Clinical and demographic factors associated with antimuscarinic medication use in older hospitalized patients

Quality of anticholinergic burden scales and their impact on clinical outcomes: a systematic review

PURPOSE

Older people are at risk of anticholinergic side effects due to changes affecting drug elimination and higher sensitivity to drug's side effects. Anticholinergic burden scales (ABS) were developed to quantify the anticholinergic drug burden (ADB). We aim to identify all published ABS, to compare them systematically and to evaluate their associations with clinical outcomes.

METHODS

We conducted a literature search in MEDLINE and EMBASE to identify all published ABS and a Web of Science citation (WoS) analysis to track validation studies implying clinical outcomes. Quality of the ABS was assessed using an adapted AGREE II tool. For the validation studies, we used the Newcastle-Ottawa Scale and the Cochrane tool Rob2.0. The validation studies were categorized into six evidence levels based on the propositions of the Oxford Center for Evidence-Based Medicine with respect to their quality. At least two researchers independently performed screening and quality assessments.

RESULTS

Out of 1297 records, we identified 19 ABS and 104 validations studies. Despite differences in quality, all ABS were recommended for use. The anticholinergic cognitive burden (ACB) scale and the German anticholinergic burden scale (GABS) achieved the highest percentage in quality. Most ABS are validated, yet validation studies for newer scales are lacking. Only two studies compared eight ABS simultaneously. The four most investigated clinical outcomes delirium, cognition, mortality and falls showed contradicting results.

CONCLUSION

There is need for good quality validation studies comparing multiple scales to define the best scale and to conduct a meta-analysis for the assessment of their clinical impact.

Quality of anticholinergic burden scales and their impact on clinical outcomes: a systematic review

Purpose

Older people are at risk of anticholinergic side effects due to changes affecting drug elimination and higher sensitivity to drug’s side effects. Anticholinergic burden scales (ABS) were developed to quantify the anticholinergic drug burden (ADB). We aim to identify all published ABS, to compare them systematically and to evaluate their associations with clinical outcomes.

Methods

We conducted a literature search in MEDLINE and EMBASE to identify all published ABS and a Web of Science citation (WoS) analysis to track validation studies implying clinical outcomes. Quality of the ABS was assessed using an adapted AGREE II tool. For the validation studies, we used the Newcastle-Ottawa Scale and the Cochrane tool Rob2.0. The validation studies were categorized into six evidence levels based on the propositions of the Oxford Center for Evidence-Based Medicine with respect to their quality. At least two researchers independently performed screening and quality assessments.

Results

Out of 1297 records, we identified 19 ABS and 104 validations studies. Despite differences in quality, all ABS were recommended for use. The anticholinergic cognitive burden (ACB) scale and the German anticholinergic burden scale (GABS) achieved the highest percentage in quality. Most ABS are validated, yet validation studies for newer scales are lacking. Only two studies compared eight ABS simultaneously. The four most investigated clinical outcomes delirium, cognition, mortality and falls showed contradicting results.

Conclusion

There is need for good quality validation studies comparing multiple scales to define the best scale and to conduct a meta-analysis for the assessment of their clinical impact.

Electronic supplementary material

The online version of this article (10.1007/s00228-020-02994-x) contains supplementary material, which is available to authorized users.

Associations between Anticholinergic Burden and Adverse Health Outcomes in Parkinson Disease

Background

Elderly adults should avoid medications with anticholinergic effects since they may increase the risk of adverse events, including falls, delirium, and cognitive impairment. However, data on anticholinergic burden are limited in subpopulations, such as individuals with Parkinson disease (PD). The objective of this study was to determine whether anticholinergic burden was associated with adverse outcomes in a PD inpatient population.

Methods

Using the Cerner Health Facts® database, we retrospectively examined anticholinergic medication use, diagnoses, and hospital revisits within a cohort of 16,302 PD inpatients admitted to a Cerner hospital between 2000 and 2011. Anticholinergic burden was computed using the Anticholinergic Risk Scale (ARS). Primary outcomes were associations between ARS score and diagnosis of fracture and delirium. Secondary outcomes included associations between ARS score and 30-day hospital revisits.

Results

Many individuals (57.8%) were prescribed non-PD medications with moderate to very strong anticholinergic potential. Individuals with the greatest ARS score (≥4) were more likely to be diagnosed with fractures (adjusted odds ratio (AOR): 1.56, 95% CI: 1.29–1.88) and delirium (AOR: 1.61, 95% CI: 1.08–2.40) relative to those with no anticholinergic burden. Similarly, inpatients with the greatest ARS score were more likely to visit the emergency department (adjusted hazard ratio (AHR): 1.32, 95% CI: 1.10–1.58) and be readmitted (AHR: 1.16, 95% CI: 1.01–1.33) within 30-days of discharge.

Conclusions

We found a positive association between increased anticholinergic burden and adverse outcomes among individuals with PD. Additional pharmacovigilance studies are needed to better understand risks associated with anticholinergic medication use in PD.

Oral pharmacotherapy for overactive bladder in older patients: mirabegron as a potential alternative to antimuscarinics

OBJECTIVE

Overactive bladder (OAB) is a particular challenge to treat in older adults with co-morbid conditions taking multiple medications. Antimuscarinics (e.g., solifenacin, fesoterodine) and β3-adrenergic receptor agonists (mirabegron) are similarly efficacious; however, antimuscarinics may be associated with side effects that result in poor persistence and contribute to anticholinergic burden, particularly in those taking other medications with anticholinergic properties. With a mechanism of action distinct from antimuscarinics, mirabegron has a different tolerability profile and does not contribute to anticholinergic burden. The objective of this review was to compare and contrast the tolerability profiles of antimuscarinics and mirabegron in older patients to inform practice.

METHODS

Prospective trials or retrospective subgroup analyses of antimuscarinics for the treatment of OAB in older patients were identified through a search of PubMed. Tolerability data and results of subgroup analyses of mirabegron in patients aged ≥65 and ≥75 years from a pooled analysis of three trials each of 12 weeks and a 1 year trial are described.

RESULTS

Anticholinergic adverse events (AEs) including dry mouth and constipation were more frequent with antimuscarinics versus mirabegron. In patients aged ≥65 years, dry mouth occurred with a six-fold higher incidence with tolterodine extended-release (ER) 4 mg than with mirabegron 25 mg or 50 mg over 12 weeks, and a three-fold higher incidence with tolterodine ER than mirabegron 50 mg over 1 year. Mirabegron had a low incidence of central nervous system effects. A systematic review of the cardiovascular safety profile of mirabegron has not identified any clinically significant effects on blood pressure or pulse rate at therapeutic doses amongst patients aged ≥65 years.

CONCLUSIONS

Mirabegron has a more favorable tolerability profile than antimuscarinics amongst older patients and may provide an improved benefit-to-risk ratio and therefore be considered as an alternative to antimuscarinics for older patients.

Measuring anticholinergic drug exposure in older community-dwelling Australian men: a comparison of four different measures

AIMS

Anticholinergic drug exposure is associated with adverse outcomes in older people. While a number of tools have been developed to measure anticholinergic drug exposure, there is limited information about the agreement and overlap between the various scales. The aim of this study was to investigate the agreement and overlap between different measures of anticholinergic drug exposure in a cohort of community-dwelling older men.

METHODS

A cross-sectional study was used to compare anticholinergic drug exposure calculated using the Anticholinergic Risk Scale (ARS), the Anticholinergic Drug Scale (ADS), the Anticholinergic Cognitive Burden (ACB) and the Drug Burden Index anticholinergic subscale (DBI-ACH) in a cohort of community-dwelling men aged 70 years and older (n = 1696). Statistical agreement, expressed as Cohen's kappa (κ), between these measurements was calculated.

RESULTS

Differences were found between the tools regarding the classification of anticholinergic drug exposure for individual participants. Thirteen percent of the population used a drug listed as anticholinergic on the ARS, 39% used a drug listed on the ADS and the ACB, and 18% of the population used one or more anticholinergic drugs listed on the DBI-ACH. While agreement was good between the ACB and ADS (κ = 0.628, 95% CI 0.593, 0.664), little agreement was found between remaining tools (κ = 0.091-0.264).

CONCLUSIONS

With the exception of the ACB and ADS, there was poor agreement regarding anticholinergic drug exposure among the four tools compared in this study. Great care should be taken when interpreting anticholinergic drug exposure using existing scales due to the wide variability between the different scales.

Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review

Background

The cumulative effect of taking multiple medicines with anticholinergic properties termed as anticholinergic burden can adversely impact cognition, physical function and increase the risk of mortality. Expert opinion derived risk scales are routinely used in research and clinical practice to quantify anticholinergic burden. These scales rank the anticholinergic activity of medicines into four categories, ranging from no anticholinergic activity (= 0) to definite/high anticholinergic activity (= 3). The aim of this systematic review was to compare anticholinergic burden quantified by the anticholinergic risk scales and evaluate associations with adverse outcomes in older people.

Methods

We conducted a literature search in Ovid MEDLINE, EMBASE and PsycINFO from 1984-2014 to identify expert opinion derived anticholinergic risk scales. In addition to this, a citation analysis was performed in Web of Science and Google Scholar to track prospective citing of references of selected articles for assessment of individual scales for adverse anticholinergic outcomes. The primary outcomes of interest were functional and cognitive outcomes associated with anticholinergic burden in older people. The critical appraisals of the included studies were performed by two independent reviewers and the data were extracted onto standardised forms.

Results

The primary electronic literature search identified a total of 1250 records in the 3 different databases. On the basis of full-text analysis, we identified 7 expert-based anticholinergic rating scales that met the inclusion criteria. The rating of anticholinergic activity for medicines among these rating scales was inconsistent. For example, quetiapine was rated as having high anticholinergic activity in one scale (n = 1), moderate in another scale (n = 1) and low in two other scales (n = 2). Citation analysis of the individual scales showed that the Anticholinergic Cognitive Burden (ACB) scale was the most frequently validated expert based anticholinergic scale for adverse outcomes (N = 13).

Conclusions

In conclusion, there is not one standardised tool for measuring anticholinergic burden. Cohort studies have shown that higher anticholinergic burden is associated with negative brain effects, poorer cognitive and functional outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-015-0029-9) contains supplementary material, which is available to authorized users.

Associations between different measures of anticholinergic drug exposure and Barthel Index in older hospitalized patients

OBJECTIVE

To compare associations between four measures of anticholinergic exposure (anticholinergic risk scale, ARS; anticholinergic drug burden, DBAC; number and use versus no use of anticholinergic drugs), Barthel Index (BI, physical function) and Abbreviated Mental Test (AMT, cognitive function) on admission in older hospitalized patients.

METHODS

Prospective observational study of a consecutive series of 271 older patients (age 83 ± 7 years) from community-dwelling and institutionalized settings, admitted to an acute geriatric admission unit between 28 September 2011 and 18 December 2011. The main outcome measures were BI quartiles (primary outcome) and AMT (secondary outcome) on admission.

RESULTS

Anticholinergic prevalence was 47%. Multinomial logistic regression showed higher DBAC was associated with a greater risk of being in the lower BI quartiles versus highest BI quartile (Q4). This risk was significant for Q3 (p = 0.04) and Q2 (p = 0.02) but not for Q1 (p = 0.06). A greater number of anticholinergic drugs was associated with a higher risk of being in Q2 (p = 0.02). This risk was not significant for either Q3 (p = 0.10) or Q1 (p = 0.06). No significant associations were observed either with use of anticholinergic medication or with ARS and BI quartiles. AMT did not show independent associations with any of the four measures of anticholinergic exposure.

CONCLUSION

In older hospitalized patients, DBAC and some crude measures of anticholinergic exposure, but not ARS, showed independent associations with lower BI, but not AMT. These results highlight differences between various measures of anticholinergic drug exposure when studying their associations with functional status.

Minimizing anticholinergic drug prescribing in older hospitalized patients: a full audit cycle

INTRODUCTION

Anticholinergic drugs are associated with poor outcomes in older patients but no specific intervention strategies aimed at reducing anticholinergic drug exposure have been described.

OBJECTIVES

To identify whether a consultant-led medication review targeting anticholinergics would reduce anticholinergic drug exposure [number of anticholinergic drugs and Anticholinergic Risk Scale (ARS) score].

METHODS

The first phase of the audit included 70 consecutive admissions (mean age 84 years, 53 women). ARS score was calculated on admission and after initial consultant review. Re-audit was undertaken on another 70 consecutive admissions (mean age 83 years, 43 women) after introducing a system of informing the responsible consultant of the ARS score at their first review.

RESULTS

Drugs with anticholinergic effects (n = 53) were prescribed preadmission to 45/140 (32%) of patients. Consultant geriatrician review reduced ARS scores (p = 0.01), especially following the introduction of the information system (p = 0.002). In the first arm of the audit, 51 (73%) patients had ARS of 0 after a consultant's review compared with 47 (67%) patients on admission, whilst 67 (96%) patients had ARS of 2 or less after a consultant's review compared with 63 (90%) patients on admission. In the second arm of the audit, 59 (84%) patients had ARS of 0 after a consultant's review compared with 48 (69%) patients on admission, whilst 70 (100%) patients had ARS of 2 or less after a consultant's review compared with 69 (99%) patients on admission. Anticholinergic drugs were either stopped, or their dose reduced, in 35% of patients in the first arm of the audit and in 73% of patients in the re-audit (odds ratio 5.0, 95% confidence interval 1.4-17.8).

CONCLUSION

Consultant-led medication review (standard practice) was effective at reducing anticholinergic drug exposure in the acute setting. A system of alerting clinicians to patients prescribed anticholinergic medications further reduced anticholinergic drug exposure.

The relationship between total anticholinergic burden (ACB) and early in-patient hospital mortality and length of stay in the oldest old aged 90 years and over admitted with an acute illness

The use of prescription drugs in older people is high and many commonly prescribed drugs have anticholinergic effects. We examined the relationship between ACB on mortality and in-patient length of stay in the oldest old hospitalised population. This was a retrospective analysis of prospective audit using hospital audit data from acute medical admissions in three hospitals in England and Scotland. Baseline use of possible or definite anticholinergics was determined according to the Anticholinergic Cognitive Burden Scale. The main outcome measures were decline in-hospital mortality, early in-hospital mortality at 3- and 7-days and in-patient length of stay. A total of 419 patients (including 65 patients with known dementia) were included [median age=92.9, inter-quartile range (IQR) 91.4-95.1 years]. 256 (61.1%) were taking anticholinergic medications. Younger age, greater number of pre-morbid conditions, ischemic heart disease, number of medications, higher urea and creatinine levels were significantly associated with higher total ACB burden on univariate regression analysis. There were no significant differences observed in terms of in-patient mortality, in-patient hospital mortality within 3- and 7-days and likelihood of prolonged length of hospital stay between ACB categories. Compared to those without cardiovascular disease, patients with cardiovascular disease showed similar outcome regardless of ACB load (either =0 or >0 ACB). We found no association between ACB and early (within 3- and 7-days) and in-patient mortality and hospital length of stay outcomes in this cohort of oldest old in the acute medical admission setting.

Anticholinergic drugs and functional outcomes in older patients undergoing orthopaedic rehabilitation

BACKGROUND

Medications with anticholinergic (antimuscarinic) effects negatively affect physical and cognitive function in community-dwelling older patients. However, it is unknown if anticholinergic drugs exert detrimental effects in older patients undergoing rehabilitation.

OBJECTIVE

The purpose of our study was to assess the effect of anticholinergic drug exposure on functional outcomes in older patients undergoing rehabilitation. We speculated that higher anticholinergic drug exposure would be associated with reduced functional outcomes in this group.

METHODS

Data on clinical characteristics, full medication, anticholinergic drug exposure (total number of anticholinergic drugs [tAD] and Anticholinergic Risk Scale [ARS] score), and Barthel index (BI) score were collected on admission and discharge in a consecutive series of 117 older patients (age 79 [7] years) admitted to the orthopaedic rehabilitation unit of a teaching hospital between July 2010 and March 2011. Outcome measures were BI changes (BI on discharge - BI on admission) during rehabilitation (primary outcome) and length of stay (secondary outcome).

RESULTS

Anticholinergic drugs were prescribed in 38 patients (32.5%). Median and interquartile range for tAD = 0 (0-1); for ARS = 0 (0-1). Poisson regression showed that higher tAD (incidence rate ratio [IRR] = 0.92; 95% CI, 0.88-0.97; P = 0.003) and ARS scores (IRR = 0.97; 95% CI, 0.95-0.99; P = 0.008) on admission independently predicted lower BI changes. Being a woman (IRR = 0.87; 95% CI, 0.78-0.97; P = 0.01), lower Abbreviated Mental Test scores (IRR = 0.94; 95% CI, 0.91-0.97; P < 0.001), and lower BI on admission (IRR = 0.98; 95% CI, 0.97-0.98; P < 0.001), but not tAD or ARS scores, independently predicted increasing length of stay.

CONCLUSIONS

Higher anticholinergic drug exposure on admission independently predicts reduced functional outcomes, but not length of stay, in older patients undergoing orthopaedic rehabilitation.

Polypharmacy and food-drug interactions among older persons: a review

Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.