Interventions for reducing anticholinergic medication burden in older adults-a systematic review and meta-analysis

INTRODUCTION

Anticholinergic medications block the neurotransmitter acetylcholine in the brain and peripheral nervous system. Many medications have anticholinergic properties, and the cumulative effect of these medications is termed anticholinergic burden. Increased anticholinergic burden can have short-term side effects such as dry mouth, blurred vision and urinary retention as well as long-term effects including dementia, worsening physical function and falls.

METHODS

We carried out a systematic review (SR) with meta-analysis (MA) looking at randomised controlled trials addressing interventions to reduce anticholinergic burden in older adults.

RESULTS

We identified seven papers suitable for inclusion in our SR and MA. Interventions included multi-disciplinary involvement in medication reviews and deprescribing of AC medications. Pooled data revealed no significant difference in outcomes between control and intervention group for falls (OR = 0.76, 95% CI: 0.52-1.11, n = 647), cognition (mean difference = 1.54, 95% CI: -0.04 to 3.13, n = 405), anticholinergic burden (mean difference = 0.04, 95% CI: -0.11 to 0.18, n = 710) or quality of life (mean difference = 0.04, 95% CI: -0.04 to 0.12, n = 461).

DISCUSSION

Overall, there was no significant difference with interventions to reduce anticholinergic burden. As we did not see a significant change in anticholinergic burden scores following interventions, it is likely other outcomes would not change. Short follow-up time and lack of training and support surrounding successful deprescribing may have contributed.

Patients' perception of colonoscopy and acceptance of colonoscopy based IBD related colorectal cancer surveillance

OBJECTIVES

Patients with Inflammatory Bowel Disease (IBD) are at an increased risk of colorectal cancer (CRC). Current surveillance for CRC involves often uncomfortable colonoscopy. To assess IBD patients' perception of colonoscopy and examine preferences for hypothetical alternatives.

METHODS

IBD patients in clinical remission rated acceptable frequency of colonoscopy and hypothetical alternatives to colonoscopy-based surveillance (preference of yearly blood, yearly stool or 5-yearly imaging tests over 5-yearly colonoscopy). Participants rated discomfort of the last colonoscopy was compared with hospital records.

RESULTS

Of 282 patients with recollection of colonoscopy 65.8% rated the discomfort as moderate to severe, which correlated weakly with endoscopists' perception (r = 0.225; p = 0.015). There were no significant differences in patients' or endoscopists' perceptions of discomfort between sedated and unsedated colonoscopies. Undergoing a yearly colonoscopy was acceptable to 49.5%. Experienced discomfort did not correlate with patients' views on acceptable frequency of surveillance colonoscopy. Over 95% of patients would prefer blood, stool, or imaging tests over colonoscopy but nearly half expected sensitivities ≥95%.

CONCLUSION

A large proportion of IBD patients experienced colonoscopy as moderate to severely uncomfortable but would still accept colonoscopy surveillance frequency according to current guidance. Participants expected sensitivities ≥95% for potential alternatives to colonoscopy-based surveillance programs.

EXPERT OPINION

IBD patients frequently experience colonoscopy as uncomfortable but accept colonoscopy as the gold standard for colorectal cancer surveillance. The currently suggested frequencies of surveillance by colonoscopy are acceptable to IBD patients. They do however express a clear preference for non-invasive surveillance techniques. Some promising initial results have been obtained based on faecal or blood sampling. However, these have yet to be tested in large prospective studies to determine their sensitivity and specificity. IBD patients expect these non-invasive tests to meet high standards for sensitivity. In our view it is feasible that analogue to faecal immunochemistry based testing for general population bowel cancer screening non-invasive IBD surveillance techniques will emerge. This could lead to a reduction in the need for colonoscopy to those testing positive on faecal or blood based surveillance.

106 How do Geriatricians View Their Future Old Age?

Introduction

Despite, being a specialty intimately acquainted with growing old, there has been little research on how geriatricians view ageing in the terms it might affect themselves in the future. We wished to survey geriatricians as to how they viewed their own futures as they grew older.

Methods

We constructed a short survey using survey monkey and sent it to all BGS members, electronically. We also tweeted links to the survey from our personal accounts publicly. Only geriatricians were asked to reply. The survey was open between 25th March and 26th June 2019.

Results

143 people responded to the survey49% agreed or strongly agreed that they were looking forward to old age65% agreed or strongly agreed that they were worried about the thought of being frail70% agreed or strongly agreed that they were worried about developing dementia

Despite these responses89% agreed or strongly agreed that old age will be an enjoyable time of life76% agreed or strongly agreed that they promoted a positive image of older age to friends and colleagues85% agreed or strongly agreed that they would be enthusiastic about life in older age74% agreed or strongly agreed that they looked forward to the social life they would have in older age

Themes that arose in the free text responses regarding greatest fears for old age included dependence, physical disability and frailty, dementia, loneliness, bereavement, financial difficulties and the future of society. Respondents hopes for old age included independence and health, enjoying relationships, having more time, and contributing to society.

Conclusions

Despite, or perhaps because of, looking after frail older people as part of their profession, geriatricians have mixed feelings towards growing old themselves. Despite most agreeing that old age will be enjoyable, only half of respondents were looking forward to older age.

Dementia, dependency and loneliness were common fears for geriatricians. Geriatricians’ experience of older age is often in the form of looking after the people who are the frailest of their age group, with the most marked disease burden. Strategies for geriatricians to consider the breadth and variety of old age might come through engagement with the field of medical humanities, reflective practice and spending more time with older people who have less disease burden.

Repair of DNA lesions: mechanisms and relative repair efficiencies

DNA is frequently damaged by endogenous agents inside the cells. Some exogenous agents such as polycyclic aromatic hydrocarbons (PAHs) are ubiquitous in the environment and may thus contribute to the 'background' DNA damage in humans. DNA lesions are normally removed by various repair mechanisms. The major repair mechanisms for various DNA lesions are summarized. In contrast to the extensively studied repair mechanisms, much less is known about the relative repair efficiencies of various DNA lesions. Since DNA repair is a crucial defense against carcinogenesis, it may constitute an important factor affecting the carcinogenicity of DNA damaging agents. We have adopted a human cell-free system for measuring relative DNA repair efficiencies based on the concept of repair competition between acetylaminofluorene adducts and other DNA lesions of interest. Using this in vitro system, we determined the relative repair efficiencies of PAH adducts induced by: anti-(+/-)-benzo[a]pyrene-trans-7,8-dihydrodiol-9,10-epoxide (BPDE), anti-(+/-)-benz[a]anthracene-trans-3,4-dihydrodiol-1,2-epoxide (BADE-I), anti-(+/-)-benz[a]anthracene-trans-8,9-dihydrodiol-10, 11-epoxide (BADE-II), anti-(+/-)-benzo[b]fluoranthene-trans-9, 10-dihydrodiol-11,12-epoxide (BFDE), anti-(+/-)-chrysene-trans-1, 2-dihydrodiol-3,4-epoxide (CDE), and anti-(+/-)-dibenzo[a, l]pyrene-trans-11,12-dihydrodiol-13,14-epoxide (DBPDE). While damage by BPDE, DBPDE, CDE, and BFDE were repaired by nucleotide excision repair as efficiently as AAF adducts, the repair of BADE-I and BADE-II adducts were significantly slower in human cell extracts. Damage by DBPDE at 3 microM in vitro yielded approximately 5-fold higher DNA adducts than BPDE as determined by quantitative PCR. This potent DNA reactivity may account in part for the potent carcinogenicity of dibenzo[a,l]pyrene. The correlation of these results to the carcinogenic properties of the PAH compounds is discussed. Furthermore, we show that NER plays a role in AP site repair in vivo in the eukaryotic model organism yeast.

DNA ligation during excision repair in yeast cell-free extracts is specifically catalyzed by the CDC9 gene product

Excision repair of DNA is an important cellular response to DNA damage induced by radiation and many chemicals. In eukaryotes, base excision repair (BER) and nucleotide excision repair (NER) are two major excision repair pathways which are completed by a DNA ligation step. Using a cell-free system, we have determined the DNA ligase requirement during BER and NER of the yeast S. cerevisiae. Under nonpermissive conditions in extracts of the cdc9-2 temperature-sensitive mutant, DNA ligation in both BER and NER pathways was defective, and the repair patches were enlarged. At the permissive temperature (23 degrees C), DNA ligation during excision repair was only partially functional in the mutant extracts. In contrast, deleting the DNA ligase IV gene did not affect DNA ligation of BER or NER. Defective DNA ligation of BER and NER in cdc9-2 mutant extracts was complemented in vitro by purified yeast Cdc9 protein, but not by DNA ligase IV even when overexpressed. These results demonstrate that the ligation step of excision repair in yeast cell-free extracts is catalyzed specifically by the Cdc9 protein, the homologue of mammalian DNA ligase I.

Repair of DNA lesions induced by polycyclic aromatic hydrocarbons in human cell-free extracts: involvement of two excision repair mechanisms in vitro

Polycyclic aromatic hydrocarbons (PAHs) are significant environmental pollutants representing an important risk factor in human cancers. DNA adducts formed by the ultimate carcinogens of PAHs are potentially toxic, mutagenic and carcinogenic. DNA repair represents an important defense system against these genotoxic insults. Using a human cell-free system we have examined repair of DNA lesions induced by several PAH dihydrodiol epoxides, including anti-(+/-)-benzo[a]pyrene-trans-7,8-dihydrodiol-9,10-epoxide, anti-(+/-)-benz[a]anthracene-trans-3,4-dihydrodiol-1,2-epoxide, anti-(+/-)-benz[a]anthracene-trans-8,9-dihydrodiol-10,11-epoxide, anti-(+/-)-benzo[b]fluoranthene-trans-9,10-dihydrodiol-11,12-epoxide and anti-(+/-)-chrysene-trans-1,2-dihydrodiol-3,4-epoxide. Effective repair of DNA damage induced by these five PAH metabolites was detected. Two distinct mechanisms of excision repair were observed. The major repair mechanism is nucleotide excision repair (NER). The other mechanism is independent of NER and correlated with the presence of apurinic/apyrimidinic sites in the damaged DNA, thus presumably reflecting base excision repair (BER). However, the contribution of BER to different PAH lesions varied in vitro. These results suggest the possibility that BER may also play an important role in repair of certain PAH-induced DNA lesions.