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Tiisanoja A, Anttonen V, Syrjälä AM, Ylöstalo P. High Anticholinergic Burden and Dental Caries: Findings from Northern Finland Birth Cohort 1966. JDR Clin Trans Res 2024:23800844241253250. [PMID: 38872382 DOI: 10.1177/23800844241253250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION Anticholinergic drugs propose a threat for oral health by causing dry mouth. The aim of this cross-sectional study was to investigate whether a high anticholinergic burden was associated with the presence of initial caries lesions, manifested caries lesions, dental fillings, or tooth loss among 46-y-old people. METHODS The study population consisted of 1,906 participants from the Northern Finland Birth Cohort 1966 who underwent an oral health examination in 2012-2013. Socioeconomic and medical data were collected from questionnaires, medical records, and national registers. Nine previously published anticholinergic scales were combined and used to measure the high anticholinergic burden from the participants' medication data. Cariological status was determined according to the International Caries Detection and Assessment System, and the number of missing teeth (excluding third molars) was used as an indicator for tooth loss. The decayed, missing, and filled surfaces index was used to depict caries experience. Negative binominal regression models were used to estimate prevalence rate ratios (PRRs) and confidence intervals (CIs). RESULTS Fourteen percent of the participants (n = 276) used at least 1 anticholinergic drug and about 3% had a high anticholinergic burden (n = 61). After adjusting for confounding factors, participants with a high anticholinergic burden had a higher likelihood of having manifested carious lesions needing restorative treatment (PRR, 1.60; CI, 1.11-2.29) and more missing teeth (PRR, 1.59; CI, 1.13-2.24) when compared to participants without any or with a lower anticholinergic burden. CONCLUSIONS High anticholinergic burden was associated with a present caries experience and with tooth loss among the general middle-aged population. KNOWLEDGE TRANSFER STATEMENT The findings of this study suggest that middle-aged patients with a high anticholinergic burden may have a heightened risk of dental caries. These patients may benefit from targeted caries preventive regimes.
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Affiliation(s)
- A Tiisanoja
- Social and Health Services, Oulu, Finland
- Research Unit of Population Health, University of Oulu
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu
| | - V Anttonen
- Research Unit of Population Health, University of Oulu
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu
| | - A-M Syrjälä
- Research Unit of Population Health, University of Oulu
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu
| | - P Ylöstalo
- Research Unit of Population Health, University of Oulu
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu
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Matta R, Gomes T, Juurlink D, Jarvi K, Herschorn S, Nam RK. Receipt of Overactive Bladder Drugs and Incident Dementia: A Population-based Case-control Study. Eur Urol Focus 2022; 8:1433-1440. [PMID: 34742663 DOI: 10.1016/j.euf.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/09/2021] [Accepted: 10/08/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The differential risk of incident dementia associated with receiving various overactive bladder (OAB) drugs is unknown. OBJECTIVE To estimate the association of antimuscarinic OAB drug (exposure), compared with a β-3 agonist (mirabegron), and incident dementia. DESIGN, SETTING, AND PARTICIPANTS A population-based nested case-control study was conducted in patients treated with OAB medications in Ontario, Canada. A total of 11 392 patients aged ≥66 yr with a new diagnosis of dementia between 2010 and 2017, and 29 881 age- and sex-matched controls without dementia were included in the study. INTERVENTION Receipt of an antimuscarinic OAB drug or receipt of mirabegron, within the previous 6-12 mo. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Cases developed dementia and Alzheimer's disease. Controls were derived from the general population and matched to cases based on important baseline characteristics. Odds ratios (ORs) for incident dementia, adjusted for demographic and health-related characteristics, were determined. RESULTS AND LIMITATIONS Patients receiving solifenacin (OR 1.24; 95% confidence interval 1.08-1.43) and darifenacin (OR 1.30; 95% CI 1.08-1.56) in the prior 6 mo had increased odds of incident dementia compared with those receiving mirabegron. In the 6 mo to 1 yr prior to diagnosis, receipt of solifenacin (OR 1.34; 95% CI 1.11-1.60), darifenacin (OR 1.49; 95% CI 1.19-1.86), tolterodine (OR 1.21; 95% CI 1.02-1.45), and fesoterodine (OR 1.39; 95% CI 1.14-1.71) was associated with increased odds of incident dementia compared with receipt of mirabegron. No effect was seen with oxybutynin or trospium. Limitations included misclassification of the outcome and residual confounding associated with the use of health administrative databases. CONCLUSIONS Older adults receiving solifenacin and darifenacin in the 6 mo prior to diagnosis, and those receiving solifenacin, darifenacin, tolterodine, or fesoterodine in the year prior to diagnosis, have increased odds of incident dementia, compared with those receiving mirabegron. Oxybutynin and trospium were not associated with dementia, likely due to a protopathic bias. Careful drug selection is warranted when treating patients with OAB. PATIENT SUMMARY In a large Canadian cohort of patients who developed dementia after starting an overactive bladder (OAB) medication, those taking some anticholinergic medications for OAB have an increased risk of dementia compared with those taking mirabegron.
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Affiliation(s)
- Rano Matta
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Tara Gomes
- Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Li Ka Shing Centre for Healthcare Analytics Research and Training, St. Michael's Hospital, Toronto, Ontario, Canada
| | - David Juurlink
- Institute for Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Division of Clinical Pharmacology and Toxicology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Keith Jarvi
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Urology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sender Herschorn
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Robert K Nam
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Division of Urology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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McMichael AJ, Zafeiridi E, Ryan M, Cunningham EL, Passmore AP, McGuinness B. Anticholinergic drug use and risk of mortality for people with dementia in Northern Ireland. Aging Ment Health 2021; 25:1475-1482. [PMID: 33073601 DOI: 10.1080/13607863.2020.1830028] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- A J McMichael
- Centre for Public Health, Institute for Clinical Sciences Block B, Queens University Belfast, Belfast, Northern Ireland
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Dmochowski RR, Thai S, Iglay K, Enemchukwu E, Tee S, Varano S, Girman C, Radican L, Mudd PN, Poole C. Increased risk of incident dementia following use of anticholinergic agents: A systematic literature review and meta-analysis. Neurourol Urodyn 2020; 40:28-37. [PMID: 33098213 PMCID: PMC7821204 DOI: 10.1002/nau.24536] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/17/2020] [Accepted: 10/01/2020] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Roger R Dmochowski
- Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sydney Thai
- Department of Pharmacoepidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,CERobs Consulting, LLC, Chapel Hill, North Carolina, USA
| | - Kristy Iglay
- CERobs Consulting, LLC, Chapel Hill, North Carolina, USA.,Laylen Scientific Solutions, LLC, Flemington, New Jersey, USA
| | - Ekene Enemchukwu
- Department of Urology, School of Medicine, Stanford University, Stanford, California, USA
| | - Silvia Tee
- School of Medicine, Section of Geriatric Medicine - Primary Care and Population Health, Stanford University, Stanford, California, USA
| | - Susann Varano
- Clinical Research Consulting, Milford, Connecticut, USA
| | - Cynthia Girman
- Department of Pharmacoepidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,CERobs Consulting, LLC, Chapel Hill, North Carolina, USA
| | - Larry Radican
- Peloton Advantage, an Open Health Company, Parsippany, New Jersey, USA
| | - Paul N Mudd
- Clinical Development, Urovant Sciences, Inc., Durham, North Carolina, USA
| | - Charles Poole
- Department of Epidemiology, Gillings School of Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
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Auvinen KJ, Räisänen J, Voutilainen A, Jyrkkä J, Mäntyselkä P, Lönnroos E. Interprofessional Medication Assessment has Effects on the Quality of Medication Among Home Care Patients: Randomized Controlled Intervention Study. J Am Med Dir Assoc 2020; 22:74-81. [PMID: 32893136 DOI: 10.1016/j.jamda.2020.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Multimorbidity and complex medications increase the risk of medication-related problems, especially in vulnerable home care patients. The objective of this study was to examine whether interprofessional medication assessment has an effect on medication quality among home care patients. DESIGN The FIMA (Finnish Interprofessional Medication Assessment) study was a randomized, controlled study comparing physician-led interprofessional medication assessment and usual care. SETTING AND PARTICIPANTS The FIMA study was conducted in home care settings in Finland. The participants were ≥65-year-old home care patients with ≥6 drugs daily, dizziness, orthostatic hypotension, or a recent fall. METHODS Primary outcome measures over the 6-month follow-up were number of drugs, drug-drug-interactions, medication-related risk loads, and use of potentially inappropriate medications (PIMs) examined by SFINX, RENBASE, PHARAO, and Meds75+ databases. The databases classified information as follows: A (no known pharmacologic or clinical basis for an increased risk), B (evidence not available/uncertain), C (moderately increased risk which may have clinical relevance), and D (high risk, best to avoid). Logistic regression adjusted for age, sex, and the baseline level of the outcome measure served as statistical methods. RESULTS The mean number of all drugs for home care patients (n = 512) was 15. The odds of drug-induced impairment of renal function (RENBASE D, P = .020) and medication-related risk loads for bleeding (PHARAO D, P = .001), anticholinergic effects (PHARAO D, P = .009), and constipation (PHARAO D, P = .003) decreased significantly in the intervention group compared with usual care. The intervention also reduced the odds of using PIMs (Meds75+ D, P = .005). There were no significant changes in drug-drug-interactions or number of drugs. CONCLUSIONS AND IMPLICATIONS FIMA intervention improved the medication quality of home care patients. Risks for renal failure, anticholinergic effects, bleeding, constipation, and the use of PIMs were reduced significantly.
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Affiliation(s)
- Kati J Auvinen
- The East Savo Hospital District, Savonlinna, Finland; Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland.
| | - Johanna Räisänen
- Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Ari Voutilainen
- Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Johanna Jyrkkä
- Assessment of Pharmacotherapies, Finnish Medicines Agency, Kuopio, Finland
| | - Pekka Mäntyselkä
- Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland; Kuopio University Hospital, Primary Health Care Unit, Kuopio, Finland
| | - Eija Lönnroos
- Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
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Kouladjian O'Donnell L, Gnjidic D, Chen TF, Hilmer SN. Integration of an electronic Drug Burden Index risk assessment tool into Home Medicines Reviews: deprescribing anticholinergic and sedative medications. Ther Adv Drug Saf 2019; 10:2042098619832471. [PMID: 30858967 PMCID: PMC6402056 DOI: 10.1177/2042098619832471] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 01/30/2019] [Indexed: 01/31/2023] Open
Abstract
Background: Our aim in this research was to establish whether integrating an electronically generated calculation and report on the Drug Burden Index (DBI) in the Home Medicines Review (HMR) setting is an accurate, feasible and useful risk assessment tool to assess risk of anticholinergic and sedative medications; and to establish whether the intervention of DBI together with HMR is associated with a reduced use of anticholinergic and sedative medications in older community-dwelling adults in Australia. Methods: An interventional feasibility study was conducted. Accredited clinical pharmacists (APs) were recruited to participate. Each AP was educated on implementation of the DBI into HMR practice and given access to the DBI Calculator© web-based software to generate the DBI report for inclusion in HMR reports for general practitioners (GPs). APs recruited patients (⩾65 years) who were referred to them for HMRs. Patients were sent a letter about their DBI exposure, and a prompt to visit their GP to discuss their medication management options. GPs, APs and patients were asked to evaluate the feasibility and utility of the DBI report. A medication inventory was collected from patients at the time of the HMR and at 3 months to determine whether the intervention affected deprescribing of medications with anticholinergic and sedative effects. Results: Regarding the feasibility of the DBI report as a risk assessment tool within HMR, 89% of APs and 67% of GPs agreed that it would be feasible. The DBI Calculator© was potentially inaccurate, as 26% of DBI scores were underestimated and 7% were overestimated (at baseline). At 3 months, the median (interquartile range) DBI for patients (n = 100) significantly decreased from 0.82 (0–1.33) to 0.67 (0–1.29) (p = 0.014). Additionally, of patients with a DBI > 0 (n = 66), 36.4% had their DBI score decrease, and 6.1% had a score increase. Conclusion: This study demonstrated that integration of the DBI Calculator© into HMR is a feasible and useful method to prompt deprescribing of anticholinergic and sedative medications in older adults. There is potential for the accuracy of the web-based platform to be improved. Registration of trial: Name: Feasibility study of the Drug Burden Index with Home Medicines Review. Website: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=368523 Trial ID: ACTRN 12615000539538.
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Affiliation(s)
- Lisa Kouladjian O'Donnell
- Departments of Clinical Pharmacology and Aged Care, Level 13 Kolling Building, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065, Australia
| | - Danijela Gnjidic
- School of Pharmacy, Faculty of Medicine and Health and Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Timothy F Chen
- School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Sarah N Hilmer
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital, Sydney, NSW, Australia NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Sydney Medical School University of Sydney, NSW, Australia
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Ziad A, Olekhnovitch R, Ruiz F, Berr C, Bégaud B, Goldberg M, Zins M, Mura T. Anticholinergic drug use and cognitive performances in middle age: findings from the CONSTANCES cohort. J Neurol Neurosurg Psychiatry 2018; 89:1107-1115. [PMID: 30196250 PMCID: PMC6166611 DOI: 10.1136/jnnp-2018-318190] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 06/11/2018] [Accepted: 07/09/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND Previous studies have shown associations between the use of anticholinergics (AC) and cognitive performance in the elderly, considering AC as a homogeneous set of drugs. The present study aims to assess the relationship between exposure to AC drugs and cognitive performance in middle-aged adults according to AC potency and drug class. METHODS Our cross-sectional study used baseline data of 34 267 participants aged 45-70 from the Consultants des centres d'examen de santé de la sécurité sociale (CONSTANCES) cohort. The cumulative exposure to AC was measured using national reimbursement databases over the 3-year period preceding assessment of cognitive performance. Eight classes of AC drugs were differentiated. Episodic verbal memory, language abilities and executive functions were evaluated by validated neuropsychological tests. Analyses were controlled on lifestyle and health status variables. RESULTS This study showed a negative association between overall cumulative AC exposure and cognitive performances after adjustment. The use of drugs with possible AC effect according to the Anticholinergic Cognitive Burden scale (ACB-1 score) was only associated with executive functions. Analyses of AC exposure across drug classes showed a negative association between the use of AC antipsychotics and all cognitive functions assessed. Heterogeneous associations were found for the use of AC anxiolytics, AC opioids and AC drugs targeting the gastrointestinal tract or metabolism. We did not find significant associations between the use of antihistamines, antidepressants, cardiovascular system or other AC medications and cognitive function. CONCLUSION Association between AC drugs and cognitive performance was highly heterogeneous across drug classes; this heterogeneity will have to be considered by future studies.
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Affiliation(s)
- Abdelkrim Ziad
- ClinSearch -110, Malakoff, France.,Population-Based Epidemiological Cohorts Unit, UMS 011 Inserm-UVSQ, Paris, France.,Versailles Saint Quentin en-Yvelines University, Versailles, France.,Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U 1168, Paris, France
| | - Romain Olekhnovitch
- Population-Based Epidemiological Cohorts Unit, UMS 011 Inserm-UVSQ, Paris, France
| | | | - Claudine Berr
- INSERM, U1061, Neuropsychiatry: Epidemiological and Clinical Research, Montpellier, France.,Montpellier University Hospital, Montpellier University, Montpellier, France
| | - Bernard Bégaud
- INSERM, U1219-Pharmacoepidemiology, Université de Bordeaux, Bordeaux, France
| | - Marcel Goldberg
- Population-Based Epidemiological Cohorts Unit, UMS 011 Inserm-UVSQ, Paris, France.,Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U 1168, Paris, France.,Paris Descartes University, Paris, France
| | - Marie Zins
- Population-Based Epidemiological Cohorts Unit, UMS 011 Inserm-UVSQ, Paris, France.,Aging and Chronic Diseases, Epidemiological and Public Health Approaches, U 1168, Paris, France.,Paris Descartes University, Paris, France
| | - Thibault Mura
- INSERM, U1061, Neuropsychiatry: Epidemiological and Clinical Research, Montpellier, France .,Montpellier University Hospital, Montpellier University, Montpellier, France
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Anticholinergic burden: considerations for older adults. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2016. [DOI: 10.1002/jppr.1303] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Gray SL, Hanlon JT. Anticholinergic medication use and dementia: latest evidence and clinical implications. Ther Adv Drug Saf 2016; 7:217-224. [PMID: 27695623 DOI: 10.1177/2042098616658399] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Use of medications with anticholinergic activity is widespread in older adults. Several studies have highlighted that anticholinergic use may be associated with an increased risk of dementia. The objective of this narrative review is to describe and evaluate studies of anticholinergic medication use and dementia and provide practical suggestions for avoiding use of these medications in older adults. A comprehensive review of the literature, citations from recent reviews and the author's personal files was conducted. Four studies were found that evaluated anticholinergic use and dementia as the primary outcome. Three studies focused on overall anticholinergic medication use and reported a statistically significantly increased risk of Alzheimer's disease or dementia. In one study, dementia risk was primarily found with higher cumulative doses; people using anticholinergic medications at the minimum effective dose recommended for older adults for at least 3 years were at highest risk. In contrast, a study conducted in nursing-home residents with depression did not find that paroxetine [a highly anticholinergic selective serotonin reuptake inhibitor antidepressant, (SSRI)] increased risk for dementia compared with other SSRIs (without anticholinergic activity). Further study is needed to understand the mechanism by which anticholinergic medications may increase risk. In conclusion, there is evidence from three observational studies suggesting that anticholinergic medications may increase dementia risk. Given this potential risk and the myriad of other well-known adverse effects (i.e. constipation, blurred vision, urinary retention, and delirium) associated with anticholinergic medications, it is prudent for prescribers and older adults to minimize use of these medications and consider alternatives when possible.
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Affiliation(s)
- Shelly L Gray
- School of Pharmacy, Health Sciences Building, H-361D Box 357630, University of Washington, Seattle, WA 98195-7630, USA
| | - Joseph T Hanlon
- Division of Geriatrics, Department of Medicine, School of Medicine, Department of Pharmacy and Therapeutics, School of Pharmacy, and Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA; Geriatric Research, Education, and Clinical Center and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
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10
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Naples JG, Marcum ZA, Perera S, Gray SL, Newman AB, Simonsick EM, Yaffe K, Shorr RI, Hanlon JT. Concordance Between Anticholinergic Burden Scales. J Am Geriatr Soc 2016; 63:2120-4. [PMID: 26480974 DOI: 10.1111/jgs.13647] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate concordance of five commonly used anticholinergic scales. DESIGN Cross-sectional secondary analysis. SETTING Pittsburgh, Pennsylvania, and Memphis, Tennessee. PARTICIPANTS Community-dwelling adults aged 70 to 79 with baseline medication data from the Health, Aging, and Body Composition Study (N = 3,055). MEASUREMENTS Any anticholinergic use, weighted scores, and total standardized daily dosage were calculated using five anticholinergic measures (Anticholinergic Cognitive Burden (ACB) Scale, Anticholinergic Drug Scale (ADS), Anticholinergic Risk Scale (ARS), Drug Burden Index anticholinergic component (DBI-ACh), and Summated Anticholinergic Medications Scale (SAMS)). Concordance was evaluated using kappa statistics and Spearman rank correlations. RESULTS Any anticholinergic use in rank order was 51% for the ACB, 43% for the ADS, 29% for the DBI-ACh, 23% for the ARS, and 16% for the SAMS. Kappa statistics for all pairwise use comparisons ranged from 0.33 to 0.68. Similarly, concordance as measured using weighted kappa statistics ranged from 0.54 to 0.70 for the three scales not incorporating dosage (ADS, ARS, ACB). Spearman rank correlation between the DBI-ACh and SAMS was 0.50. CONCLUSION Only low to moderate concordance was found between the five anticholinergic scales. Future research is needed to examine how these differences in measurement affect their predictive validity with respect to clinically relevant outcomes, such as cognitive impairment.
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Affiliation(s)
- Jennifer G Naples
- Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Zachary A Marcum
- School of Pharmacy, University of Washington, Seattle, Washington
| | - Subashan Perera
- Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shelly L Gray
- School of Pharmacy, University of Washington, Seattle, Washington
| | - Anne B Newman
- Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eleanor M Simonsick
- Intramural Research Program, National Institute on Aging, Baltimore, Maryland
| | - Kristine Yaffe
- Department of Psychiatry, University of California at San Francisco, San Francisco, California.,Department of Neurology, University of California at San Francisco, San Francisco, California.,Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, California.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Ronald I Shorr
- Geriatric Research, Education and Clinical Center, Malcolm Randall Veterans Affairs Medical Center, Gainesville, Florida
| | - Joseph T Hanlon
- Division of Geriatrics, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
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11
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Elliott RA, Stehlik P. Identifying Inappropriate Prescribing for Older People. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2013.tb00284.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Rohan A Elliott
- Austin Health, Centre for Medication Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences; Monash University
| | - Paulina Stehlik
- Centre for Medication Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences; Monash University; Parkville Victoria
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12
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Felton M, Hanlon JT, Perera S, Thorpe JM, Marcum ZA. Racial differences in anticholinergic use among community-dwelling elders. THE CONSULTANT PHARMACIST : THE JOURNAL OF THE AMERICAN SOCIETY OF CONSULTANT PHARMACISTS 2015; 30:240-5. [PMID: 25893702 PMCID: PMC4405895 DOI: 10.4140/tcp.n.2015.240] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Few studies have examined racial differences in potentially inappropriate medication use. The objective of this study was to examine racial disparities in using prescription and/or nonprescription anticholinergics, a type of potentially inappropriate medication, over time. DESIGN Longitudinal. SETTING Data from the Health, Aging, and Body Composition Study (years 1, 5, and 10). PARTICIPANTS Three thousand fifty-five community-dwelling older adults, both blacks and whites, at year 1. MAIN OUTCOME MEASURE Highly anticholinergic medication use per the 2012 American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. RESULTS Blacks represented 41.4% of the participants at year 1. At year 1, 13.4% of blacks used an anticholinergic medication compared with 17.8% of whites, and this difference persisted over the ensuing 10-year period. Diphenhydramine was the most common anticholinergic medication reported at baseline and year 5, and meclizine at year 10, for both races. Controlling for demographics, health status, and access to care factors, blacks were 24% to 45% less likely to use any anticholinergics compared with whites over the years considered (all P < 0.05). CONCLUSION The use of prescription and/or nonprescription anticholinergic medications was less common in older blacks than whites over a 10-year period, and the difference was unexplained by demographics, health status, and access to care.
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Affiliation(s)
- Maria Felton
- School of Pharmacy at the University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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13
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Block CK, Logue E, Thaler NS, Scarisbrick DM, Mahoney JJ, Scott J, Duff K. The interaction between medical burden and anticholinergic cognitive burden on neuropsychological function in a geriatric primary care sample. Arch Clin Neuropsychol 2014; 30:105-13. [PMID: 25549761 DOI: 10.1093/arclin/acu073] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Poorer neuropsychological function is associated with increased medical burden (MB) and the use of more anticholinergic medications. However, the interaction between MB and anticholinergic cognitive burden (AB) on neuropsychological performance is unknown. In a sample of 290 elderly primary care patients, those with a greater level of AB demonstrated poorer Total Index performance on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Further, an interaction effect was noted such that there was a greater anticholinergic effect on RBANS Total, Attention, and Delayed Memory Index scores for participants with fewer MB. Participants with more MB demonstrated poorer performance irrespective of their level of AB. These results indicate that MB effects may be overshadowed by anticholinergic effects in older patients.
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Affiliation(s)
- Cady K Block
- Department of Psychiatry and Behavioral Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73126-0901, USA
| | - Erin Logue
- Department of Psychiatry and Behavioral Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73126-0901, USA
| | - Nicholas S Thaler
- UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA 90095-1759, USA
| | - David M Scarisbrick
- Department of Psychiatry and Behavioral Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73126-0901, USA
| | - James J Mahoney
- Department of Psychiatry and Behavioral Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73126-0901, USA
| | - James Scott
- Department of Psychiatry and Behavioral Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, OK 73126-0901, USA
| | - Kevin Duff
- The University of Utah, Salt Lake City, UT 84108, USA
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14
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Development and validation of the RASP list (Rationalization of Home Medication by an Adjusted STOPP list in Older Patients): A novel tool in the management of geriatric polypharmacy. Eur Geriatr Med 2014. [DOI: 10.1016/j.eurger.2013.12.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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15
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Greene M, Steinman MA, McNicholl IR, Valcour V. Polypharmacy, drug-drug interactions, and potentially inappropriate medications in older adults with human immunodeficiency virus infection. J Am Geriatr Soc 2014; 62:447-53. [PMID: 24576251 DOI: 10.1111/jgs.12695] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES To describe the frequency of medication-related problems in older adults with human immunodeficiency virus (HIV) infection. DESIGN Retrospective chart review. SETTING Community. PARTICIPANTS HIV-positive individuals aged 60 and older and age- and sex-matched HIV-negative individuals. MEASUREMENTS Total number of medications, potentially inappropriate medications (PIMs) according to the modified Beers Criteria, anticholinergic drug burden according to the Anticholinergic Risk Scale (ARS), and drug-drug interactions using the Lexi-Interact online drug interactions database. RESULTS Of 89 HIV-positive participants, most were Caucasian (91%) and male (94%), with a median age of 64 (range 60-82). Common comorbidities included hyperlipidemia, hypertension, and depression. Participants were taking a median of 13 medications (range 2-38), of which only a median of four were antiretrovirals. At least one PIM was prescribed in 46 participants (52%). Sixty-two (70%) participants had at least one Category D (consider therapy modification) drug-drug interaction, and 10 (11%) had a Category X (avoid combination) interaction. One-third of these interactions were between two nonantiretroviral medications. Fifteen participants (17%) had an ARS score of 3 or greater. In contrast, HIV-negative participants were taking a median of six medications, 29% had at least one PIM, and 4% had an ARS score of 3 or greater (P < .05 for each comparison, except P = .07 for anticholinergic burden). CONCLUSION HIV-positive older adults have a high frequency of medication-related problems, of which a large portion is due to medications used to treat comorbid diseases. These medication issues were substantially higher than HIV-negative participants. Attention to the principles of geriatric prescribing is needed as this population ages in order to minimize complications from multiple medication use.
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Affiliation(s)
- Meredith Greene
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California; San Francisco Veterans Affairs Medical Center, San Francisco, California
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West T, Pruchnicki MC, Porter K, Emptage R. Evaluation of anticholinergic burden of medications in older adults. J Am Pharm Assoc (2003) 2013; 53:496-504. [DOI: 10.1331/japha.2013.12138] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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17
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Prescription patterns of anticholinergic agents and their associated factors in Korean elderly patients with dementia. Int J Clin Pharm 2013; 35:711-8. [PMID: 23708883 DOI: 10.1007/s11096-013-9793-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Accepted: 05/11/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Dementia is a disorder that is characterized by a chronic, progressive loss of cognitive function. Anticholinergic agents that are often used with elderly patients may cause a decline in cognitive capacity; therefore, they must be used with caution. OBJECTIVE We aimed to identify the prescription patterns for anticholinergic drugs in elderly outpatients with a documented diagnosis of dementia through a retrospective analysis of electronic medical records. In addition, the study aimed to identify factors influencing these prescription patterns. SETTING The Kyung Hee University Hospital in Korea. METHODS We studied outpatients aged ≥ 65 years registered with dementia between January 1, 2011 and December 31, 2011. We reviewed prescription histories, identified anticholinergic prescriptions during the study period using the anticholinergic risk scale (ARS), and examined prescription patterns in the subjects. After analysing the ARS scores for each drug and subject, we performed a statistical analysis of the factors affecting prescription patterns for anticholinergic medications in patients with ARS scores of ≥ 2. MAIN OUTCOME MEASURE Prescription data on anticholinergic agents. RESULTS Of 773 elderly dementia patients, 362 patients (46.83 %) were prescribed at least one anticholinergic medication. Of the ARS 2-point anticholinergics, nortriptyline was prescribed most frequently. Among ARS 3-point anticholinergics, cyproheptadine was prescribed most frequently. An ARS score of ≥ 2 was given in 255 (32.98 %) patients. A multivariate logistic regression analysis of the factors associated with anticholinergic prescription patterns revealed that those patients with comorbid Parkinson's disease received significantly fewer prescriptions (OR = 0.544; 95% CI 0.364-0.813) and those patients who were prescribed 6-10 or ≥ 11 medications were significantly more likely to receive anticholinergic prescriptions (OR = 3.410; 95 % CI 2.228-5.220 and OR = 4.688; 95 % CI 2.993-7.344, respectively). CONCLUSION Approximately 33% of the elderly dementia patients in this study were prescribed clinically significant medication regimens totaling an ARS score of ≥ 2. Our findings show that the total number of medications and comorbid Parkinson's disease both influence prescription patterns for anticholinergic medications.
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