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Al-Azayzih A, Jarab AS, Bani-Ahmad E, Smadi S, Kharaba Z, Al-Kubaisi KA. Anticholinergic burden risk and prevalence of medications carrying anticholinergic properties in elderly cancer patients in Jordan. Saudi Pharm J 2023; 31:101710. [PMID: 37559866 PMCID: PMC10406854 DOI: 10.1016/j.jsps.2023.101710] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/20/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Geriatric cancer patients are susceptible to adverse drug events due to the complexity of their chemotherapy regimens and collateral treatments for their comorbid conditions. Prescribing medications with anticholinergic burden characteristics can complicate their condition, leading to negative impacts on their health outcomes and quality of life, including an increase in adverse drug event frequency, physical and cognitive impairments. OBJECTIVE This study aims to examine the prevalence of anticholinergic prescribing and identify the cumulative anticholinergic load risk associated with drugs prescribed to elderly cancer patients. Also, to identify the predictors that might lead to raised anticholinergic burden in these patients. METHODOLOGY This retrospective cross-sectional study included elderly patients (age ≥ 65) diagnosed with cancer and admitted to the adult oncology unit at King Abdullah University Hospital (KAUH) in Jordan during the period between (January 1st, 2019, and January 1st, 2022). The medication charts of 420 patients were evaluated for study outcomes. RESULTS Of the total subjects, females represented 49.3%, and the average age was 72.95 (SD = 7.33). A total of 354 (84.3%) patients were prescribed at least one drug carrying anticholinergic burden properties. Median for anticholinergic medications was 3 (IQR = 4). Our study found that 194 (46.2%) patients were at a high risk of adverse events associated with anticholinergic load (cumulative score ≥ 3). Metoclopramide, furosemide, and tramadol were the most frequently prescribed drugs with anticholinergic properties. Alimentary tract drugs with anticholinergic action were the most commonly encountered items in our study population. CONCLUSION Our study revealed a significantly high prevalence of anticholinergic prescribing among elderly cancer patients. Nearly half of the patients were at high risk of developing serious effects related to anticholinergic activity from the drugs administered. Polypharmacy was strongly associated with increased anticholinergic burden score. Evidence-based recommendations utilizing prescribing strategies for safer alternatives and deprescribing of inappropriate medications could reduce such inappropriate prescribing.
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Affiliation(s)
- Ahmad Al-Azayzih
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology. P.O. Box 3030, Irbid 22110, Jordan
| | - Anan S. Jarab
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology. P.O. Box 3030, Irbid 22110, Jordan
- College of Pharmacy, AL Ain University, Abu Dhabi, United Arab Emirates
| | - Enas Bani-Ahmad
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology. P.O. Box 3030, Irbid 22110, Jordan
| | - Saja Smadi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology. P.O. Box 3030, Irbid 22110, Jordan
| | - Zelal Kharaba
- College of Pharmacy, AL Ain University, Abu Dhabi, United Arab Emirates
- Honorary Associate Lecturer, Faculty of Medical Sciences, Newcastle University, Newcastle upon tyne, UK
| | - Khalid A. Al-Kubaisi
- Department of Pharmacy Practice and Pharmacotherapeutics, College of Pharmacy, University of Sharjah, Sharjah, United Arab Emirates
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Cheong VL, Mehdizadeh D, Todd OM, Gardner P, Zaman H, Clegg A, Alldred DP, Faisal M. The extent of anticholinergic burden across an older Welsh population living with frailty: cross-sectional analysis of general practice records. Age Ageing 2023; 52:afad136. [PMID: 37505992 PMCID: PMC10378723 DOI: 10.1093/ageing/afad136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Anticholinergic medicines are associated with adverse outcomes for older people. However, little is known about their use in frailty. The objectives were to (i) investigate the prevalence of anticholinergic prescribing for older patients, and (ii) examine anticholinergic burden according to frailty status. METHODS Cross-sectional analysis of Welsh primary care data from the Secure Anonymised Information Linkage databank including patients aged ≥65 at their first GP consultation between 1 January and 31 December 2018. Frailty was identified using the electronic Frailty Index and anticholinergic burden using the Anticholinergic Cognitive Burden (ACB) scale. Descriptive analysis and logistic regression were conducted to (i) describe the type and frequency of anticholinergics prescribed; and (ii) to estimate the association between frailty and cumulative ACB score (ACB-Sum). RESULTS In this study of 529,095 patients, 47.4% of patients receiving any prescription medications were prescribed at least one anticholinergic medicine. Adjusted regression analysis showed that patients with increasing frailty had higher odds of having an ACB-Sum of >3 compared with patients who were fit (mild frailty, adj OR 1.062 (95%CI 1.061-1.064), moderate frailty, adj OR 1.134 (95%CI 1.131-1.136), severe frailty, adj OR 1.208 (95%CI 1.203-1.213)). CONCLUSIONS Anticholinergic prescribing was high in this older population. Older people with advancing frailty are exposed to the highest anticholinergic burden despite being the most vulnerable to the associated adverse effects. Older people with advancing frailty should be considered for medicines review to prevent overaccumulation of anticholinergic medications, given the risks of functional and cognitive decline that frailty presents.
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Affiliation(s)
- V-Lin Cheong
- Medicines Management & Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- School of Healthcare, University of Leeds, Leeds, UK
| | - David Mehdizadeh
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
- NIHR Yorkshire and Humber Patient Safety Translational Research Centre, Bradford, UK
| | - Oliver M Todd
- Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Peter Gardner
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
- NIHR Yorkshire and Humber Patient Safety Translational Research Centre, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
| | - Hadar Zaman
- School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
- NIHR Yorkshire and Humber Patient Safety Translational Research Centre, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
| | - Andrew Clegg
- NIHR Yorkshire and Humber Patient Safety Translational Research Centre, Bradford, UK
- Academic Unit for Ageing and Stroke Research (University of Leeds), Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
| | - David P Alldred
- School of Healthcare, University of Leeds, Leeds, UK
- NIHR Yorkshire and Humber Patient Safety Translational Research Centre, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
| | - Muhammad Faisal
- NIHR Yorkshire and Humber Patient Safety Translational Research Centre, Bradford, UK
- Wolfson Centre for Applied Health Research, Bradford, UK
- Faculty of Health Studies, University of Bradford, Bradford, UK
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Lim J, Jeong S, Jang S, Jang S. Hospitalization and emergency department visits associated with potentially inappropriate medication in older adults: self-controlled case series analysis. Front Public Health 2023; 11:1080703. [PMID: 37469702 PMCID: PMC10352109 DOI: 10.3389/fpubh.2023.1080703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 05/30/2023] [Indexed: 07/21/2023] Open
Abstract
Introduction Potentially inappropriate medications (PIM) and resulting adverse health outcomes in older adults are a common occurrence. However, PIM prescriptions are still frequent for vulnerable older adults. Here, we sought to estimate the risk of hospitalization and emergency department (ED) visits associated with PIM prescriptions over different exposure periods and PIM drug categories. Methods We used the National Health Insurance Service-Elderly Cohort Database (NHIS-ECDB) to construct the cohort and implemented a Self-Controlled Case Series (SCCS) method. Hospitalization or ED visits during the exposure and post-exposure periods were compared to those during the non-exposure period, and six PIM drug categories were evaluated. A conditional Poisson regression model was applied, and the risk of outcomes was presented as the incidence rate ratio (IRR). All potential time-varying covariates were adjusted by year. A total of 43,942 older adults aged ≥65 y who had at least one PIM prescription and the events of either hospitalization or ED visits between Jan 2016 and Dec 2019 were selected.. Results Mean days of each exposure period was 46 d (±123); risk was highest in exposure1 (1-7 d, 37.8%), whereas it was similar during exposure2 (15-28 d), and exposure3 (29-56 d) (16.6%). The mean number of total PIM drugs administered during the study period was 7.34 (±4.60). Both hospitalization and ED visits were significantly higher in both exposure (adjusted IRR 2.14, 95% Confidence Interval (CI):2.11-2.17) and post-exposure periods (adjusted IRR 1.41, 95% CI:1.38-1.44) in comparison to non-exposure period. The risk of adverse health outcomes was highest during the first exposure period (1-14 d), but decreased gradually over time. Among the PIM categories, pain medication was used the most, followed by anticholinergics. All PIM categories significantly increased the risk of hospitalization and ED visits, ranging from 1.18 (other PIM) to 2.85 (pain medication). Sensitivity analyses using the first incidence of PIM exposure demonstrated similar results. All PIM categories significantly increased the risk of hospitalization and ED visits, with the initial period of PIM prescriptions showing the highest risk. In subgroup analysis stratified by the number of medications, PIM effects on the risk of hospitalization and ED visits remained significant but gradually attenuated by the increased number of medications. Discussion Therefore, the development of deprescribing strategies to control PIM and polypharmacy collectively is urgent and essential.
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Affiliation(s)
- Jaeok Lim
- College of Pharmacy and Gachon Institute of Pharmaceutical Sciences, Gachon University, Incheon, Republic of Korea
| | - Sohyun Jeong
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | - Suhyun Jang
- College of Pharmacy and Gachon Institute of Pharmaceutical Sciences, Gachon University, Incheon, Republic of Korea
| | - Sunmee Jang
- College of Pharmacy and Gachon Institute of Pharmaceutical Sciences, Gachon University, Incheon, Republic of Korea
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Temporal Trends Over Two Decades in the Use of Anticholinergic Drugs Among Older Community-Dwelling People in Helsinki, Finland. Drugs Aging 2022; 39:705-713. [PMID: 35913553 PMCID: PMC9463322 DOI: 10.1007/s40266-022-00968-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Knowledge of the adverse effects of drugs with anticholinergic properties (DAPs) has increased in recent decades. However, research on the temporal trends of the clinical use of DAPs is still sparse. OBJECTIVES The aim of this study was to investigate the temporal trends of DAP use over two decades in the older community-dwelling population and to explore the medication classes contributing to the use of DAPs. METHODS The study involved random samples of ≥ 75-year-old community-dwelling Helsinki citizens in 1999, 2009, and 2019 from the Helsinki Ageing Study. A postal questionnaire inquired about their health, functioning, and medications. The medications were categorized as DAPs according to Duran's list. In addition, we grouped DAPs into various medication groups. RESULTS The prevalence and burden of DAPs on Duran's list showed a decreasing trend over the years. In 1999 the prevalence was 20% and the burden 0.35, in 2009 they were 22% and 0.35, respectively, and in 2019 they were 16% and 0.23, respectively. There were no differences in how the 75- and 80-year-olds used DAPs compared with those aged 85 years and older. The proportion of typical antipsychotics, benzodiazepines, hypnotics, urinary antispasmodics, and asthma/chronic obstructive pulmonary disease medications decreased, whereas the proportion of atypical antipsychotics, antidepressants, strong opioids, and antihistamines increased. In particular the use of mirtazapine increased-to 3.9% in 2019. In 2019 the three most prevalent groups of DAPs were antidepressants (7.4%), opioids (2.7%), and antihistamines (2.4%). CONCLUSIONS The decrease in the use of DAPs on Duran's list is a welcome change. Although the use of old, strong DAPs has decreased, new DAPs have simultaneously emerged. Physicians need continuous education in prescribing DAPs and more recent information on the use and effects of DAPs is needed in order to decrease their exposure among the rapidly growing older population.
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Ramos H, Moreno L, Pérez-Tur J, Cháfer-Pericás C, García-Lluch G, Pardo J. CRIDECO Anticholinergic Load Scale: An Updated Anticholinergic Burden Scale. Comparison with the ACB Scale in Spanish Individuals with Subjective Memory Complaints. J Pers Med 2022; 12:jpm12020207. [PMID: 35207695 PMCID: PMC8876932 DOI: 10.3390/jpm12020207] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/30/2022] [Accepted: 01/31/2022] [Indexed: 11/30/2022] Open
Abstract
The increase in life expectancy has also been accompanied by an increase in the use of medication to treat chronic diseases. Polypharmacy is associated with medication-related problems such as the increase in the anticholinergic burden. Older people are more susceptible to anticholinergic effects on the central nervous system and this, in turn, may be related to cognitive impairment. In this paper, we develop an updated anticholinergic burden scale, the CRIDECO Anticholinergic Load Scale (CALS) via a systematic review of the literature and compare it with the currently most used Anticholinergic Burden Scale (ACB). Our new scale includes 217 different drugs with anticholinergic properties, 129 more than the ACB. Given the effect that anticholinergic medications have on cognitive performance, we then used both scales to investigate the relationship between anticholinergic burden and cognitive impairment in adult Spanish subjects with subjective memory complaint. In our population, we observed an association between cognitive impairment and the anticholinergic burden when measured by the new CALS, but not when the ACB was applied. The use of a more comprehensive and upgraded scale will allow better discrimination of the risk associated with the use of anticholinergic medications on cognitive impairment. CALS can help raise awareness among clinicians of the problems associated with the use of medications, or combinations of them, with large anticholinergic effect, and promote a better personalized pharmacological approach for each patient.
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Affiliation(s)
- Hernán Ramos
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Department of Pharmacy, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain
| | - Lucrecia Moreno
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Department of Pharmacy, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain
| | - Jordi Pérez-Tur
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Institut de Biomedicina de València-CSIC, CIBERNED, Unitat Mixta de Neurologia i Genetica, IIS La Fe, 46010 Valencia, Spain
| | - Consuelo Cháfer-Pericás
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Alzheimer Disease Research Group, Health Research Institute La Fe, 46026 Valencia, Spain
| | - Gemma García-Lluch
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Alzheimer Disease Research Group, Health Research Institute La Fe, 46026 Valencia, Spain
| | - Juan Pardo
- Cátedra DeCo MICOF-CEU UCH, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain; (H.R.); (L.M.); (J.P.-T.); (C.C.-P.); (G.G.-L.)
- Embedded Systems and Artificial Intelligence Group, Universidad Cardenal Herrera-CEU, CEU Universities, 46115 Valencia, Spain
- Correspondence:
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Effectiveness of Interventions to Improve the Anticholinergic Prescribing Practice in Older Adults: A Systematic Review. J Clin Med 2022; 11:jcm11030714. [PMID: 35160166 PMCID: PMC8836376 DOI: 10.3390/jcm11030714] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/23/2022] [Accepted: 01/25/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Pharmacotherapy in older adults is one of the most challenging aspects of patient care. Older people are prone to drug-related problems such as adverse effects, ineffectiveness, underdosage, overdosage, and drug interactions. Anticholinergic medications are associated with poor outcomes in older patients, and there is no specific intervention strategy for reducing drug burden from anticholinergic activity medications. Little is known about the effectiveness of current interventions that may likely improve the anticholinergic prescribing practice in older adults. AIMS This review seeks to document all types of interventions aiming to reduce anticholinergic prescribing among older adults and assess the current evidence and quality of existing single and combined interventions. METHODS We systematically searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and PsycINFO from January 1990 to August 2021. Only studies that examined the effect of interventions in older people focused on improving compliance with anticholinergic prescribing guidelines with quantifiable data were included. The primary outcome of interest was to find the effectiveness of interventions that enhance the anticholinergic prescribing practice in older adults. RESULTS We screened 3168 records and ended up in 23 studies that met the inclusion criteria. We found only single-component interventions to reduce anticholinergic prescribing errors in older people. Pharmacists implemented interventions without collaboration in nearly half of the studies (n = 11). Medication review (43%) and education provision (26%) to healthcare practitioners were the most common interventions. Sixteen studies (70%) reported significant reductions in anticholinergic prescribing errors, whereas seven studies (30%) showed no significant effect. CONCLUSION This systematic review suggests that healthcare practitioner-oriented interventions have the potential to reduce the occurrence of anticholinergic prescribing errors in older people. Interventions were primarily effective in reducing the burden of anticholinergic medications and assisting with deprescribing anticholinergic medications in older adults.
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Soundararajan K, Balchandra P. Staff Awareness of Anti-Cholinergic Burden (ACB) - A Qualitative Cross-Sectional Study in a Tertiary Care Hospital. Cureus 2021; 13:e14141. [PMID: 33927943 PMCID: PMC8075820 DOI: 10.7759/cureus.14141] [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] [Indexed: 11/05/2022] Open
Abstract
Introduction and hypothesis Anticholinergics are commonly used for a variety of conditions including urinary incontinence. Many studies show the ill effects of anticholinergics on cognition resulting in increased morbidity and mortality. However, the interaction of anticholinergic medications and cumulative anti-cholinergic burden (ACB) of different medications are not well known in general population and amongst health care professionals. Our aim is to study the extent of current awareness of ACB amongst health care professionals which plays a crucial role in educating patients and avoiding these morbidities. Methods A single centre cross-sectional study of 50 health care professionals who participated voluntarily. A questionnaire was designed to assess the knowledge, beliefs and attitudes towards anticholinergic burden and participants were also asked to choose the ACB score for 17 commonly used medications. Results A total of 74% participants admitted to have no understanding of the term ACB, 48% participants prescribe anticholinergics in their daily role, 44% knew that cognition was adversely affected by anticholinergics, and 16% participants were aware of scoring system. Only 16% participants routinely counsel women of cognitive side effects when anticholinergics are started. 86% reported that they would avoid prescribing medications which might affect cognition if possible. If given choice as a patient, 94% would avoid these medications if they were informed of the specific side effects like impaired cognition, physical decline, falls, hospital admissions and increased mortality. Conclusion Anticholinergic burden (ACB) is a serious phenomenon associated with increased morbidity and mortality in the general population as well as elderly population. It is evident from this study that the knowledge and awareness of ACB in our health care staff are still lacking.
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Affiliation(s)
- Kamalaveni Soundararajan
- Obstetrics and Gynaecology, Hull University Teaching Hospitals NHS Trust, Kingston upon Hull, GBR
| | - Pooja Balchandra
- Obstetrics and Gynaecology, Hull University Teaching Hospitals NHS Trust, Kingston upon Hull, GBR
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Prevalence and Factors Associated with Cumulative Anticholinergic Burden Among Older Long-Stay Nursing Home Residents with Overactive Bladder. Drugs Aging 2021; 38:311-326. [PMID: 33682017 PMCID: PMC8007511 DOI: 10.1007/s40266-021-00833-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Overactive bladder (OAB), the primary cause of urinary incontinence in nursing homes, is commonly treated with anticholinergic medications; however, the elderly population is vulnerable to the adverse effects associated with anticholinergic burden. Given the relatively high prevalence of OAB among nursing home residents, it is important to understand the magnitude of anticholinergic burden in this population. OBJECTIVES The objectives of this study were to (1) examine the prevalence of cumulative anticholinergic burden among long-stay nursing home (LSNH) residents with OAB; and (2) identify the factors associated with varying levels of cumulative anticholinergic burden. METHODS This was a retrospective, cohort study using Minimum Data Set-linked Medicare claims data. Anticholinergic burden was determined based on the Anticholinergic Cognitive Burden scale and patient-specific dosing using defined daily dose. The Andersen Behavioral Model framework was used to identify the predisposing, enabling, and need factors associated with levels of anticholinergic burden. Multivariable logistic regression models were developed to determine the factors associated with levels of anticholinergic burden. RESULTS A total of 123,308 LSNH residents with OAB were identified; 87.2% had some degree of anticholinergic burden and 27.3% had high cumulative burden. Multiple factors were associated with higher levels of burden, including younger age, female sex, and non-Hispanic White ethnicity (predisposing factors); dual eligibility, Southern geographic region, and rural residence (enabling factors); and a number of comorbidities and concomitant medications (need factors). CONCLUSIONS This study revealed a high level of anticholinergic burden among LSNH residents. Multiple factors were associated with a high level of burden. There is a need to optimize the use of anticholinergics due to their significant safety concerns in the LSNH setting.
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Fadare JO, Obimakinde AM, Aina FO, Araromi EJ, Adegbuyi TA, Osasona OE, Agbesanwa TA. Anti-Cholinergic Drug Burden Among Ambulatory Elderly Patients in a Nigerian Tertiary Healthcare Facility. Front Pharmacol 2021; 12:580152. [PMID: 33584317 PMCID: PMC7878669 DOI: 10.3389/fphar.2021.580152] [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: 07/04/2020] [Accepted: 01/04/2021] [Indexed: 01/25/2023] Open
Abstract
Background: The use of drugs with anticholinergic effects among elderly patients is associated with adverse clinical outcomes. There is paucity of information about anticholinergic drug burden among Nigerian elderly population. Objectives: To determine the anticholinergic drug burden among elderly Nigerian patients. Methods: This was a retrospective cross-sectional study conducted among elderly patients (aged 65 and above) who visited the Family Medicine outpatients' clinics of the Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria between July 1 and October 31, 2018. Information extracted from the case files included patient's age, sex, diagnoses, and list of prescribed medications. Medicines with anticholinergic effects were identified and scored using the anticholinergic drug burden calculator (http://www.acbcalc.com). Results: The medical records of 400 patients were analyzed with females accounting for 60.5% of the study population. The mean age of participants was 73 ± 7.4 years with only 28 (7%) of patients having more than two co-morbid conditions. Polypharmacy was identified in 152 (38%) of the patients while 147 (36.7%) had drugs with anticholinergic effects prescribed. The anticholinergic burden was high in 60 (15%) patients. Polypharmacy was significantly associated with having more than two diagnosed conditions and high anticholinergic burden (p value of < 0 .001 and 0.013 respectively). There was significant correlation between total number of prescribed drugs and count of diagnoses (r = 0.598; p < 0 .000) and between total number of prescribed drugs and number of drugs with anticholinergic effects (r = 0 .196; p < 0 .000). Conclusion: The anticholinergic burden in this group of elderly Nigerian patients was low; majority (67%) had no exposure to drugs with anticholinergic effects with only 15% having high anticholinergic burden. Polypharmacy and multiple diagnosed conditions were positively associated with high anticholinergic burden. Based on the positive and significant correlations found in this study, a reduction in the number of prescribed medicines especially those with significant anticholinergic effects used for secondary indications may lessen the anticholinergic burden among the elderly.
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Affiliation(s)
- Joseph O. Fadare
- Department of Pharmacology and Therapeutics, College of Medicine, Ekiti State University, Ado-Ekiti, Nigeria
- Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
| | - Abimbola Margaret Obimakinde
- Department of Community Medicine, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Family Medicine, University College Hospital Ibadan, Ibadan, Nigeria
| | - Felix O. Aina
- Department of Family Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
| | - Ebisola J. Araromi
- Department of Pharmacology and Therapeutics, College of Medicine, Ekiti State University, Ado-Ekiti, Nigeria
| | | | - Oluwatoba E. Osasona
- Department of Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
| | - Tosin A. Agbesanwa
- Department of Family Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Nigeria
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Lozano-Ortega G, Walker DR, Johnston K, Mickle A, Harrigan S, Rogula B, Kristy RM, Hairston JC, Schermer CR. Comparative Safety and Efficacy of Treatments for Overactive Bladder Among Older Adults: A Network Meta-analysis. Drugs Aging 2020; 37:801-816. [PMID: 32960422 PMCID: PMC7595992 DOI: 10.1007/s40266-020-00792-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cumulative exposure to one or more anticholinergic medications ("anticholinergic burden") is associated with an increased risk of adverse outcomes, particularly among older individuals. Mirabegron, an oral selective β3-adrenergic receptor agonist, has demonstrated efficacy in managing the symptoms of overactive bladder without contributing to anticholinergic burden. However, it is not known whether the favorable safety profile of mirabegron relative to antimuscarinics varies with increasing age among a patient population who may have a high anticholinergic burden. OBJECTIVE The primary objective of this study was to indirectly compare the safety and efficacy profile of mirabegron relative to antimuscarinics in older adults with overactive bladder. METHODS A systematic literature review was conducted to identify randomized controlled trials that reported safety and efficacy endpoints among patients aged ≥ 65 years. Identified randomized controlled trials were subsequently synthesized via a network meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in designing, performing, and reporting the literature review were followed. In line with current best practices, the network meta-analysis was conducted using a Bayesian approach and according to the overall general guidance for evidence synthesis developed by the National Institute for Health and Care Excellence decision support unit. Estimates of relative safety were assessed via the odds ratio and estimates of relative efficacy were assessed via means and credible intervals. RESULTS A total of 3078 abstracts, 300 of which underwent full-text screening, were identified using the search criteria. Twenty articles reporting on 21 randomized controlled trials were eligible for data extraction and synthesis. Following review, five safety and five efficacy endpoints were considered for inclusion in the network meta-analysis. Regarding findings typical of anticholinergic exposure in older adults, mirabegron was not associated with an increased odds of dry mouth (odds ratio 95% credible interval 0.76 [0.26-2.37]) or constipation (1.08 [0.39-3.02]) relative to placebo, whereas antimuscarinics were strongly associated with these events (odds ratio range 3.78-7.85 and 2.12-4.66, respectively). In this older population, mirabegron was associated with a similar odds of experiencing adverse event-related treatment discontinuations relative to placebo (0.99 [0.57-1.70]), while the odds of experiencing an adverse event-related treatment discontinuation for antimuscarinics had a range of 1.14-3.03 (in most cases, the association was mild). No increased odds of experiencing overall treatment-emergent adverse events was observed for mirabegron or antimuscarinics (odds ratio range 1.25-1.55), apart from fesoterodine (2.23 [1.37-3.37]). Finally, a similar treatment effect was observed across all efficacy endpoints between mirabegron and antimuscarinics in this older population. CONCLUSIONS This study indicates that the safety and efficacy profile of mirabegron remains favorable compared with antimuscarinics among older adults. This includes safety outcomes typically associated with anticholinergic burden, which were less frequently observed in patients treated with mirabegron.
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Affiliation(s)
| | - David R. Walker
- Astellas Pharma Global Development, Inc., Northbrook, IL USA
| | - Karissa Johnston
- Broadstreet Health Economics and Outcomes Research, Vancouver, BC Canada
| | - Alexis Mickle
- Broadstreet Health Economics and Outcomes Research, Vancouver, BC Canada
| | - Sean Harrigan
- Broadstreet Health Economics and Outcomes Research, Vancouver, BC Canada
| | - Basia Rogula
- Broadstreet Health Economics and Outcomes Research, Vancouver, BC Canada
| | - Rita M. Kristy
- Astellas Pharma Global Development, Inc., Northbrook, IL USA
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Perioperative Management of Elderly patients (PriME): recommendations from an Italian intersociety consensus. Aging Clin Exp Res 2020; 32:1647-1673. [PMID: 32651902 PMCID: PMC7508736 DOI: 10.1007/s40520-020-01624-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Surgical outcomes in geriatric patients may be complicated by factors such as multiple comorbidities, low functional performance, frailty, reduced homeostatic capacity, and cognitive impairment. An integrated multidisciplinary approach to management is, therefore, essential in this population, but at present, the use of such an approach is uncommon. The Perioperative Management of Elderly patients (PriME) project has been established to address this issue. AIMS To develop evidence-based recommendations for the integrated care of geriatric surgical patients. METHODS A 14-member Expert Task Force of surgeons, anesthetists, and geriatricians was established to develop evidence-based recommendations for the pre-, intra-, and postoperative care of hospitalized older patients (≥ 65 years) undergoing elective surgery. A modified Delphi approach was used to achieve consensus, and the strength of recommendations and quality of evidence was rated using the U.S. Preventative Services Task Force criteria. RESULTS A total of 81 recommendations were proposed, covering preoperative evaluation and care (30 items), intraoperative management (19 items), and postoperative care and discharge (32 items). CONCLUSIONS These recommendations should facilitate the multidisciplinary management of older surgical patients, integrating the expertise of the surgeon, the anesthetist, the geriatrician, and other specialists and health care professionals (where available) as needed. These roles may vary according to the phase and setting of care and the patient's conditions.
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The Prevalence of Anticholinergic Drugs and Correlation with Pneumonia in Elderly Patients: A Population-Based Study in Taiwan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17176260. [PMID: 32872121 PMCID: PMC7503732 DOI: 10.3390/ijerph17176260] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/19/2020] [Accepted: 08/25/2020] [Indexed: 12/21/2022]
Abstract
Anticholinergic drugs may increase the risk of serious respiratory infection, especially in the elderly. The study aims to investigate the prevalence of anticholinergic drugs and the correlation of incident pneumonia associated with the use of anticholinergic drugs among the elderly in Taiwan. The study population was 275,005 elderly patients aged ≥65 years old, selected from the longitudinal health insurance database (LHID) in 2016. Among all the elderly patients, about 60% had received anticholinergic medication at least once. Furthermore, the study selected elderly patients who had not been diagnosed with pneumonia and had not received any anticholinergic drugs in the past year in order to evaluate the correlation between pneumonia and anticholinergic drugs. The study excluded elderly patients who died or had received related drugs of incident pneumonia during the study period and selected elderly patients receiving anticholinergic drugs as the case group. Propensity score matching (PSM) on a 1:1 scale was used to match elderly patients that were not receiving any anticholinergic drugs as the control group, resulting in a final sample of 32,215 patients receiving anticholinergic drugs and 32,215 patients not receiving any anticholinergic drugs. Conditional logistic regression was used to estimate the association between anticholinergic drugs and pneumonia after controlling for potential confounders. Compared with patients not receiving anticholinergic drugs, the adjusted odds ratio of patients receiving anticholinergic drugs was 1.33 (95% confidence interval: 1.18 to 1.49). Anticholinergic medication is common among elderly patients in Taiwan. Elderly patients receiving anticholinergic drugs may increase their risk of incident pneumonia. The safety of anticholinergic drugs in the elderly should be of concern in Taiwan.
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Anticholinergic Burden in Children, Adults and Older Adults in Slovenia: A Nationwide Database Study. Sci Rep 2020; 10:9337. [PMID: 32518392 PMCID: PMC7283335 DOI: 10.1038/s41598-020-65989-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/17/2020] [Indexed: 11/11/2022] Open
Abstract
Anticholinergic burden has been widely studied in specific patient populations with specific conditions. However, the prevalence in the general population is poorly understood. This retrospective cross-sectional study was a nationwide database analysis of outpatient prescriptions of anticholinergic medications. The study was based on Slovenian health claims data of all outpatient prescriptions in 2018. Anticholinergic burden was evaluated using the Anticholinergic Cognitive Burden scale. Three age groups were analysed: children (≤18 years), adults (19–64 years) and older adults (≥65 years). Anticholinergic medications were prescribed to 29.8% of the participants; 7.6% were exposed to a clinically significant anticholinergic burden. The proportion of patients exposed to anticholinergic burden was highest in older adults (43.2%), followed by adults (25.8%) and children (20.7%). The most frequently prescribed medications with the highest anticholinergic activity were antipsychotics and medications for urinary diseases (42.8% and 40.2%, respectively). Medications with second highest activity were mostly antiepileptics (87.3%). Medications with possible anticholinergic activity included diverse therapeutic groups. Anticholinergic burden is highest in older adults but is also considerable among adults and children. Medications with anticholinergic activity belong to diverse therapeutic groups. Further research is needed on safe use of these medications in all age groups.
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López-Álvarez J, Sevilla-Llewellyn-Jones J, Agüera-Ortiz L. Anticholinergic Drugs in Geriatric Psychopharmacology. Front Neurosci 2019; 13:1309. [PMID: 31866817 PMCID: PMC6908498 DOI: 10.3389/fnins.2019.01309] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/22/2019] [Indexed: 12/31/2022] Open
Abstract
Drugs with anticholinergic action are widely prescribed in the elderly population due to their potential clinical benefits. However, these benefits are limited by adverse effects which may be serious in particular circumstances. This review presents different aspects of the use of anticholinergics in old age with a focus in psychogeriatric patients. We critically review published data on benefits and disadvantages of anticholinergics, which are often controversial. Prevalence, pathophysiology and measurement methods of the anticholinergic action of drugs are discussed. We also present the most important drawbacks resulting from its use, including effects on cognition in healthy and cognitively impaired people, in aged schizophrenia patients, emergence of delirium and psychiatric symptoms, influence in functionality, hospitalization, institutionalization and mortality, and the potential benefits and limitations of their discontinuation. Finally, we suggest practical recommendations for the safe use of anticholinergics in clinical conditions affecting elderly patients, such as dementia, schizophrenia and acute hallucinatory episodes, depression, anxiety, Parkinson's disease, cardiovascular conditions and urinary incontinence.
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Affiliation(s)
- Jorge López-Álvarez
- Servicio de Psiquiatría, Hospital 12 de Octubre (imas12), Madrid, Spain.,Instituto de Investigación, Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Julia Sevilla-Llewellyn-Jones
- Instituto de Psiquiatría y Salud Mental, Hospital Clínico San Carlos, Madrid, Spain.,Instituto de Investigación (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| | - Luis Agüera-Ortiz
- Servicio de Psiquiatría, Hospital 12 de Octubre (imas12), Madrid, Spain.,Instituto de Investigación, Hospital 12 de Octubre (imas12), Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental, Ministry of Science and Innovation, Madrid, Spain.,Departamento de Medicina Legal, Psiquiatría y Patología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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Keine D, Zelek M, Walker JQ, Sabbagh MN. Polypharmacy in an Elderly Population: Enhancing Medication Management Through the Use of Clinical Decision Support Software Platforms. Neurol Ther 2019; 8:79-94. [PMID: 30900186 PMCID: PMC6534631 DOI: 10.1007/s40120-019-0131-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Polypharmacy is a growing problem in the United States. The use of multiple medications increases the likelihood that a patient will experience potential drug interactions and adverse drug reactions (ADRs). Those individuals with dementia or Alzheimer's disease (AD) are at greater risk, due to age, comorbidities, and an increased likelihood of being on a greater number of neuroactive medications. METHODS uMETHOD Health (uMH) has developed a precision medicine platform to address dementia and mild AD through the creation of personalized, multidomain treatment plans. Many interactions and ADRs may be observed, such as drug-drug interactions (DDIs), drug-gene interactions (DGIs), anticholinergic cognitive burden (ACB), and depression-inducing drugs (DIDs). uMH's algorithms can parse these interactions, rate them based on input from open-source databases, and then record all these interactions in a generated treatment plan. A total of 295 individuals aged 65 and older were included in this analysis. RESULTS Of 295 individuals, 97.59% were on at least one medication, with an overall mean of 11.5 medications per person; 83.66% were on five or more medications. A total of 102 DGIs, 3642 DDIs, and one high-priority DDI were found in this population. There was a significant increase in the number of DDIs as medications per person increased (P value < 0.0001). Of the population, 65.86% were on one or more anticholinergic drugs. There was a significant difference in the ACB score between individuals with cognitive decline and those without. In total, 60.98% of the overall population were on DIDs, with a mean of 1.19 medications per person. CONCLUSIONS The results of this work show that older populations have a high medication burden. With the growing elderly and AD populations, medication management for polypharmacy is a need that grows direr every year. uMH's platform was able to identify a multitude of polypharmacy problems that individuals are currently facing. FUNDING uMETHOD Health.
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Affiliation(s)
| | | | | | - Marwan N Sabbagh
- Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, NV, USA
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Yoon SK, Okyere BA, Strasser D. Polypharmacy and Rational Prescribing: Changing the Culture of Medicine One Patient at a Time. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00220-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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