladder (OAB); however, real-world evidence is limited. This postmarketing surveillance study aimed to assess the effectiveness and safety of onabotulinumtoxinA in Korean patients with UI associated with NDO or OAB with an inadequate response or intolerance to anticholinergics.

Methods

Patients received 200 U (NDO) or 100 U (OAB) of onabotulinumtoxinA. Effectiveness (assessed using the validated International Consultation on Incontinence Questionnaire-Short Form [ICIQ-SF]) and safety were assessed for 1–4 months after onabotulinumtoxinA administration.

Results

Overall, 686 patients (NDO, 161; OAB, 525) comprised the safety population; of these, 612 patients were analyzed for effectiveness. There was a significant decrease (P<0.0001) in the mean (standard deviation) ICIQ-SF scores in the NDO (–6.8±5.5) and OAB (–6.0±6.4) groups after onabotulinumtoxinA administration. A decrease of >5 points from baseline in the ICIQ-SF score was observed in 64.9% and 47.3% of patients in the NDO and OAB groups, respectively. Following treatment, 59.9% in the NDO group and 43.0% in the OAB group were dry. There was no effect of age on effectiveness in either group. Only 10 adverse drug reactions (ADRs) were reported in 5.6% of NDO patients and 20 ADRs in 3.2% of OAB patients. Most ADRs in both groups were related to the lower urinary tract such as dysuria (NDO, 1.2%; OAB, 0.6%) and urinary retention (NDO, 0.6%; OAB, 1.5%).

Conclusions

Effectiveness and safety of onabotulinumtoxinA in Korea in a real-world setting was demonstrated.

The Brain NGF Metabolic Pathway in Health and in Alzheimer's Pathology

Emerging research has re-emphasized the role of the cortical cholinergic system in the symptomology and progression of Alzheimer's disease (AD). Basal forebrain (BF) cholinergic nuclei depend on target-derived NGF for survival during development and for the maintenance of a classical cholinergic phenotype during adulthood. In AD, BF cholinergic neurons lose their cholinergic phenotype and function, suggesting an impairment in NGF-mediated trophic support. We propose that alterations to the enzymatic pathway that controls the maturation of proNGF to mature NGF and the latter's ulterior degradation underlie this pathological process. Indeed, the NGF metabolic pathway has been demonstrated to be impaired in AD and other amyloid pathologies, and pharmacological manipulation of NGF metabolism has consequences in vivo for both levels of proNGF/NGF and the phenotype of BF cholinergic neurons. The NGF pathway may also have potential as a biomarker of cognitive decline in AD, as its changes can predict future cognitive decline in patients with Down syndrome as they develop preclinical Alzheimer's pathology. New evidence suggests that the cholinergic system, and by extension NGF, may have a greater role in the progression of AD than previously realized, as changes to the BF precede and predict changes to the entorhinal cortex, as anticholinergic drugs increase odds of developing AD, and as the use of donepezil can reduce rates of hippocampal and cortical thinning. These findings suggest that new, more sophisticated cholinergic therapies should be capable of preserving the basal forebrain thus having profound positive effects as treatments for AD.

Deprescribing in Older Nursing Home Patients: Focus on Innovative Composite Measures for Dosage Deintensification

Deprescribing, which includes stopping or reducing the dosage of medications, is designed to improve safety and prevent adverse drug reactions in older patients. To date, there has been limited work on measuring decreases in dosage intensity, or deintensification, across therapeutic classes of medications. Given the ongoing focus on central nervous system (CNS) medications and the frequency with which providers encounter hypertension and diabetes in older nursing home patients, the objective of this expert review is to describe and critique innovative composite dosage intensity measures that have been, or could be, applied to quantify deintensification within three therapeutic medication targets commonly encountered in nursing home patients: CNS agents, antihypertensive therapy, and antidiabetic therapy and the extent to which they are associated with health outcomes. Composite measures for CNS medication intensity considered dividing a patient's daily dose by defined daily dosage (DDD), or the minimum effective adult or geriatric daily dosage. In contrast, composite measures for antihypertensives used either DDD or maximum recommended daily dosage in the denominator. We were not able to identify any composite measure of intensity for antidiabetic classes. There was a paucity of interventional studies that showed reducing the dosage intensity resulted in improved health outcomes. In conclusion, we identified several innovative composite measures of dosage intensity for CNS and antihypertensive medications, and discussed possible approaches for developing an antidiabetic regimen composite measure. It is critical for future research to compare and contrast various measures and to determine their impact on important clinical outcomes.

Anticholinergic burden in adult and elderly people with intellectual disabilities: Results from an Italian multicenter cross-sectional study

BACKGROUND

Adults and older people with intellectual disabilities (ID) frequently receive anti-cholinergic drugs in chronic use, but no studies in Italy to date have investigated cumulative anticholinergic exposure and factors associated with high anticholinergic burden in this frail population.

AIM

To probe the cumulative exposure to anticholinergics and the demographic, social and clinical factors associated with high exposure.

METHODS

The 2012 updated version of the Anticholinergic Burden Score (ACB) was calculated for a multicentre sample of 276 adult and older people over 40 years with ID and associations with factors assessed.

RESULTS

Overall, antipsychotics, antiepileptics, anxiolytics, and antidepressants were the most frequent classes contributing to the total ACB score. People living in residential care were more likely exposed to high anticholinergic burden (an ACB score of 3+): both community housing (odds ratio [OR] 4.63, 95%CI 1.08-19.95) and nursing home facility ([OR] 9.99, 95%CI 2.32-43.04). There was also a significant association between an ACB score of 3+ and reporting mental health conditions ([OR] 25.56, 95% CI 8.08-80.89) or a neurological disease ([OR] 4.14, 95%CI 1.32-12.94). Neither demographic characteristics (age and gender) nor other clinical conditions (somatic comorbidity, levels and typology of ID) were associated with higher anticholinergic load. A high burden of anticholinergic was significantly more frequent in laxative users (22.6% ACB3+ vs. 5.1% ACB 0) (p = 0.003).

CONCLUSIONS

Psychotropics drugs were the highest contributors to the anticholinergic burden in adult and old age ID, especially in those people living in institutional settings with mental health and/or neurological conditions. High anticholinergic load has shown to be associated with the use of laxatives.

Quo Vadis Botulinum Toxin: Normative Constraints and Quality of Life for Patients With Idiopathic OAB?

Background: Idiopathic overactive bladder (iOAB), with or without urge incontinence (UI), has significant psychosocial effects on patients' quality of life (QoL). The first choice of treatment for iOAB is anticholinergics and, alternatively, the β-3-adrenoceptor agonist mirabegron. However, systemic side effects and contraindications should be considered for both medications.

Objective: We report the efficacy, safety and effects on QoL of botulinum toxin therapy (onabotulinum toxin type A, BOTOX®, Allergan) among patients with iOAB ± UI.

Patients and Methods: Between 2005 and 2013, 51 patients were treated with onabotulinum toxin A (100 units). The inclusion criteria were the presence of confirmed iOAB ± UI with previous use of anticholinergic medication. Micturition frequency, pad count, postvoid residual volume and QoL were evaluated using two validated questionnaires [the Client Satisfaction Questionnaire-8 (CSQ-8) and the King's Health Questionnaire (KHQ)]. Statistical analysis was performed with SPSS 24.0 (p < 0.05).

Results: After botulinum toxin injection, a significant improvement in iOAB ± UI symptoms was observed. The micturition frequency decreased from 10.4 ± 0.5 to 5.2 ± 0.4 micturitions per day (p = 0.026), and the pad count decreased from 3.6 ± 1.0 to 1.2 ± 0.3 pads per day (p = 0.033). Anticholinergics were not used during the administration of botulinum toxin therapy. Complications and postoperative need for intermittent self-catheterization (ISC) were not observed. Overall, 72 and 24% of patients reported being “satisfied” or “very satisfied” with the treatment. Additionally, 66% of patients would choose botulinum toxin again for the treatment of iOAB.

Conclusion: Botulinum toxin therapy is an efficient, safe, and life-improving treatment for iOAB.

Individualizing medical treatment of overactive bladder

Overactive bladder (OAB) syndrome is highly prevalent in both men and women and might have negative impact on quality of life. Clinical trials of OAB usually highly select participants that may not reflect the real-world practice of OAB patients. The spectrum of OAB includes patients with idiopathic, neuropathic, with bladder outlet obstruction, and patients in elderly and medical comorbidities. Patients might have poor response to OAB medication or have adverse events after treatment. Therefore, treatment of OAB should be individualized to obtain therapeutic efficacy and avoid unacceptable adverse events. This article reviews the recently published literature and provides a guide for physicians to choose the appropriate treatment for different OAB patients.

Association of Anticholinergic Risk Score With Functional Status in Patients Preparing for Pelvic Reconstructive Surgery

OBJECTIVES

Anticholinergic medication use has been associated with cognitive impairment and other functional limitations, particularly in older patients. The anticholinergic risk score (ARS) can be used to measure a patient's cumulative exposure to medications with anticholinergic properties. Our primary objective was to evaluate the correlation between ARS and functional status, as measured by instrumental activities of daily living (IADL), in patients preparing to undergo urogynecologic surgery. The secondary objective was to examine the correlation between ARS and physical function in this same cohort.

METHODS

This was a planned cross-sectional analysis of a prospective cohort study to evaluate the impact of urogynecologic surgery on functional status. The ARS was calculated by summing the ARSs of each patient's medications and classified as high (ARS > 5) or low (ARS ≤ 5). A patient's ability to live independently was determined using the IADL questionnaire. The patient's physical function status was determined using the functional comorbidity index.

RESULTS

One hundred twenty-two patients were evaluated. A total of 89.3% of subjects had a low and 10.7% had a high ARS score. For our primary outcome, high ARS was associated with low IADL in logistic regression controlling for age and formal education level (odds ratio, 8.0; 95% confidence interval, 1.4-46.9). For our secondary outcome, ARS was not associated with the functional comorbidity index (P = 0.24).

CONCLUSIONS

These data support recognition of ARS as a potential risk factor for low functional status in patients planning urogynecologic surgery.

National Prescribing Trends for High-Risk Anticholinergic Medications in Older Adults

OBJECTIVES

To estimate prescribing tends of and correlates independently associated with high-risk anticholinergic prescriptions in adults aged 65 and older in office-based outpatient visits.

DESIGN

Repeated cross-sectional analysis.

SETTING

National Ambulatory Medical Care Survey (NAMCS).

PARTICIPANTS

A national sample of office-based physician visits by adults aged 65 and older from 2006 to 2015 (n=96,996 unweighted).

MEASUREMENTS

Prescriptions of high-risk anticholinergics, regardless of indication, were identified, and overall prescribing trends were estimated from 2006 to 2015. Stratified analyses of prescribing trends according to physician specialty and anticholinergic drug class were also performed. We used a multivariable logistic regression analysis to estimate the odds of high-risk anticholinergic prescription.

RESULTS

Between 2006 and 2015, a high-risk anticholinergic prescription was listed for 5,876 (6.2%) 96,996 visits of older adults, representative of 14.6 million total visits nationally. The most common drug classes were antidepressants, antimuscarinics, and antihistamines, which accounted for more than 70% of prescribed anticholinergics. Correlates independently associated with greater odds of receiving a high-risk anticholinergic prescription were female sex, the Southern geographic region, specific physician specialties (e.g., psychiatry, urology), receipt of 6 or more concomitantly prescribed medications, and related clinical diagnoses (e.g., urinary continence) (p<.01 for all).

CONCLUSION

The prevalence of high-risk anticholinergic prescriptions was stable over time but varied according to physician specialty and drug class. Quality prescribing should be promoted because safer alternatives are available.

Therapeutic efficacy of low-dose (25 mg) mirabegron therapy for patients with mild to moderate overactive bladder symptoms due to central nervous system diseases

OBJECTIVE

The incidence of overactive bladder (OAB) increases with age, especially in patients with central nervous system (CNS) disorders such as cerebrovascular accident (CVA) and Parkinson's disease (PD). Mirabegron is a novel medication for the treatment of OAB. The present study investigated the therapeutic effect of mirabegron on OAB patients with CNS diseases.

METHODS

Patients with CVA, PD, dementia, and OAB symptoms were consecutively enrolled in the study group, and mirabegron 25 mg q.d. was prescribed. Clinical effects, evaluated using the Overactive Bladder Symptom Score (OABSS), Urinary Sensation Scale (USS), International Prostate Symptom Score (IPSS), and Patient Perception of Bladder Condition (PPBC), as well as urodynamic parameters and adverse events were assessed at baseline and 4 and 12 weeks after treatment.

RESULTS

In all, 44 patients (mean [± SD] age 77.7 ± 9.49 years) with OAB due to CVA (n = 27), PD (n = 6), and dementia (n = 11) were included in the present prospective study. Mirabegron resulted in significant improvements in symptom scores on the OABSS (P = .02), USS (P = .009), total IPSS (P = .002), Storage and Voiding domains of the IPSS (P = .001 and .017, respectively), and PPBC (P = .001). No significant changes were noted in post-void residual, maximum flow rate, and voided volume after treatment. Only 5 patients dropped out due to poor therapeutic efficacy and shifted to antimuscarinics. Three patients complained of adverse effects, including dizziness and dysuria. No patient complained of urine retention or constipation.

CONCLUSION

Mirabegron 25 mg once daily effectively decreased urgency symptoms in elderly OAB patients with CNS lesions after the 12-week treatment period. The adverse events were mild and only noted in a few cases.