Anticholinergic Burden Score Research Articles

Association of Anticholinergic Drug Use With Risk for Late Age-Related Macular Degeneration

Amyloid-β is a major component of retinal drusen, the primary lesions of age-related macular degeneration (AMD), and autopsy and animal models suggested that anticholinergic drug (ACD) use increased brain amyloid-β deposition. To investigate the association between exposure to ACDs and late AMD (features of neovascular AMD or geographic atrophy of the retinal pigment epithelium in at least 1 eye). A multicenter case-control study in 4 French ophthalmologic centers comprising 200 cases with late AMD and 200 controls enrolled from July 2016 to June 2017. Exposure to at least 3 months of ACDs started before AMD diagnosis was recorded during a specific interview. A dose-effect association with cumulative exposure duration and Anticholinergic Burden Score was explored. The association between ACD exposure and AMD was assessed by multivariate logistic regression analysis adjusted for age, sex, smoking status, family history of AMD, alcohol consumption, and use of anticoagulant and anti-inflammatory drugs. Odds ratios (ORs) and 95% confidence intervals were estimated. Association between exposure to ACDs and late AMD. Among case participants, the mean (SD) age was 74.8 (9.2) years, 129 (64.5%) were women, 192 (96%) were white, 65 (32.5%) had geographic atrophy, 135 (67.5%) had neovascular AMD, 116 (58%) had unilateral AMD, and 84 (42%) had bilateral AMD. Among control participants, the mean (SD) age was 75.5 (7.2) years, with 116 (58%) women and 187 (93.5%) white participants. Twenty-six cases (13%) and 10 controls (5%) were exposed to ACDs throughout life for at least 3 months before AMD onset. Risk of AMD was increased with ever exposure to ACDs (adjusted OR [aOR], 2.84; 95% CI, 1.33-6.06; P = .007), high Anticholinergic Burden Score (≥3) (aOR, 6.42; 95% CI, 1.38-29.92; P = .02), and longest cumulative exposure to ACD (≥15 years) (aOR, 5.88; 95% CI, 1.22-28.31; P = .03). Risk of late AMD may be increased with at least 3 months' use of ACDs. A dose-effect association was suggested by a greater association with prolonged use and high Anticholinergic Burden Score. Further studies, in particular those with longitudinal design, are needed to confirm this association.

Baseline anticholinergic burden from medications predicts incident fatal and non-fatal stroke in the EPIC-Norfolk general population.

Stroke is primarily a disease of older age, with a substantial impact on global mortality and morbidity. Medications with anticholinergic effects are widely used, but no studies have been conducted to examine the relationship between anticholinergic burden (ACB) and stroke in a general population. The sample was drawn from the EPIC-Norfolk cohort. Baseline assessments were carried out during 1993-97 and participants were followed up until March 2016. Participants were divided into four groups according to their total ACB score at baseline; these groups were those with a total ACB score of 0, 1, 2-3 and >3. After exclusion, Cox proportional hazards models were constructed to determine the associations between the ACB score groups and the risk of incident stroke and stroke mortality. Sensitivity analysis and propensity score matched analyses were performed. In total 25639 participants attended the first health check; 3917 participants were excluded, leaving 21722 participants to be included. Participants had a mean age [standard deviation (SD)] of 58.9 (9.2) years (54.4% women). Of these, 2131 suffered incident stroke and 562 died from stroke. Mean follow-up was approximately 18 years for both outcomes. In the fully adjusted model, those with an ACB of >3 had 59% relative risk of incident stroke {hazard ratio [HR] [95% confidence interval (CI) 1.59 [1.34-1.89]} and 86% relative risk of stroke mortality [1.86 (1.37-2.53)] compared with those in ACB 0 category. Sensitivity analyses and propensity score matched analyses showed similar results. Our results provide an incentive for the cautious use of medications with anticholinergic properties, to help reduce the global burden of stroke.

Anticholinergic drug exposure is associated with delirium and postdischarge institutionalization in acutely ill hospitalized older patients.

Several studies investigated the possible association between anticholinergic drugs and diverse clinical outcomes in older persons, but the results are inconsistent. The aim of this study was to investigate whether anticholinergic drug exposure is associated with delirium on admission, length of hospital stay, postdischarge institutionalization and in‐hospital mortality in acutely ill hospitalized older patients. In this observational chart review study, we included acutely ill patients aged 65 and older who were admitted to the geriatric ward of the Erasmus University Medical Center, Rotterdam, The Netherlands, between 2012 and 2015 (n = 905). Anticholinergic drug exposure on admission was defined as the use of anticholinergic drugs, total number of anticholinergic drugs and anticholinergic drug burden score (ADB), quantified with the Anticholinergic Risk Scale (ARS), the Anticholinergic Cognitive Burden scale (ACB) and the list of Chew et al. (Chew). Logistic regression analyses were performed to investigate possible associations between anticholinergic drug exposure and the aforementioned outcomes. Analyses were adjusted for age, sex, comorbidities, non‐anticholinergic drugs and delirium, where appropriate. Moderate and high ADB measured with the ARS were associated with delirium on admission with odds ratios (OR) of 1.70 (95% confidence interval (CI) = 1.16–2.49) and 1.83 (95% CI = 1.06–3.15), respectively. High ADB measured with the ARS was also associated with postdischarge institutionalization (OR = 2.43, 95% CI = 1.24–4.75). No associations were found using the ACB and Chew. Future studies are warranted to investigate the clinical usefulness of the ARS in reducing complications in older persons.

Clinical and Functional Characteristics of Nursing Facility Residents with Opioid-Induced Constipation.

Our goal was to determine the prevalence, clinical characteristics, and treatment differences of opioid-induced constipation (OIC) in older adults with noncancer pain compared with opioid-treated patients without OIC. Retrospective database analysis. United States nursing facilities: Patients, Participants, facility residents. None. Minimum data set and prescription claims, pain, impaired cognition, falls, delirium, and drug treatment. We found an OIC prevalence of 8.9%. Nursing facility residents with OIC are more likely to have severe pain (31.3% vs. 29%; P < 0.001), pain in the last 5 days (71.2% vs. 69.2%; P < 0.001), almost constant pain (18.1% vs.13.3%; P < 0.001), and pain interfering with daily activities (36.1% vs. 30%; P < 0.001). Strong opioids were more likely prescribed and the duration of use was longer than in non-OIC nursing facility residents. Cognitive impairment (56.3% vs. 49.8%; P < 0.001), fall rate (4.8% vs. 2.5%; P = 0.023), delirium indicators (confusion assessment method; P < 0.001), urinary incontinence (59.1% vs. 54.9%; P < 0.001), depression (66.5% vs. 61.6%; P < 0.001), and depression severity score (4.7% vs. 4.3%; P < 0.001) were higher in nursing facility residents with OIC. Nursing facility residents with OIC had a higher percentage of concomitantly prescribed anticholinergic medications (76.7% vs. 70.0%; P < 0.001) and a higher mean anticholinergic burden score (1.4% vs. 1.1%; P < 0.001). Over-the-counter laxatives were used more often than prescription laxatives: polyethylene glycol (43%), docusate (31.1%), and senna/sennosides (23%) vs. lactulose (18.1%) and lubiprostone (2.2%). Nursing facility residents with OIC experience suboptimal pain relief, additional anticholinergic adverse drug-related effects, and a decreased quality of life.

Cognitive burden of anticholinergic medications in psychotic disorders

BackgroundPatients with psychotic disorders are often treated with numerous medications, many of which have anticholinergic activity. We assessed cognition in relation to the cumulative anticholinergic burden of multiple drugs included in treatment regimens of participants from the Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP) study. MethodClinically stable participants with schizophrenia (n=206), schizoaffective disorder (n=131), and psychotic bipolar disorder (n=146) were examined. Anticholinergic properties of all scheduled drugs were quantified using the Anticholinergic Drug Scale (ADS). ADS scores were summed across individual drugs to create a total ADS burden score for each participant and examined in relation to the Brief Assessment of Cognition in Schizophrenia (BACS). ResultsAnticholinergic burden aggregated across all medications was inversely related to cognitive performance starting at ADS scores of 4 in participants with schizophrenia. Those with ADS scores ≥4 had lower composite BACS scores compared to those with ADS<4 (p=0.004). Among BACS subtests, Verbal Memory was the most adversely affected by high anticholinergic burden. Despite similar anticholinergic burden scores across groups, a significant threshold effect of anticholinergic burden was not detected in schizoaffective or psychotic bipolar disorder. ConclusionWe identified an adverse effect threshold of anticholinergic burden on cognition in clinically stable participants with schizophrenia. This relationship was not identified in affective psychoses. Examination of other medications, doses, and clinical measures did not account for these findings. Patients with schizophrenia may have increased cognitive susceptibility to anticholinergic medications and the aggregate effects of one's medication regimen may be important to consider in clinical practice.

Anticholinergic burden in inpatient psychogeriatric population – Do we care?

BackgroundAlthough recent studies have found that there is significant association between anticholinergic and cognitive impairment, especially in the elderly population, there seems to be minimal emphasis on anticholinergic burden (ACB) when prescribing medications to the inpatient psychogeriatric population.AimTo evaluate the prescribing patterns in Older Person Mental Health Inpatient Unit (OPMHU), whether the ACB Score on admission has been reviewed for lowest possible ACB while maintaining therapeutic effects. A protocol will be developed to ensure that ACB is reviewed for future admissions and discharges.MethodologyFifty patients admitted and discharged from OPMHU are recruited retrospectively from 30th September 2015, excluding outliers and deceased patients. For those who had multiple admissions during that period, only the most recent admission would be included for evaluation. Individual ACB score is calculated on admission and discharge based on pharmacist final medication summary. Their mental health records are also audited for any documented ACB review by the treating team, while making note for any pre-existing cognitive impairment.ResultACB has not been taken into consideration in all patients by the treating team on admission as well as when prescribing medications on discharge. Hence, it is unsurprising that the ACB score showed an increment of 30% on discharge (3.25) when compared to the admission score (2.5).ConclusionThe study found that although ACB poses significant risks on cognitive impairment, this knowledge has not been employed pragmatically. A protocol should be developed to ensure that ACB is evaluated and managed accordingly.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Impact of residential medication management reviews on anticholinergic burden in aged care residents

Objectives:The primary objective of this study was to investigate the impact of Residential Medication Management Reviews (RMMRs) on anticholinergic burden quantified by seven anticholinergic risk scales.Design:Retrospective analysis.Setting:Accredited pharmacists conducted RMMRs in aged-care facilities (ACFs) in Sydney, Australia.Participants:RMMRs pertained to 814 residents aged 65 years or older.Measurements:Anticholinergic burden was quantified using seven scales at baseline, after pharmacists’ recommendations and after the actual GP uptake of pharmacists’ recommendations. Change in the anticholinergic burden was measured using the Wilcoxon sign rank test.Results:At baseline, depending on the scale used to estimate the anticholinergic burden, between 36% and 67% of patients were prescribed at least one regular anticholinergic medication (ACM). Anticholinergic burden scores were significantly (p < 0.001) lower after pharmacists’ recommendations as determined by each of the seven scales. The reduction in anticholinergic burden was also significant (p < 0.001) after GPs’ acceptance of the pharmacists’ recommendations according to all scales with the exception of one scale which reached borderline significance (p = 0.052).Conclusion:Despite the limitations of the retrospective design and differences in the estimation of anticholinergic burden, this is the first study to demonstrate that RMMRs are effective in reducing ACM prescribing in ACF residents, using a range of measures of anticholinergic burden. Future studies should focus on whether a decrease in anticholinergic burden will translate into improvement in clinical outcomes.

Does anticholinergics drug burden relate to global neuro-disability outcome measures and length of hospital stay?

Primary objective: To assess the relationship between disability, length of stay (LOS) and anticholinergic burden (ACB) with people following acquired brain or spinal cord injury.Research design: A retrospective case note review assessed total rehabilitation unit admission.Methods and procedures: Assessment of 52 consecutive patients with acquired brain/spinal injury and neuropathy in an in-patient neuro-rehabilitation unit of a UK university hospital. Data analysed included: Northwick Park Dependency Score (NPDS), Rehabilitation complexity Scale (RCS), Functional Independence Measure and Functional Assessment Measure FIM-FAM (UK version 2.2), LOS and ACB. Outcome was different in RCS, NPDS and FIM-FAM between admission and discharge.Main outcomes and results: A positive change was reported in ACB results in a positive change in NPDS, with no significant effect on FIM-FAM, either Motor or Cognitive, or on the RCS. Change in ACB correlated to the length of hospital stay (regression correlation = −6.64; SE = 3.89). There was a significant harmful impact of increase in ACB score during hospital stay, from low to high ACB on NPDS (OR = 9.65; 95% CI = 1.36–68.64) and FIM-FAM Total scores (OR = 0.03; 95% CI = 0.002–0.35).Conclusions: There was a statistically significant correlation of ACB and neuro-disability measures and LOS amongst this patient cohort.

Treating the neuropsychiatric symptoms of dementia: A case based approach

INTRODUCTION It is estimated that about 90% of older adults with dementia experience neuropsychiatric symptoms. These symptoms include but are not limited to agitation, aggression, delusions, and hallucinations. Neuropsychiatric symptoms are often treated with antipsychotics. However, the use of antipsychotics in the dementia population is associated with an increased risk of death, mostly due to cerebrovascular events. All antipsychotic medications (both first generation and second generation) have a Black Box Warning for increased mortality in elderly patients with dementiarelated psychosis.

Anticholinergic Burden Assessed Using General Practice Electronic Records

ABSTRACTAimTo determine the anticholinergic burden (ACB) of an Australian primary care population.MethodA cross‐sectional study was undertaken of medication data from 11 general practices. Participants were active patients aged 65 years and over seen at least 3 times in the last 2 years (n = 4853). The ACB score was calculated based on a UK peer‐reviewed scoring system (Fox) and a modified scale (Fox‐plus) that included medications not present in the Fox scale. The main outcome measure was total ACB from prescribed medications.ResultsA Fox ACB score ≥ 4 is associated with increased risk of morbidity and mortality, 249 (9%) females, 130 (6%) males and 379 (8%) overall fell in this category. Applying the Fox‐plus ACB scale, 983 (36%) females, 630 (30%) males and 1613 (33%) overall fell in this category.ConclusionA large proportion of the elderly population may have cognitive impairment because of their therapy. Alternative medications or strategies are needed to maintain therapeutic benefits with a low ACB.

Health service utilization, use of psychotropic agents and anticholinergic burden of older people with dementia in Taiwan: A nationwide 10-year cohort study

Introduction.–Taiwan is aging fast and the escalationof elderly population will result in various health care challenges to the health care system. Among all health care challenges, dementia is of particular impact to the health care system and little was known regarding to the impact of dementia on health care utilization. Methods.– A population-based random sample of 33,864 subjects aged65orolderwasobtainedasadynamiccohort. Those studysubjects who had filed at least one service claim from 2000 to 2009 for either outpatient care or inpatient carewith a principal diagnosis of dementia were identified and determine the incidence of dementia. A total of 11,915 patients with dementia and 11,915 matched controls by propensity score were identified to investigate health utilization, use of psychotropics and anticholinergic burden. Results.– The annual incidence rates of dementia increased from 0.1% to 0.19% per year from 2000 to 2009. In our matching cohort, counts of hospitalization, outpatients’ visits, length of stay (LOS) were significantly higher in dementia patients (P<0.0001). Number of psychotropic drugs and defined daily dose (DDD) including antipsychogropics, hyponotics, antidepressants and anticholinergic burden score were significantly higher in dementia group compared to control group (P<0.0001). The prescription and DDD of psychotropic drugs and anticholingergic burden were higher in dementia patients with receiving acute care compared those without receiving acute care (P<0.0001). Conclusion.– The annual incidence of dementia progressively increased from 2000–2009. Health utilization such as the counts of hospitalization, outpatient visits, LOS, theuseof psychotropicdrugs and anticholingergic burden were higher in dementia patients.

The impact of anticholinergic burden in Alzheimer's Dementia-the Laser-AD study

to examine the effect of medications with anticholinergic effects on cognitive impairment and deterioration in Alzheimer's dementia (AD). cognitive function was measured at baseline and at 6- and 18-month follow-up using the Mini-Mental State Exam (MMSE), the Severe Impairment Battery (SIB) and the Alzheimer's Disease Assessment Battery, Cognitive subsection (ADAS-COG) in a cohort study of 224 participants with AD. Baseline anticholinergic Burden score (ABS) was measured using the Anticholinergic Burden scale and included all prescribed and over the counter medication. the sample was 224 patients with Alzheimer's dementia and 71.4% were women. Their mean age was 81.0 years [SD 7.4 (range 55-98)]. The mean number of medications taken was 3.6 (SD 2.4) and the mean anticholinergic load was 1.1 (SD 1.4, range 0-7). The total number of drugs taken and anticholinergic load correlated (rho = 0.44; P < 0.01). There were no differences in MMSE and other cognitive functioning at either 6 or 18 months after adjusting for baseline cognitive function, age, gender and use of cholinesterase inhibitors between those with, and those without high anticholinergenic load. medications with anticholinergic effect in patients with AD were not found to effect deterioration in cognition over the subsequent 18 months. Our study did not support a continuing effect of these medications on people with AD who are established on them.

Prescribing Practices of Anticholinergic Medications and Their Association With Cognition in an Extended Care Setting

The current study examined prescribing patterns of anticholinergic (AC) medications and their association with cognitive function in 450 nondemented and nondelirious older adults hospitalized in a postacute extended care center. Participants completed a brief neuropsychological battery that included measures of general mental status, memory, judgment, and executive functioning as part of standard clinical care. An AC burden score was calculated for each participant based on medications taken the day of the testing using the Anticholinergic Drug Scale. Although use of AC medications was common, the majority of participants were taking medications with only minimal AC properties. AC burden and total number of AC medications were negatively correlated with age. AC burden was not associated with lower performance on any of the cognitive measures. In sum, current prescribing practices of AC medications are not associated with negative cognitive effects in a sample of older adults hospitalized in an extended care center.

Anticholinergic burden and the risk of falls among elderly psychiatric inpatients: a 4-year case-control study.

Falls are an everyday risk for the elderly and their etiology is multifactorial. Because there are little data focusing on falls among elderly psychiatric inpatients, we aimed to retrospectively assess the characteristics of inpatients that had sustained a fall during hospitalization. Over 4 years, all adverse-event reports of falls were reviewed. Inclusion criteria were age >65 years and intact cognition. The control group consisted of the previous and next admission of an elderly patient to the same ward. Anticholinergic score was calculated for each patient. Of 414 admissions of elderly patients, 34 (8.2%) patients had had a fall. The control group (n = 68) did not differ in mean age, distribution of diagnoses, or use of benzodiazepines, antidepressants, or antipsychotics. Two variables were significantly associated with falls: female gender (68% vs. 39%, p < .05) and anticholinergic burden score (ABS) (mean: 3.7 vs. 2.1, p < .05). Our results support reported findings of higher rates of falls among elderly women and suggest that ABS may be a risk factor for falls.