Anticholinergic Burden Research Articles

Disentangling drug contributions: anticholinergic burden in older adults linked to individual medications: a cross-sectional population-based study

BackgroundMedications with potent anticholinergic properties have well-documented adverse effects. A high cumulative anticholinergic burden may arise from the concurrent use of multiple medications with weaker anticholinergic effects. We sought to identify patterns of high anticholinergic burden and associated patient characteristics.MethodsWe identified patients aged ≥ 65 who filled ≥ 1 medication with anticholinergic adverse effects in 2019 and had a cumulative Anticholinergic Burden score (ACB) ≥ 4 (i.e., high anticholinergic burden) in a large US health insurer. We classified patients based on how they attained high burden, as follows: 1) only filling strong or moderate anticholinergic medications (i.e., ACB = 2 or 3, “moderate/strong”), 2) only filling lightly anticholinergic medications (i.e., ACB = 1, “light/possible”), and 3) filling any combination (“mix”). We used multinomial logistic regression to assess the association between measured patient characteristics and membership in the three anticholinergic burden classifications, using the moderate/strong group as the referent.ResultsIn total, 83,286 eligible patients with high anticholinergic burden were identified (mean age: 74.3 years (SD:7.1), 72.9% female). Of these, 4.5% filled only strong/moderate anticholinergics, 4.3% filled only light/possible anticholinergics, and the rest filled a mix (91.2%). Within patients in the mixed group, 64.3% of medication fills were for light/possible anticholinergics, while 35.7% were for moderate/strong anticholinergics. Compared with patients in the moderate/strong anticholinergics group, patients filling only light/possible anticholinergics were more likely to be older (adjusted Odds Ratio [aOR] per 1-unit of age: 1.06, 95%CI: 1.05–1.07), less likely to be female (aOR: 0.56, 95%CI: 0.50–0.62 vs. male), more likely to have comorbidities (e.g., heart failure aOR: 3.18, 95%CI: 2.70–3.74 or depression aOR: 1.20, 95%CI: 1.09–1.33 vs. no comorbidity), and visited fewer physicians (aOR per 1-unit of change: 0.98, 95%CI: 0.97–0.98). Patients in the mixed group were older (aOR per 1-unit of age: 1.02, 95%CI: 1.02–1.03) and less likely to be female (aOR: 0.89, 95%CI: 0.82–0.97 vs. male) compared with those filling moderate/strong anticholinergics.ConclusionMost older adults accumulated high anticholinergic burden through a combination of light/possible and moderate/strong anticholinergics rather than moderate/strong anticholinergics, with light/possible anticholinergics being the major drivers of overall anticholinergic burden. These insights may inform interventions to improve prescribing in older adults.

The impact of anticholinergic burden on clinical outcomes in older hospitalised surgical patients.

Polypharmacotherapy is an ever-increasing issue with an ageing patient population. Anticholinergic medications make up a large proportion of patient medication but cause significant side effects, contributing to well-documented issues within the older population and in hospital medicine. This review explores the documented impact of anticholinergic burden in older surgical patients on postoperative delirium, infection, length of stay and readmission, urinary retention, ileus and mortality. It also highlights the need for further high-quality research into anticholinergic burden management among older surgical patients to further impact practice and policy in the area.

Anticholinergic burden among in-patients: a cross-sectional study on prevalence, determinants, and impact on mortality in Ethiopia.

Numerous studies report that anticholinergic burden (ACB) has been linked with several health consequences, including increased hospital admissions, prolonged hospitalization, and physical and cognitive impairment. However, low- and middle-income settings, as well as younger individuals, are underrepresented. To assess the prevalence and determinants of ACB, and to assess the impact of ACB on in-hospital mortality among adult in-patients at University of Gondar Comprehensive Specialized Hospital (UOGCSH). A cross-sectional study was conducted from June to August 2022 at UOGCSH among adult in-patients. A pre-tested questionnaire was utilized to collect data from patients and their corresponding medical charts. A consecutive sampling technique was used to select the participants. Descriptive statistics were used to summarize socio-demographic and clinical characteristics. Chi-squared, Fisher's exact, and Wilcoxon rank sum tests, as appropriate, were used to determine associations between independent variables and ACB. Kaplan-Meier survival curve and Cox proportional hazards regression test were used to assess the impact of ACB on in-hospital mortality. A total of 420 adult in-patients, median (interquartile range) age of 38 (26, 55) years, participated in this study. Over half (58.3%) were exposed to anticholinergic medicines, with a high ACB (⩾3) seen in 11.2% of participants. High ACB was associated with higher median number of medicines per patient (p = 0.003) higher median hospital length of stay (p = 0.033), and having mental and behavioral disorders (p < 0.001). No significant association was found between ACB and in-hospital mortality (log-rank test p = 0.26, Cox regression adjusted hazard ratio: 1.47, 95% CI: 0.335-6.453, p = 0.61). Among adult in-patients, a significant majority (58.3%) were subjected to medications possessing anticholinergic properties, with a noteworthy 11.2% of the study subjects exhibiting a high ACB. Participants with higher median length of hospital stay were more likely to have high ACB even in this relatively younger adult patient population.

Features of Polypharmacy in Dutch Older Outpatients with Personality Disorders: A Cross-sectional Study

Introduction: Pharmacotherapy in older adults with personality disorders (PDs) can be even more complicated compared to younger adults, because older adults stand at risk for polypharmacy and its negative consequences due to somatic comorbidities and biological age-related changes. Aims: This study’s primary objective serves to describe the point prevalence of polypharmacy in older adults with PDs. Next, we described 1) the number of psychotropics employed, 2) classes of psychotropics, 3) the number of somatic medication, and 4) the anticholinergic burden of the total medication. Methods: This cross sectional study was performed at a clinical center of excellence for older adults with PDs in the Netherlands. Fifty outpatients aged 65 years and older with a primary diagnosis of a PD were selected from an alphabetically ordered list. Data from the files on polypharmacy (use of five medications or more daily), use of medication and the anticholinergic burden (ARS score) was collected. Results: Polypharmacy was present in 72% of older adults with PDs. The mean number of psychotropics was 2.0 (SD 1.4) psychotropics per person, for somatic medication the mean was 6.2 (SD 3.6). Antidepressants were the most frequently prescribed (used by 62%), followed by anxiolytics (used by 40%). The mean ARS score was 1.1 points (SD 1.7). Conclusions: The prevalence of polypharmacy in older adults with PDs stands high, due to the high use of both psychotropics and somatic medication. Although this study provides important and new information on the use of medication in older adults, its representation of the population may be limited due to the tertiary care setting and small sample size excluding certain PDs (e.g., schizoid or obsessive-compulsive PD). Also, we did not register or measure the consequences of polypharmacy.

Drug-induced cognitive impairment and dementia

One of the reasons for the development or worsening of cognitive impairment (CI) may be the use of a number of drugs: non-steroidal anti-inflammatory drugs, antiarrhythmics, antidepressants, glucocorticosteroids, antitumor drugs and a number of others. The negative effect of drugs on cognitive functions is realized due to many pathophysiological mechanisms: disruption of hormonal regulation, decreased neuronal excitability, increased activity of gamma-aminobutyric acid receptors, decreased cerebral circulation, atrophic changes in the brain; many mechanisms have not been fully established. Risk factors for the development of drug-induced CIs are: old age or childhood, brain damage, chronic diseases, genetic factors, the patient's initial CI, polypharmacy, dose and duration of drug use, acute infectious diseases, metabolic disorders, dehydration, acute urinary retention, etc. To diagnose and differentially diagnose drug-induced CI, it is necessary to establish a connection between the start of taking a suspected drug-inducer and a decrease in cognitive functions. The first step in the treatment of drug-induced CI is the abolition of an inducer drug or a reduction in its dose, in cases where it is impossible to discontinue the drug and there is no replacement, special slow-release dosage forms can be considered. The main measures to prevent drug-induced CI include the use of drugs with the lowest risk of their development, assessment of drug interactions, and the use of modern scales to assess the risk of developing this side-effect (anticholinergic burden scale, etc.).

Medications and cognitive risk in Aboriginal primary care: a cross-sectional study.

Aboriginal and Torres Strait Islander people are ageing with high rates of comorbidity, yet little is known about suboptimal prescribing in this population. The prevalence of potentially suboptimal prescribing and associated risk factors were investigated among older patients attending primary care through Aboriginal Community Controlled Health Services (ACCHSs). Medical records of 420 systematically selected patients aged ≥50 years attending urban, rural and remote health services were audited. Polypharmacy (≥ 5 prescribed medications), potentially inappropriate medications (PIMs) as per Beers Criteria and anticholinergic burden (ACB) were estimated and associated risk factors were explored with logistic regression. The prevalence of polypharmacy, PIMs and ACB score ≥3 was 43%, 18% and 12% respectively. In multivariable logistic regression analyses, polypharmacy was less likely in rural (odds ratio (OR) = 0.43, 95% confidence interval (CI) = 0.24-0.77) compared to urban patients, and more likely in those with heart disease (OR = 2.62, 95% CI = 1.62-4.25), atrial fibrillation (OR = 4.25, 95% CI = 1.08-16.81), hypertension (OR = 2.14, 95% CI = 1.34-3.44), diabetes (OR = 2.72, 95% CI = 1.69-4.39) or depression (OR = 1.91, 95% CI = 1.19-3.06). PIMs were more frequent in females (OR = 1.88, 95% CI = 1.03-3.42) and less frequent in rural (OR = 0.41, 95% CI = 0.19-0.85) and remote (OR = 0.58, 95% CI = 0.29-1.18) patients. Factors associated with PIMs were kidney disease (OR = 2.60, 95% CI = 1.37-4.92), urinary incontinence (OR = 3.00, 95% CI = 1.02-8.83), depression (OR = 2.67, 95% CI = 1.50-4.77), heavy alcohol use (OR = 2.83, 95% CI = 1.39-5.75) and subjective cognitive concerns (OR = 2.69, 95% CI = 1.31-5.52). High ACB was less common in rural (OR = 0.10, 95% CI = 0.03-0.34) and remote (OR = 0.51, 95% CI = 0.25-1.04) patients and more common in those with kidney disease (OR = 3.07, 95% CI = 1.50-6.30) or depression (OR = 3.32, 95% CI = 1.70-6.47). Associations between potentially suboptimal prescribing and depression or cognitive concerns highlight the importance of considering medication review and deprescribing for these patients.

Mapping potentially inappropriate medications in older adults using the Anatomical Therapeutic Chemical (ATC) classification system.

Potentially inappropriate medications (PIMs) in older adults are medications in which risks often outweigh benefits and are suggested to be avoided. Worldwide, many distinct guidelines and tools classify PIMs in older adults. Collating these guidelines and tools, mapping them to a medication classification system, and creating a crosswalk will enhance the utility of PIM guidance for research and clinical practice. We used the Anatomical Therapeutic Chemical (ATC) Classification System, a hierarchical classification system, to map PIMs from eight distinct guidelines and tools (2019 Beers Criteria, Screening Tool for Older Person's Appropriate Prescriptions [STOPP], STOPP-Japan, German PRISCUS, European Union-7 Potentially Inappropriate Medication [PIM] list, Centers for Medicare & Medicaid Services [CMS] High-Risk Medication, Anticholinergic Burden Scale, and Drug Burden Index). Each PIM was mapped to ATC Level 5 (drug) and to ATC Level 4 (drug class). We then used the crosswalk (1) to compare PIMs and PIM drug classes across guidelines and tools to determine the number of PIMs that were index (drug-induced adverse event) or marker (treatment of drug-induced adverse event) drug of prescribing cascades, and (2) estimate the prevalence of PIM use in older adults continuously enrolled with fee-for-service Medicare in 2018 as use cases. Data visualization and descriptive statistics were used to assess guidelines and tools for both use cases. Out of 480 unique PIMs identified, only three medications-amitriptyline, clomipramine, and imipramine and two drug classes-N06AA (tricyclic antidepressants) and N06AB (selective serotonin reuptake inhibitors), were noted in all eight guidelines and tools. Using the crosswalk, 50% of classes of index drugs and 47% of classes of marker drugs of known prescribing cascades were PIMs. Additionally, 88% of Medicare beneficiaries were dispensed ≥1 PIM across the eight guidelines and tools. We created a crosswalk of eight PIM guidelines and tools to the ATC classification system and created two use cases. Our findings could be used to expand the ease of PIM identification and harmonization for research and clinical practice purposes.

Increased anticholinergic medication use in middle-aged and older autistic adults and its associations with self-reported memory difficulties and cognitive decline.

Many commonly used prescription and over-the-counter medicines have potent anticholinergic (AC) effects. Among older adults, AC medications are associated with cognitive impairment and risk for cognitive disorders, including Alzheimer's disease. Collectively, the impact of AC medications is known as anticholinergic cognitive burden (ACB). Because of the high rates of co-occurring medical and psychiatric conditions, autistic adults may have high AC exposure and, thus, may experience elevated ACB. However, no research has characterized AC exposure or examined its associations with cognitive outcomes in autistic adults. Autistic adults (40-83 years) recruited via Simons Powering Autism Research's (SPARK) Research Match service self-reported their medication use (N = 415) and memory complaints (N = 382) at Time (T)1. At T2, 2 years later, a subset of T1 participants (N = 197) self-reported on decline in cognition. Medications were coded using two scales of AC potency. A high proportion (48.2%-62.9%, depending upon the AC potency scale) of autistic adults reported taking at least one medication with AC effects, and 20.5% to 26.5% of autistic adults reported clinically-relevant levels of AC medication (potency ≥3). After controlling for birth-sex, and age, hierarchical linear regression models showed total ACB scores and AC potency values of ≥3 predicted greater memory complaints. Logistic regression models showed that AC medicines at T1 were associated with self-reported cognitive decline at follow-up 2 years later. Understanding AC medications-including potentially earlier AC polypharmacy-and their impacts on cognition (e.g., dementia risk) in autistic adults is warranted.

Clinical pharmacist-led assessment and management of anticholinergic burden and fall risk in geriatric patients

BackgroundThe aim of this study was to examine the risk of fall with the surrogate outcome of the Aachen Falls Prevention Scale and to assess the clinical pharmacist interventions in order to minimize anticholinergic drug burden and associated risk of fall according to a fall risk assessment scale in the older adults.MethodsPatients who admitted to the geriatric outpatient clinic of a university hospital and taking at least one anticholinergic drug were evaluated both retrospectively and prospectively as groups of different patients by the clinical pharmacist. Patients’ anticholinergic burden was assessed using the Anticholinergic Cognitive Burden Scale. For fall risk assessment, the Aachen Falls Prevention Scale was also administered to each patient whose anticholinergic burden was determined in the prospective phase of the study.ResultsA total of 601 patients were included. Risk of falls increased 2.50 times in patients with high anticholinergic burden (OR (95% CI) = 2.503 (1.071–5.852); p = 0.034), and the existing history of falls increased the risk of high anticholinergic burden 2.02 times (OR (95%CI) = 2.026 (1.059–3.876); p = 0.033). In addition, each unit increase in the fall scale score in the prospective phase increased the risk of high anticholinergic burden by 22% (p = 0.028). Anticholinergic burden was significantly reduced as a result of interventions by the clinical pharmacist in the prospective phase (p = 0.010).ConclusionOur study revealed that incorporating a clinical pharmacist in the handling of geriatric patients aids in the detection, reduction, and prevention of anticholinergic adverse effects.

Changes in Anticholinergic Burden in Parkinson’s Disease After Deep Brain Stimulation

ObjectiveThis study aimed to evaluate the effect of deep brain stimulation (DBS) on anticholinergic burden in Parkinson’s disease (PD) and the association of anticholinergic burden with cognition. Materials and MethodsA retrospective chart review in patients with PD who underwent bilateral subthalamic nucleus (STN) or globus pallidus internus (GPi) DBS from 2010 to 2020 reviewed medications with anticholinergic burden at baseline, six months, and one year (N = 216) after surgery. The cumulative anticholinergic burden at each visit was calculated using the Anticholinergic Risk Scale (ARS). ResultsARS scores were significantly lower for patients six months and one year after surgery than at baseline (z = 6.58, p < 0.0001; z = 6.99, p < 0.0001). Change in ARS scores at both six months and one year were driven by down-titration of PD medications (z = 9.35, p < 0.0001; z = 8.61, p < 0.0001), rather than changes in pain, psychiatric, or urinary medications with anticholinergic effects. There was no significant difference in change in ARS scores at one year between targets (t = 0.41, p = 0.68). In addition, there was no significant association between anticholinergic burden and cognitive performance. ConclusionGPi and STN DBS are associated with decreased anticholinergic burden due to PD medications in the first year after surgery.

Anticholinergic deprescribing interventions for reducing risk of cognitive decline or dementia in older adults with and without prior cognitive impairment.

Anticholinergics are medications that block the action of acetylcholine in the central or peripheral nervous system. Medications with anticholinergic properties are commonly prescribed to older adults. The cumulative anticholinergic effect of all the medications a person takes is referred to as the anticholinergic burden. A high anticholinergic burden may cause cognitive impairment in people who are otherwise cognitively healthy, or cause further cognitive decline in people with pre-existing cognitive problems. Reducing anticholinergic burden through deprescribing interventions may help to prevent onset of cognitive impairment or slow the rate of cognitive decline. Primary objective • To assess the efficacy and safety of anticholinergic medication reduction interventions for improving cognitive outcomes in cognitively healthy older adults and older adults with pre-existing cognitive issues. Secondary Objectives • To compare the effectiveness of different types of reduction interventions (e.g. pharmacist-led versus general practitioner-led, educational versus audit and feedback) for reducing overall anticholinergic burden. • To establish optimal duration of anticholinergic reduction interventions, sustainability, and lessons learnt for upscaling • To compare results according to differing anticholinergic scales used in medication reduction intervention trials • To assess the efficacy of anticholinergic medication reduction interventions for improving other clinical outcomes, including mortality, quality of life, clinical global impression, physical function, institutionalisation, falls, cardiovascular diseases, and neurobehavioral outcomes. We searched CENTRAL on 22 December 2022, and we searched MEDLINE, Embase, and three other databases from inception to 1 November 2022. We included randomised controlled trials (RCTs) of interventions that aimed to reduce anticholinergic burden in older people and that investigated cognitive outcomes. Two review authors independently assessed studies for inclusion, extracted data, and assessed the risk of bias of included studies. The data were not suitable for meta-analysis, so we summarised them narratively. We used GRADE methods to rate our confidence in the review results. We included three trials with a total of 299 participants. All three trials were conducted in a cognitively mixed population (some cognitively healthy participants, some participants with dementia). Outcomes were assessed after one to three months. One trial reported significantly improved performance on the Digit Symbol Substitution Test (DSST) in the intervention group (treatment difference 0.70, 95% confidence interval (CI) 0.11 to 1.30), although there was no difference between the groups in the proportion of participants with reduced anticholinergic burden. Two trials successfully reduced anticholinergic burden in the intervention group. Of these, one reported no significant difference between the intervention versus control in terms of their effect on cognitive performance measured by the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) immediate recall (mean between-group difference 0.54, 95% CI -0.91 to 2.05), CERAD delayed recall (mean between-group difference -0.23, 95% CI-0.85 to 0.38), CERAD recognition (mean between-group difference 0.77, 95% CI -0.39 to 1.94), and Mini-Mental State Examination (mean between-group difference 0.39, 95% CI -0.96 to 1.75). The other trial reported a significant correlation between anticholinergic burden and a test of working memory after the intervention (which suggested reducing the burden improved performance), but reported no effect on multiple other cognitive measures. In GRADE terms, the results were of very low certainty. There were no reported between-group differences for any other clinical outcome we investigated. It was not possible to investigate differences according to type of reduction intervention or type of anticholinergic scale, to measure the sustainability of interventions, or to establish lessons learnt for upscaling. No trials investigated safety outcomes. There is insufficient evidence to reach any conclusions on the effects of anticholinergic burden reduction interventions on cognitive outcomes in older adults with or without prior cognitive impairment. The evidence from RCTs was of very low certainty so cannot support or refute the hypothesis that actively reducing or stopping prescription of medications with anticholinergic properties can improve cognitive outcomes in older people. There is no evidence from RCTs that anticholinergic burden reduction interventions improve other clinical outcomes such as mortality, quality of life, clinical global impression, physical function, institutionalisation, falls, cardiovascular diseases, or neurobehavioral outcomes. Larger RCTs investigating long-term outcomes are needed. Future RCTs should also investigate potential benefits of anticholinergic reduction interventions in cognitively healthy populations and cognitively impaired populations separately.

The association between anticholinergic/sedative burden and physical frailty in people aging with HIV.

This study aimed to estimate the strength of the association between anticholinergic/sedative burden and concurrent physical frailty in people aging with HIV. This cross-sectional analysis examined baseline data from 824 adults with a mean age of 53 enrolled in the Positive Brain Health Now study. Anticholinergic medications were identified using four methods: Anticholinergic Cognitive Burden (ACB) Scale, Anticholinergic Risk Scale (ARS), Anticholinergic Drug Scale (ADS), and the anticholinergic list of the Anticholinergic and Sedative Burden Catalog (ACSBC). Sedatives were identified using the Sedative Load Model (SLM) and the sedative list of the ACSBC. Physical frailty was assessed using a modified Fried Frailty Phenotype (FFP) based on self-report items. Multivariable logistic regression models, adjusted for sociodemographic factors, lifestyle considerations, HIV-related variables, comorbidities, and co-medication use, were used to estimate odds ratios (ORs). Anticholinergic burden demonstrated associations with frailty across various methods: total anticholinergic burden (OR range: 1.22-1.32; 95% confidence interval (CI) range: 1.03-1.66), sedative burden (OR range: 1.18-1.24; 95% CI range: 1.02-1.45), high anticholinergic burden (OR range: 2.12-2.74; 95% CI range: 1.03-6.19), and high sedative burden (OR range: 1.94-2.18; 95% CI: 1.01-4.34). The anticholinergic and sedative burdens may represent modifiable risk factors for frailty in people aging with HIV. Future studies should evaluate the effects of reducing anticholinergic and sedative burdens on frailty outcomes and explore the prognostic value of diverse scoring methods.

Anticholinergic burden and cognitive impairment. Where do we stand?

AbstractBackgroundPolypharmacy is commonly observed among elderly patients and may increase the risk of anticholinergic burden, which is associated with frailty and cognitive impairment, among other side effects. As the long period association between anticholinergics and cognitive impairment remains under study, the present work aims to assess whether a significative anticholinergic burden is associated with cognitive impairment diagnosis.MethodPatients between 50 and 80 years old were recruited at the Cognitive Disorders Unit from the Hospital Universitari I Politècnic La Fe of Valencia (Spain). Medical interviews, neurological examinations, neuropsychological tests, and CSF biomarkers were assessed to classify patients as Alzheimer’s Disease (AD) patients (based on the NIA‐AA criteria), other cognitive impairment (OCI) patients (when they had other cognitive impairments than AD), and controls (cognitively healthy patients without CSF biomarkers alteration). Pharmacological history was obtained throw medical history review and classified using the ATC/DDD classification (https://www.whocc.no/atc_ddd_index/). The CRIDECO Anticholinergic Burden Scale was applied to anticholinergic burden in all patients. A significant anticholinergic burden was considered when the overall punctuation was equal to or higher than 3 points. All the subjects signed the informed consent. This project was approved by an Ethics Committee (2020‐705‐1).ResultAn amount of 517 patients aged between 50 and 80 years participated in the present study. From them, 274 patients had AD, 192 were OCI, and 51 were control patients. Statistical differences were found between anticholinergic burden and diagnosis. The 24% of the cohort had a significant anticholinergic burden and were mainly AD and OCI patients. OCI patients had the highest rate of anticholinergic burden (29%), followed by AD patients (25%) and control patients (17%). Women showed a higher anticholinergic burden than men (p‐value &lt;0.05). No differences were found between anticholinergic burden and CSF AD biomarkers.ConclusionAnticholinergic medication is more prescribed among patients with cognitive impairment, compared with control patients. As these drugs may promote the detrimental effects of anticholinergic burden on cognition, it is imperative to review the medications in patients at risk of dementia, especially women.

P81: Anticholinergic Burden of Patients Assessed by UK Memory Clinics: An Audit

Objective:It is estimated that there are 55 million people living with dementias globally. With so few effective treatments available for dementias, it is vital that services optimise the management of risk factors for patients to slow their disease progression as much as possible. Commonly prescribed medications with anticholinergic effects can cause iatrogenic cognitive impairment and lead to faster decline in people living with dementia. United Kingdom (UK) national guidelines recommend minimising their use when assessing people with suspected dementia or during medication reviews of people with dementia. We proposed to audit how many people were being referred to memory assessment services in two UK locations with a significant anticholinergic burden, which medications were responsible, and whether this impacted on diagnosis.Methods:We developed an audit tool based on national guidelines to gather data on the age, gender, medications, diagnosis and cognitive impairment of the first 50 patients assessed in the Memory Assessment Services in Wolverhampton and Walsall in 2022. We used the anticholinergic effect on cognition scale (AEC) to measure patients’ anticholinergic burdens and identify the most frequently prescribed medications.Results:We collected data from 30 patients from Wolverhampton and 20 patients from Walsall. Across the two locations, only 10% presented with a significant anticholinergic burden, with 24% having some anticholinergic burden that was not considered significant. Every patient with a significant anticholinergic burden was later diagnosed with dementia.Most of the anticholinergic medications that were prescribed are generally prescribed for psychiatric or neurological indications and the most frequently prescribed drug was amitriptyline.Conclusion:The prescription of anticholinergic medications was not as prevalent as predicted in our sample. It may be that anticholinergic medication are less prescribed for physical illnesses as alternatives that do not cross the blood-brain barrier are available. Psychogeriatricians are well placed to review the anticholinergic medications that are commonly prescribed during the assessment of suspected dementia, due to their familiarity with these medications. In response to our findings, we plan to update our memory clinic assessment tools to highlight the need for clinicians to review patients’ anticholinergic burden during assessment.

Anticholinergic burden and polypharmacy in primary care referrals to tertiary outpatient clinics in Brazil

AbstractBackgroundAnticholinergic burden (ACB) and polypharmacy are associated with cognitive/functional impairment in the elderly and their frequency in primary care has been poorly studied in Brazil. We aimed to evaluate the frequency ACB/polypharmacy and association with cognitive impairment in two large tertiary care outpatients memory clinics in Brazil.MethodsWe retrospectively analyzed records of referrals from primary care to two tertiary outpatients memory clinics in Brazil (Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre and Hospital Santa Marcelina (HSM), São Paulo) from 2014 to 2022. Sociodemographic, clinical and medications in use in the first appointments were recorded. The ACB was calculated using the Brazilian Anticholinergic Activity Drug (BAAD) score, which classified drugs according to their central anticholinergic activity from 1 to 3, with higher values indicating greater anticholinergic activity. The BAAD score was dichotomized as = 0 or ≥ 1. Polypharmacy was defined as ≥ 5 drugs. A logistic regression was performed using age, sex, education, disease duration, dementia etiology, center and Mini Mental State Examination (MMSE) as covariates.ResultsAmong 980 referrals (HCPA = 429; HSM = 551), 602 (64.9%) had a final diagnosis of dementia, HCPA = 226 (56.1%); HSM = 376 (71.8%); p&lt;0.001. Alzheimer’s disease, 93 (21.7%) and multifactorial dementia, 109 (19.8%), was the most common dementia diagnosis in HCPA and HSM, respectively. Most patients, 666 (74%), had BAAD ≥ 1 and nearly half 438 (48.7%) had polypharmacy, with no difference between centers (Table 1). BAAD was not different between diagnoses, but polypharmacy was more frequent in vascular (71, 63.4%) and multifactorial (82, 59.9%) dementia. BAAD was associated with MMSE (OR 0.95, IC 95% 0.93‐0.97) and polypharmacy (OR 3.71, IC 95% 2.66‐5.24). In addition to BAAD, polypharmacy was also associated with female sex (OR 1.45, IC 95% 1.09‐1.91) and age (OR 1.01, IC 95% 1‐1.02).ConclusionMost patients referred from primary care were using some drug with anticholinergic activity and almost half had polypharmacy, which suggests liberality in the prescription of medications in this context.

The complex relationship between anticholinergic medication, frailty, and hospitalization in patients with early‐stage dementia

AbstractBackgroundAnticholinergic medications are associated with frailty and hospitalization in patients with dementia. It is unclear if anticholinergic burden mediates the relationship between frailty and hospitalization or if specific dementia syndromes moderate the direct and indirect relationships between these three factors.MethodWe analyzed electronic health record and claims data for member‐patients diagnosed with dementia with Lewy bodies (DLB), Alzheimer’s disease (AD), or vascular dementia (VD) from an integrated healthcare system in the U.S. between October 2015 and August 2022. The Anticholinergic Cognitive Burden Scale (ACB), Claims‐based Frailty Index (frail ≥0.20), and number of hospital admissions were calculated for the 12‐month period prior to dementia diagnosis. Patient demographics, ACB score, frailty status, and hospitalization frequency were compared between dementia syndromes. Baron and Kenny regression‐based method was used to evaluate if ACB is a mediator between frailty and hospitalization. DLB, AD, and VD were included as interactions with ACB and frailty in stratified mediation models to determine if dementia syndrome moderated the relationship. Significant interaction terms indicate a moderating effect of dementia syndrome. All models included patient age and sex as covariates.ResultWe identified 3166 patients (DLB n = 175; AD n = 2478; VD n = 513). Approximately 23% of patients with DLB were prescribed 5+ anticholinergic medications (17.2% with VD; 9.9% with AD; p&lt;.001). Two or more hospitalizations were documented in 12.5% of patients with VD (10.3% with DLB; 5.5% with AD; p&lt;.001). The ACB score was 3.7 greater for patients with frailty compared to those without (3.2, 4.4, p&lt;.001). The relationship between frailty and hospitalization was mediated by ACB (higher ACB was associated with increased utilization; Table 1). A diagnosis of AD or VD moderated the indirect relationship between frailty and hospitalization, but the specific dementia syndrome did not moderate the path between ACB and hospitalization (Table 2; Figure 1).ConclusionIn the year prior to dementia diagnosis, frailty was associated with a higher number of anticholinergic medications, which, in turn, was associated with a greater number of hospitalizations. A diagnosis of VD increased the expected rates of hospitalization for frail patients, while an AD diagnosis decreased the magnitude of the association between frailty and hospitalization.

How potentially inapropriate are psychotropic drugs prescribing in acute psychiatric unit for the elderly? Results from a large multicentric audit in France

Adverse drug reactions (ADRs) are a major public health issue, especially when it comes to the elderly. Potentially inappropriate prescribing (PIP) are one of the causes of ADRs in older people. A PIP can be defined as a prescription for which the benefit/risk ratio is unfavourable compared to other therapeutic alternatives. Psychotropic drugs are the second highest risk class for ADRs in the elderly. In order to reduce the prevalence of PIP, prescription assistance tools have been created. An inventory of PIP of psychotropic drugs in older patients hospitalized in psychiatry units was carried out in a French regional setting in 2019. A criteria grid was established based on 2 tools: STOPP/START criteria and Laroche's list adapted to French practice. This grid targeted each class of psychotropic drugs, drugs with a high anticholinergic burden and non-recommended combinations of psychotropic drugs. Three hundred forty-seven patients were included. A high prevalence of PPI was found for each class of psychotropic drugs. The highest prevalence of PPI was found among benzodiazepines (90.3%): long-term prescription, long half-life drugs, respiratory insufficiency or cognitive impairment condition. 56.5% of the subjects had a not-recommended combination of psychotropic drugs (prescription of drugs of the same pharmacotherapeutic class), 26% had a PIP of antipsychotics: prescription for insomnia, use of phenothiazine, 11.8% of drugs with anticholinergic properties and 7.4% of antidepressants: especially prescription of tricyclic drugs. These results obtained on a large population underline the interest of considering the specificities of prescriptions in the elderly. It shows both the interest and the limits of the current criteria defining the PIP in the context of a hospitalization in psychiatry for an acute disorder in elderly subjects.

Higher anticholinergic burden is associated with poor nutritional outcome

Higher anticholinergic burden is associated with poor nutritional outcome

Association of different scales anticholinergic burden with sarcopenia in older adults

Association of different scales anticholinergic burden with sarcopenia in older adults

The effect of the anticholinergic burden on mortality following elective cardiac surgery

Objective The cumulative effect of drugs with anticholinergic properties may pose a significant risk in the post-discharge period of patients who have undergone elective cardiac surgery. The aim of this study was to investigate the association between anticholinergic burden and 6-month postdischarge mortality in older cardiac surgery patients. Methods This study performed a retrospective longitudinal analysis of patients undergoing elective cardiac surgery at a tertiary care centre from January 2021 to January 2022. The Deyo-Charlson comorbidity index (D-CCI) was used to estimate the burden of comorbidities. The anticholinergic burden was assessed using the Anticholinergic Cognitive Burden scale (ACB) and Drug Burden Index (DBI) scale. All-cause postdischarge mortality was determined from electronic medical records. Results A total of 255 older adults who had undergone elective cardiac surgery and had been followed up for at least 6 months were included in this study. Approximately 12.5% (n = 32) of older patients died within 6 months of discharge. In multivariate Cox regression analysis, ACB (HR:1.31, 95%CI:1.10–1.56 p = 0.01) and DBI (HR:2.08, 95%CI:1.27–3.39 p = 0.01) showed significantly increased risk of 6-month postdischarge mortality after adjusting for several possible confounders (age, gender, D-CCl, and American Society of Anaesthesiologists (ASA) score). Overall event-free survival differed significantly between patients undergoing cardiac surgery based on anticholinergic burden according to the group-stratified ACB and DBI scales (χ2: 5.907, log-rank test, p = 0.015 and χ2: 15.389, log-rank test, p < 0.001 respectively). Conclusion The anticholinergic burden is associated with 6-month all-cause post-discharge mortality in older cardiac surgery patients. A deprescribing approach should be considered, especially for older adults in the perioperative period. TRIAL REGISTRATION The trial was retrospectively registered at ClinicalTrials.gov. Identifier: NCT05312684 Registered on 5 April 2022.