Effect of anticholinergic use for the treatment of overactive bladder on cognitive function in postmenopausal women

Anticholinergic deprescribing interventions for reducing risk of cognitive decline or dementia in older adults with and without prior cognitive impairment

BACKGROUND

Anticholinergics are medications that block the action of acetylcholine in the central or peripheral nervous system. Medications with anticholinergic properties are commonly prescribed to older adults. The cumulative anticholinergic effect of all the medications a person takes is referred to as the anticholinergic burden. A high anticholinergic burden may cause cognitive impairment in people who are otherwise cognitively healthy, or cause further cognitive decline in people with pre-existing cognitive problems. Reducing anticholinergic burden through deprescribing interventions may help to prevent onset of cognitive impairment or slow the rate of cognitive decline.

OBJECTIVES

Primary objective • To assess the efficacy and safety of anticholinergic medication reduction interventions for improving cognitive outcomes in cognitively healthy older adults and older adults with pre-existing cognitive issues. Secondary Objectives • To compare the effectiveness of different types of reduction interventions (e.g. pharmacist-led versus general practitioner-led, educational versus audit and feedback) for reducing overall anticholinergic burden. • To establish optimal duration of anticholinergic reduction interventions, sustainability, and lessons learnt for upscaling • To compare results according to differing anticholinergic scales used in medication reduction intervention trials • To assess the efficacy of anticholinergic medication reduction interventions for improving other clinical outcomes, including mortality, quality of life, clinical global impression, physical function, institutionalisation, falls, cardiovascular diseases, and neurobehavioral outcomes.

SEARCH METHODS

We searched CENTRAL on 22 December 2022, and we searched MEDLINE, Embase, and three other databases from inception to 1 November 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of interventions that aimed to reduce anticholinergic burden in older people and that investigated cognitive outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion, extracted data, and assessed the risk of bias of included studies. The data were not suitable for meta-analysis, so we summarised them narratively. We used GRADE methods to rate our confidence in the review results.

MAIN RESULTS

We included three trials with a total of 299 participants. All three trials were conducted in a cognitively mixed population (some cognitively healthy participants, some participants with dementia). Outcomes were assessed after one to three months. One trial reported significantly improved performance on the Digit Symbol Substitution Test (DSST) in the intervention group (treatment difference 0.70, 95% confidence interval (CI) 0.11 to 1.30), although there was no difference between the groups in the proportion of participants with reduced anticholinergic burden. Two trials successfully reduced anticholinergic burden in the intervention group. Of these, one reported no significant difference between the intervention versus control in terms of their effect on cognitive performance measured by the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) immediate recall (mean between-group difference 0.54, 95% CI -0.91 to 2.05), CERAD delayed recall (mean between-group difference -0.23, 95% CI-0.85 to 0.38), CERAD recognition (mean between-group difference 0.77, 95% CI -0.39 to 1.94), and Mini-Mental State Examination (mean between-group difference 0.39, 95% CI -0.96 to 1.75). The other trial reported a significant correlation between anticholinergic burden and a test of working memory after the intervention (which suggested reducing the burden improved performance), but reported no effect on multiple other cognitive measures. In GRADE terms, the results were of very low certainty. There were no reported between-group differences for any other clinical outcome we investigated. It was not possible to investigate differences according to type of reduction intervention or type of anticholinergic scale, to measure the sustainability of interventions, or to establish lessons learnt for upscaling. No trials investigated safety outcomes.

AUTHORS' CONCLUSIONS

There is insufficient evidence to reach any conclusions on the effects of anticholinergic burden reduction interventions on cognitive outcomes in older adults with or without prior cognitive impairment. The evidence from RCTs was of very low certainty so cannot support or refute the hypothesis that actively reducing or stopping prescription of medications with anticholinergic properties can improve cognitive outcomes in older people. There is no evidence from RCTs that anticholinergic burden reduction interventions improve other clinical outcomes such as mortality, quality of life, clinical global impression, physical function, institutionalisation, falls, cardiovascular diseases, or neurobehavioral outcomes. Larger RCTs investigating long-term outcomes are needed. Future RCTs should also investigate potential benefits of anticholinergic reduction interventions in cognitively healthy populations and cognitively impaired populations separately.

Cognitive Effects of Anticholinergic Load in Women with Overactive Bladder

Overactive bladder syndrome (OAB) is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urgency incontinence, in the absence of urinary tract infection or other obvious pathology. The mainstay of treatment of OAB is anticholinergic/antimuscarinic medication. These drugs block muscarinic receptors throughout the body, not only the bladder, including in the brain, which may lead to cognitive side effects. Anticholinergic load or burden is the cumulative effect of taking drugs that are capable of producing anticholinergic adverse effects. The elderly are more susceptible to these effects, especially as there is increased permeability of the blood brain barrier. The anticholinergic drugs for OAB are able to enter the central nervous system and lead to central side effects. There is increasing evidence that a high anticholinergic load is linked to the development of cognitive impairment and even dementia. Some studies have found an increased risk of mortality. In view of this, care is needed when treating OAB in the elderly. Trospium chloride is a quaternary amine anticholinergic, which has a molecular structure, which theoretically means it is less likely to cross the blood brain barrier and exert central side effects. Alternatively, mirabegron can be used, which is a beta-3 adrenoceptor agonist, which does not add to the anticholinergic load or exert central nervous system side effects. Conservative therapy can be used as an alternative to pharmacological treatment in the form of behavioral modification, fluid management and bladder retraining. Neuromodulation or the use of botox can also be alternatives, but success may be less in the older adult and will require increased hospital attendances.

Protocol for a multicenter randomized, double blind, controlled pilot trial of higher neural function in overactive bladder patients after anticholinergic, beta-3 adrenergic agonist, or placebo

Introduction

Overactive bladder (OAB) syndrome has a negative impact on quality of life and prevalence increases with advanced age. Anticholinergics (AC) and beta-3 adrenergic agonists (β3a) are commonly prescribed medications for treatment of OAB. AC medication has been associated with dementia in population studies and with cortical atrophy in imaging studies. Higher neural effects of both classes of OAB medications have not been evaluated with functional neuroimaging. Longitudinal clinical assessments of cognition after OAB therapy with AC has produced conflicting results. β3a medication is has not been associated with dementia in clinical studies; however, higher neural effects are unknown.

Our multicenter, double blind, randomized, placebo-controlled trial uses functional magnetic resonance imaging (fMRI) and cognitive testing to evaluate the effects of AC and β3a on brain functional connectivity in females with non-neurogenic OAB.

Methods and Analysis

and analysis: Female patients with OAB symptoms ages 50–90 years old without baseline cognitive impairment, moderate to severe depression or anxiety, neurologic disorders, or significant incomplete bladder emptying are invited to participate. Subjects are randomized to one of three interventions for 29 ± 1 day: AC (Solifenacin succinate, Teva), β3a (Mirabegron, Myrbetriq, Astellas), or placebo. Functional neuroimaging data at baseline and post-intervention will be analyzed accordingly. Clinical cognitive assessments will be compared from baseline to post-intervention.

Ethics

All qualifying patients are properly consented before enrolling in this study that has been approved by the Institutional Review Board of participating institutions.

Anticholinergic Drugs for Overactive Bladder in Frail Older Patients: The Case Against

Urinary incontinence (UI) is a common and disabling problem among older people. Anticholinergic drugs (ADs) are a pharmacological option recommended for overactive bladder or mixed UI when non-pharmacological approaches have failed. However, UI is a more prevalent and complex condition in frail older people and to simply assume that AD actions are the same across all age groups would be wrong. This article reviews evidence for the efficacy and safety of these drugs, especially when prescribed for frail older people. Although ADs have a small but statistically significant benefit for UI in non-frail people, the vast majority choose to discontinue treatment because they feel that the beneficial effects do not outweigh the burden of taking the medication. Not only are the most frail older people more likely to experience adverse effects but there is also no evidence that these drugs are effective for UI. In addition, there is a mounting body of evidence that they impair cognitive function. The continued use of ADs in frail older people simply does not hold water.

Dealing with complex overactive bladder syndrome patient profiles with focus on fesoterodine: in or out of the EAU guidelines?

Overactive bladder (OAB) syndrome is a common, complex, and challenging condition. To assist the management of these patients, the European Association of Urology (EAU) updates its guidelines annually. This review reports the presentations from the symposium titled “Dealing with complex OAB patient profiles: in or out of the EAU guidelines?” held at the 32nd EAU Annual Congress in March 2017 in London. The symposium focused on three groups of OAB patients: women who may also suffer pelvic organ prolapse, stress urinary incontinence, the genitourinary syndrome of menopause (GSM); patients at risk of cognitive impairment; and elderly patients. The aim of the symposium was to determine how the 2017 EAU guidelines can best assist physicians, as well as to assess the benefits of fesoterodine in these patients. The EAU guidelines recommend antimuscarinic agents (grade A) for the medical treatment of OAB. In women, OAB is correlated with GSM, both of which are underdiagnosed and undertreated. Fesoterodine decreases OAB symptoms and the associated limitation of physical activity. A combination of fesoterodine and vaginal estrogens is appropriate for OAB associated with GSM. In patients at risk of cognitive impairment, prescribers should pay particular attention to the choice of medication. Fesoterodine is a Pgp substrate with limited ability to cross the blood–brain barrier, which may explain the lack of negative effects on the central nervous system observed in clinical trials of this agent. OAB should not be regarded as a normal consequence of aging. Fesoterodine has been extensively investigated in the elderly, and is the only anticholinergic drug licensed for OAB in this population, rated B (beneficial) according to the Fit for the Aged classification for lower-urinary-tract symptoms. The EAU guidelines are a valuable resource for physicians managing patients with OAB, and the pharmacological properties of fesoterodine offer credible clinical advantages in these three patient groups.

Prescription medicine use by pedestrians and the risk of injurious road traffic crashes: A case-crossover study

BACKGROUND

While some medicinal drugs have been found to affect driving ability, no study has investigated whether a relationship exists between these medicines and crashes involving pedestrians. The aim of this study was to explore the association between the use of medicinal drugs and the risk of being involved in a road traffic crash as a pedestrian.

METHODS AND FINDINGS

Data from 3 French nationwide databases were matched. We used the case-crossover design to control for time-invariant factors by using each case as its own control. To perform multivariable analysis and limit false-positive results, we implemented a bootstrap version of Lasso. To avoid the effect of unmeasured time-varying factors, we varied the length of the washout period from 30 to 119 days before the crash. The matching procedure led to the inclusion of 16,458 pedestrians involved in an injurious road traffic crash from 1 July 2005 to 31 December 2011. We found 48 medicine classes with a positive association with the risk of crash, with median odds ratios ranging from 1.12 to 2.98. Among these, benzodiazepines and benzodiazepine-related drugs, antihistamines, and anti-inflammatory and antirheumatic drugs were among the 10 medicines most consumed by the 16,458 pedestrians. Study limitations included slight overrepresentation of pedestrians injured in more severe crashes, lack of information about self-medication and the use of over-the-counter drugs, and lack of data on amount of walking.

CONCLUSIONS

Therapeutic classes already identified as impacting the ability to drive, such as benzodiazepines and antihistamines, are also associated with an increased risk of pedestrians being involved in a road traffic crash. This study on pedestrians highlights the necessity of improving awareness of the effect of these medicines on this category of road user.

A prospective, comparative study of the occurrence and severity of constipation with darifenacin and trospium in overactive bladder

INTRODUCTION

Darifenacin and trospium are the commonly used antimuscarinics in the management of overactive bladder (OAB). Constipation is the second most common treatment related side-effect. Though its incidence with the above two medications is known, data on their comparative severity and impact on patient's well-being is lacking.

MATERIALS AND METHODS

Sixty subjects with OAB included in the study were randomized in 1:1 fashion to receive either darifenacin 7.5 mg OD or trospium extended release 60 mg OD. Treatment response was monitored using overactive bladder symptom score (OABSS). The severity of constipation was assessed using McMillan & Williams Constipation assessment scale (CAS), Bristol stool form scale and Knowles-Eccersley-Scott-Symptom (KESS) questionnaire score administered at baseline, 2 and 4 weeks of treatment.

RESULTS

OABSS improved significantly, -5.80 ± 3.99 (p = 0.0005) and -5.27 ± 2.98 (p = 0.0005) in darifenacin and trospium groups respectively. However, the difference between the two groups was not significant either at 2 weeks (p = 0.952) or 4 weeks (p = 0.654) of treatment. A significant decrease in stool consistency was noted with darifenacin treatment (p < 0.05), but the same was not seen with trospium (p = 0.076). There was no significant difference in scores of KESS questionnaire between baseline, 2 weeks and 4 weeks, both within the group and between the groups (p > 0.05). McMillan & Williams CAS scores increased at week 2 and week 4, in comparison with baseline scores in both darifenacin and trospium treated patients, however, the difference between the two groups was not statistically significant (p > 0.05).

CONCLUSION

Darifenacin and trospium are equally efficacious and comparable in tolerability in terms of constipation severity and its impact on patient well-being.

Impact of anticholinergic load on bladder function

INTRODUCTION AND HYPOTHESIS

Our aim was to evaluate the impact of anticholinergic load on urinary retention based on postvoid residual (PVR) on micturition study. Secondary objectives were to assess the effect of anticholinergic load on other urodynamic parameters.

METHODS

This was a retrospective cohort study of women who underwent urodynamics (UDS) at one academic institution. All medications being taken by the women at the time of UDS were scored using the anticholinergic risk scale (ARS). This validated scale assigns rank scores to each medication based on its anticholinergic potential. Women were dichotomized into two anticholinergic cohorts: low (0-1) or high (≥2) ARS scores.

RESULTS

During the study period, 599 women underwent UDS. ARS scores ranged from 0 to 8, with 440 (73.5 %) having low (≤1) and 159 (26.5 %) having high (≥2) scores. For our primary outcome of micturition PVR, there was no difference between low and high ARS groups (66.8 ± 108.6 ml vs. 78.6 ± 121.0 ml, p = 0.25). There was also no difference between ARS groups in other voiding function parameters. Sensitivity analyses did demonstrate a difference in micturition PVR, with ARS 0-4 (n = 583) vs. ARS ≥ 5 (n = 16): 68.3 ± 109.1 ml vs. 127.5 ± 185.7 (p < 0.01) ,as well as maximum cystometric capacity (MCC): 420.8 ± 181.3 ml vs. 526.1 ± 252.4 ml (p = 0.02).

CONCLUSIONS

Despite the prevalence and risks associated with the use of medications with anticholinergic properties, a cumulative effect on bladder function was only demonstrated with very high anticholinergic risk scores of ≥5.