Anticholinergic Cognitive Burden Score Research Articles

A SIMPLE INTERVENTION TO REDUCE ANTICHOLINERGIC DRUG USE WHILE ATTENDING A GERIATRIC DAY HOSPITAL

Attendance at a Geriatric Day Hospital has previously been shown to reduce both the overall number of medications and the number of anticholinergic medications of patients. In the present study, patients enrolled in a Geriatric Day Hospital program from January to February 2019 were divided into a control and intervention group. Anticholinergic medications in the intervention group were flagged by highlighting them in the patient chart and alerting the attending clinician, whereas no alerts were provided in the control group. Anticholinergic load was calculated using the Anticholinergic Cognitive Burden (ACB) and Drug Burden Index (DBI) scores. In comparing admit versus discharge medications in the intervention group, both the mean number of overall medications (10 vs. 9.7) and anticholinergic medications (3.5 vs. 3.1) was reduced; this was not the case in the control group, where the mean number of overall medications remained the same (11.92) and the mean number of anticholinergic medications increased (3.83 vs. 3.92). More significantly, in comparing admit versus discharge scores, both the mean ACB and DBI scores were reduced in the intervention group, but in the control group both the ACB and DBI scores either remained the same or increased at the time of discharge. This clearly shows that a simple intervention (highlighting anticholinergic medications in the patient chart) can have a clinically beneficial outcome of reducing these harmful medications in patients. With approximately 50% of the older population taking at least one anticholinergic drug, the importance of reducing anticholinergic burden cannot be overemphasized.

Is Ongoing Anticholinergic Burden Associated With Greater Cognitive Decline and Dementia Severity in Mild to Moderate Alzheimer's Disease?

Use of anticholinergic medication is associated with an increased risk of cognitive impairment and/or dementia. Despite this, the impact of continuing medication with anticholinergic properties in those diagnosed with Alzheimer's Disease (AD) is not clear. Analysis of data from NILVAD, an 18-month randomized controlled trial of Nilvadipine in AD. Effects of ongoing Anticholinergic Cognitive Burden (ACB) on cognition (ADAS-Cog: Alzheimer's Disease Cog Subsection) and dementia severity (CDR-sb: Clinical Dementia Rating - Sum of Boxes/DAD: Disability Assessment for Dementia) over 18 months was evaluated adjusting for important clinical covariates. Just over one-quarter (27.90%, n = 142/510) of patients with mild to moderate AD were prescribed a potential/definite anticholinergic. While ACB score was not associated with greater progression on the ADAS-Cog/CDR-sb over time, a higher total ACB predicted greater dementia severity on the DAD, which persisted after robust covariate adjustment (β Coef: -1.53, 95% CI: -2.83 to -0.23, p = .021). There was a significant interaction between APOE ε4 status and ACB score, with carriers experiencing greater progression on both the CDR-Sb (β Coef: 0.36, 95% CI: 0.05-0.67, p = .021) and DAD (β Coef: -3.84, 95% CI: -7.65 to 0.03, p = .049). Ongoing use of anticholinergic medication was associated with greater dementia progression on the DAD, but not the CDR-sb. APOE ε 4 carriers may be particularly vulnerable to the effect of ongoing anticholinergic medication on dementia severity, with significant APOE ε 4 x ACB score interactions demonstrated on both the DAD and CDR-sb.

Cognitive burden and polypharmacy in elderly Japanese patients treated with anticholinergics for an overactive bladder.

This study aimed to investigate the cognitive burden and polypharmacy in elderly patients treated with anticholinergics for an overactive bladder. We conducted a retrospective study of patients with an overactive bladder receiving treatment at two hospitals in Japan (Nara Medical University Hospital and Saiseikai Nara Hospital). Prescription data were collected from the medical records of the patients registered between January 2013 and April 2014. The Anticholinergic Cognitive Burden Scale was used to estimate the severity of the anticholinergic effects on the cognition of each patient. We collected the prescription data of 584 and 246 patients from the Nara Medical University Hospital and Saiseikai Nara Hospital, respectively. The mean daily total Anticholinergic Cognitive Burden score ranged between 3 and 4 (3.59 ± 1.16 at Nara Medical University Hospital vs 3.32 ± 0.78 at Saiseikai Nara Hospital, P < 0.01). At both hospitals, the mean number of prescriptions was >5 in patients ≥75 years (5.95 ± 4.43 and 5.64 ± 3.90 at Nara Medical University Hospital and Saiseikai Nara Hospitals, respectively). Our findings suggest that 10%-20% of elderly patients (≥65 years) receiving treatment with anticholinergics for an overactive bladder are in a state of polypharmacy. The total anticholinergic cognitive burden of each patient mainly depends on the anticholinergics being used for treating the overactive bladder. Especially for elderly patients with a high risk of adverse effects, including cognitive impairment, careful attention needs to be paid during selection of drugs for treating patients with an overactive bladder.

Association of Benzodiazepine and Anticholinergic Drug Usage With Incident Dementia: A Prospective Cohort Study of Community-Dwelling Older Adults

ObjectivesTo examine the association of benzodiazepines and anticholinergic drug usage with the risk of dementia. DesignProspective cohort study. SettingCommunity-dwelling participants, recruited in family practices in the Netherlands. ParticipantsIn total, 3526 individuals aged 70 to 78 years without dementia within 116 participating family practices. MethodsInformation about drug use was reported at baseline and at 2-year follow-up and was cross-checked with the participants’ electronic health records. Anticholinergic drug exposure was defined by the anticholinergic cognitive burden score. Participants were evaluated for dementia during follow-up assessments every 2 years, supplemented by information from electronic health records and the National Death Registry. ResultsDuring a median follow-up of 6.7 years, dementia developed in 233 participants (7%). In participants using benzodiazepines, 6% developed dementia vs 7% in nonusers [hazard ratio (HR) 0.71, 95% confidence interval (CI) 0.58–1.07]. Persistent usage of benzodiazepines at baseline and after 2-year follow-up did not substantially alter the point-estimate (HR 0.60, 95% CI 0.34–1.10). Use of any anticholinergic drugs was not associated with incident dementia (HR 1.01, 95% CI 0.50–1.10). Dementia risk was significantly increased for participants with persistent drug use with a high anticholinergic cognitive burden score (HR 1.95, 95% CI 1.13–3.38) though this effect was absent when excluding participants taking antidepressants or antipsychotics (HR 0.42, 95% CI 0.06–3.01). Conclusions and ImplicationsIn our study population, benzodiazepine usage was not associated with an increased risk of dementia. Persistent high anticholinergic exposure was associated with an increased risk of dementia over 6 years of follow-up, and this association was driven by antidepressant or antipsychotic drug use, suggesting confounding by indication bias contributing to this. Although this observation could ameliorate prescription hesitance, healthcare providers are still advised to carefully weigh the potential benefits of benzodiazepines and anticholinergic drugs against the associated adverse health outcomes.

Anticholinergic burden of patients with dementia attending a Psychiatry of Later Life service.

Older adults with dementia are particularly vulnerable to adverse outcomes resulting from anticholinergic use. We aimed to: (i) Examine the anticholinergic burden of patients with dementia attending a Psychiatry of Later Life (PLL) service (ii) Examine concomitant prescription of acetylcholinesterase inhibitors (AChEIs) and anticholinergics and (iii) Compare the Anticholinergic Cognitive Burden (ACB) scale with a recently published composite list of anticholinergics. Retrospective chart review of new referrals with a diagnosis of dementia (n = 66) seen by the PLL service, Tallaght University Hospital, Dublin, Ireland, over a consecutive period of 4 months. The mean ACB score was 2.2 (range = 0-9, SD = 2.1). 37.9% (n = 25) had a clinically significant ACB score (>3) and 42.1% (n = 8) of those taking AChEIs had a clinically significant ACB score. A significantly greater number of medications with anticholinergic activity were identified using the composite list versus the traditional ACB scale (2.3 v.1.5, p = 0.001). We demonstrated a significant anticholinergic burden amongst patients with dementia attending a specialist PLL service. There was no difference in anticholinergic burden between groups prescribed and not prescribed AChEIs, indicating that these medications are being prescribed without discontinuation of potentially inappropriate medications with anticholinergic activity. The true anticholinergic burden experienced by patients may be underestimated by the use of the ACB score alone, although the clinical significance of this finding is unclear. Calculation of true clinical anticholinergic burden load and its translation to a specific rating scale remains a challenge.

Anticholinergic burden before and after hospitalization in older adults with dementia: Increase due to antipsychotic medications.

To evaluate changes in the use of antipsychotics and medications with anticholinergic activity (MACs) during hospitalization in older adults with dementia and factors associated with antipsychotic prescriptions and increased anticholinergic burden (ACB). This retrospective cohort study included all patients aged 65years or older with a discharge diagnosis of dementia hospitalized at the university hospital of Udine, Italy, from 2012 to 2014. Medications dispensed within 3months before and after hospitalization were identified in community-pharmacy dispensations while those prescribed at discharge were collected from Hospital Electronic Medical Records (EMR). ACB was assessed using the Anticholinergic Cognitive Burden score. Among 1908 patients included, at discharge, 37.0% used one or more antipsychotic (9.4% before and 12.6% after hospitalization), 68.6% used one or more MAC (49.1% and 45.7%, respectively), and ACB of 38.4% of patients increased at discharge mainly because of a higher use of antipsychotics with anticholinergic activity (33% at discharge vs 12% before hospitalization). Prescription of antipsychotics at discharge was associated with prior treatment with antipsychotics (adjusted odds ratio [aOR] 4.85; 95%CI, 3.37-6.97), psychiatric conditions, (4.39; 3.47-5.54) and discharge from surgical department (2.17; 1.32-3.55). An increased ACB was associated with psychiatric conditions (1.91; 1.52-2.39), discharge from surgical (1.75; 1.09-2.80) or medical department (1.50; 1.04-2.17), and with cardiac insufficiency (1.41; 1.00-1.99). ACB was higher at discharge, and antipsychotics were the main drivers of this increase. Clinicians treating older adults with dementia should be aware of the risks associated with antipsychotics and that some of these medications may increase the risk of anticholinergic effects.

Polypharmacy in an Elderly Population: Enhancing Medication Management Through the Use of Clinical Decision Support Software Platforms.

IntroductionPolypharmacy is a growing problem in the United States. The use of multiple medications increases the likelihood that a patient will experience potential drug interactions and adverse drug reactions (ADRs). Those individuals with dementia or Alzheimer’s disease (AD) are at greater risk, due to age, comorbidities, and an increased likelihood of being on a greater number of neuroactive medications.MethodsuMETHOD Health (uMH) has developed a precision medicine platform to address dementia and mild AD through the creation of personalized, multidomain treatment plans. Many interactions and ADRs may be observed, such as drug–drug interactions (DDIs), drug–gene interactions (DGIs), anticholinergic cognitive burden (ACB), and depression-inducing drugs (DIDs). uMH’s algorithms can parse these interactions, rate them based on input from open-source databases, and then record all these interactions in a generated treatment plan. A total of 295 individuals aged 65 and older were included in this analysis.ResultsOf 295 individuals, 97.59% were on at least one medication, with an overall mean of 11.5 medications per person; 83.66% were on five or more medications. A total of 102 DGIs, 3642 DDIs, and one high-priority DDI were found in this population. There was a significant increase in the number of DDIs as medications per person increased (P value < 0.0001). Of the population, 65.86% were on one or more anticholinergic drugs. There was a significant difference in the ACB score between individuals with cognitive decline and those without. In total, 60.98% of the overall population were on DIDs, with a mean of 1.19 medications per person.ConclusionsThe results of this work show that older populations have a high medication burden. With the growing elderly and AD populations, medication management for polypharmacy is a need that grows direr every year. uMH’s platform was able to identify a multitude of polypharmacy problems that individuals are currently facing.FundinguMETHOD Health.

Drugs Contributing to Anticholinergic Burden and Risk of Fall or Fall-Related Injury among Older Adults with Mild Cognitive Impairment, Dementia and Multiple Chronic Conditions: A Retrospective Cohort Study.

It is not known whether drugs with different anticholinergic ratings contribute proportionately to overall anticholinergic score. Our objective was to assess the risk of falls or fall-related injuries as a function of the overall anticholinergic score resulting from drugs with different anticholinergic ratings among people with impaired cognition. This was a retrospective cohort study of adults aged ≥ 65years with mild cognitive impairment (MCI) or dementia and two or more additional chronic conditions (N = 10,698) in an integrated delivery system. Electronic health record data, including pharmacy fills and diagnosis claims, were used to assess anticholinergic medication use, quantified using the anticholinergic cognitive burden (ACB) scale, falls and fall-related injuries. During a median follow-up of 366days, 63% of the cohort used one or more ACB drug; 2015 (18.8%) people experienced a fall or fall-related injury. Among patients with a daily ACB score of 5, the greatest increase in risk of falls or fall-related injuries was seen when level 2 and level 3 drugs were used in combination [hazard ratio (HR) 2.06; 95% confidence interval (CI) 1.51-2.83]. Multiple ACB level 1 drugs taken together alsoincreased the hazard of a fall or fall-related injury (HR 1.16; 95% CI 1.03-1.32). The risk of fall or fall-related injury as a function of exposure to ACB level 2 drugs (HR 1.56; 95% CI 1.16-2.10) was higher than that for ACB level 1 or 3 drugs. The same daily ACB score was associated with a different degree of risk, depending on the ACB ratings of the individual drugs comprising the score. Combinations of level 2 and level 3 drugs had the greatest risk of fall or fall-related injury relative to other individuals with the same daily ACB score. Low-potency anticholinergic drugs taken together modestlyincreased the hazard of a fall or fall-related injury.

Effect of anticholinergic burden on treatment modification, delirium and mortality in newly diagnosed dementia patients starting a cholinesterase inhibitor: A population-based study.

Few studies have evaluated the association between anticholinergic burden and treatment modification after starting a cholinesterase inhibitor in clinical practice. We aimed to evaluate the effect of anticholinergic burden on anti-dementia treatment modification, delirium and mortality. We retrospectively analysed older adults (n = 25 825) who started a cholinesterase inhibitor during 2003-2011 from Korean National Health Insurance Service Senior Cohort Database. High anticholinergic burden was defined as an average daily Anticholinergic Cognitive Burden (ACB) score of >3 during the first 3 months. We investigated the impact of high anticholinergic burden on the rate of treatment modification, delirium and mortality in comparison with minimal ACB (ACB score ≤1) in propensity-matched cohorts (N = 7438). Approximately 6.0% of patients with dementia were exposed to a high anticholinergic burden within the first three months of treatment. In high anticholinergic burden cohorts, significantly more patients experienced treatment modification (34.9% vs. 32.1%) or delirium (5.6% vs. 3.6%) and the mortality rate was also higher (16.8% vs. 14.1%) than controls. A multivariate Cox proportional hazard regression analysis showed that an average ACB score >3 within the first three months significantly increased the risk of treatment modification (hazard ratio (HR): 1.12, 95% confidence interval (CI): 1.02-1.24), delirium (HR: 1.52, CI: 1.17-1.96) and mortality (HR: 1.23, CI: 1.06-1.41). This study showed that high anticholinergic burden negatively affected the treatment response to cholinesterase inhibitors and that an average ACB score >3 was an independent prognostic factor for delirium or mortality in dementia patients.

Relation Between Delirium and Anticholinergic Drug Burden in a Cohort of Hospitalized Older Patients: An Observational Study.

Delirium is a neuropsychiatric syndrome which occurs on average in one out of five hospitalized older patients. It is associated with a number of negative outcomes, including worsening of cognitive and functional status, increasing the burden on patients and caregivers, and elevated mortality. Medications with anticholinergic effect have been associated with the clinical severity of delirium symptoms in older medical inpatients, but this association is still debated. The aim was to assess the association between delirium and anticholinergic load according to the hypothesis that the cumulative anticholinergic burden increases the risk of delirium. This retrospective, cross-sectional study was conducted in a sample of older patients admitted to the Acute Geriatric Unit (AGU) of the San Gerardo Hospital in Monza (Italy) between June 2014 and January 2015. Delirium was diagnosed on admission using the 4'A's Test (4AT), a validated screening tool for delirium diagnosis, which has shown good sensitivity and specificity to detect this condition in elderly patients admitted to an AGU. Each patient's anticholinergic burden was measured with the Anticholinergic Cognitive Burden (ACB) scale, a ranking of anticholinergic medications to predict the risk of adverse effects on the central nervous system in older patients. Of the 477 eligible for the analysis, 151 (31.7%) had delirium. According to the ACB scale, 377 patients (79.0%) received at least one anticholinergic drug. Apart from quetiapine, which has a strong anticholinergic effect, the most commonly prescribed anticholinergic medications had potential anticholinergic effects but unknown clinically relevant cognitive effects according to the ACB scale (score 1). Patients with delirium had a higher anticholinergic burden than those without delirium, with a dose-effect relationship between total ACB score and delirium, which was significant at univariate analysis. A plateau risk was found in patients who scored 0-2, but patients who scored 3 or more had about three or six times the risk of delirium than those not taking anticholinergic drugs. The dose-response relationship was maintained in the multivariate model adjusted for age and sex [odds ratio (OR) 5.88, 95% confidence interval (CI) 2.10-16.60, p = 0.00007], while there was only a non-significant trend in the models adjusted also for dementia and Mini Nutritional Assessment (OR 2.73, 95% CI 0.85-8.77, p = 0.12). Anticholinergic drugs may influence the development of delirium due to the cumulative effect of multiple medications with modest antimuscarinic activity. However, this effect was no longer evident in multivariable logistic regression analysis, after adjustment for dementia and malnutrition. Larger, multicenter studies are required to clarify the complex relationship between drugs, anticholinergic burden and delirium in various categories of hospitalized older patients, including those with dementia and malnutrition.

The excess mortality risk associated with anticholinergic burden among older patients discharged from acute care hospital with depressive symptoms

BackgroundThe relationship between anticholinergic burden and mortality is controversial, and the impact of anticholinergic burden on prognosis may vary in presence of other conditions common in old age. We aimed at investigating the role of depressive symptoms as potential effect modifiers in the association between anticholinergic burden and 1-year mortality in older patients discharged from hospital. MethodsOur series consisted of 576 older patients consecutively admitted to seven geriatric and internal medicine acute care wards in the context of a prospective multicenter observational study. Overall anticholinergic burden was assessed by Anticholinergic Cognitive Burden (ACB) score. Depressive symptoms were assessed by 15-item Geriatric Depression Scale (GDS). The study outcome was all-cause mortality during 12-months follow-up. Statistical analysis was carried out by Cox regression analysis. ResultsAfter adjusting for potential confounders, discharge ACB score = 2 or more was significantly associated with the outcome among patients with GDS > 5 (HR = 3.70; 95%CI = 1.18–11.6), but not among those with GDS ≤ 5 (HR = 2.32; 95%CI = 0.90–6.24). The association was confirmed among depressed patients after adjusting for ACB score at 3-month follow-up (HR = 3.58; 95%CI = 1.21–10.7), as well as when considering ACB score as a continuous variable (HR = 1.42; 95%CI = 1.10–1.91). The interaction between ACB score at discharge and BADL dependency was statistically significant (p < .005). ConclusionsACB score at discharge may predict mortality among older patients discharged from acute care hospital carrying high GDS score e. Hospital physician should be aware that prescribing anticholinergic medications in such a vulnerable population may have negative prognostic implications.

PND114 - IMPACT OF A PHARMACIST-LED COMMUNITY INTERVENTIONAL PROGRAM TO PREVENT COGNITIVE DETERIORATION IN COMMUNITY-DWELLING HONG KONG ELDERS WITH HIGH ANTICHOLINERGIC COGNITIVE BURDEN

With the emerging evidence of high anticholinergic exposure being associated with cognitive decline or dementia in older adults, this study evaluated whether a pharmacist-led interventional program could decrease the anticholinergic cognitive burden (ACB) in a group of community-dwelling elders in Hong Kong. This study also evaluated whether lifestyle habits could be improved after said intervention regarding cognitive-beneficial lifestyles. 4462 elders referred from the CU CHAMPION outreach network during 2016 and 2017 were screened for clinical characteristics, including the ACB score and cognitive function (as measured by the Memory Impairment Screen (MIS)). Those who had a clinically relevant ACB score of 3 or above, not diagnosed with dementia, and were communicable were recruited for intervention. In the intervention, pharmacists aimed to decrease the ACB score of the elders by suggesting changes to their drug regimens through writing letters to the respective physicians or through other methods deemed appropriate. Habits towards cognitive beneficial lifestyles and diets were also assessed through a “lifestyle questionnaire”, and an educational session was arranged afterwards. After an approximate two-month period, the ACB score and lifestyle habits of these elders were reassessed. Of the 45 elders who completed the study, chlorpheniramine and other cardiac medications were found to be major contributors to the anticholinergic burden. The ACB score did not decrease at a statistically significant level after intervention, however it was found that most interventions made targeted antihistamines - suggesting sub-optimal antihistamine use. The score achieved from the lifestyle questionnaire improved significantly (p < 0.05), suggesting improvement in cognitive-beneficial lifestyle knowledge and habits. The pharmacist-led intervention improved lifestyles and antihistamine-use in community-dwelling elders. Antihistamine-use might be a potential area of focus for future pharmacist-physician collaboration opportunities in the community. Future research should evaluate whether ACB score adjustment is clinically relevant in the target population.

Anticholinergic Burden in Hospice Patients With Dementia.

End-of-life (EOL) patients with dementia have an increased risk for anticholinergic toxicities due to age-related pharmacokinetic and physiologic changes in conjunction with an increased susceptibility to drug-induced cognitive impairments. Despite this well-documented risk, the use of drugs with anticholinergic properties (DAPs) remains prevalent in EOL patients with dementia. The aims of this study were to describe prescribing patterns and characterize anticholinergic burden among hospice patients with dementia, as measured by the Anticholinergic Cognitive Burden (ACB) scale. This was a retrospective review of a national hospice patient information database. Patients included were admitted on January 1, 2016, discharged by death by December 31, 2016, and had a primary diagnosis of dementia. Patients' anticholinergic burden was calculated using ACB scores. A total of 1283 patients met the inclusion criteria. Of those, 37.1% (n = 476) were prescribed at least 1 DAP. Specifically, 28.9% (n = 371) were prescribed 1 DAP, 6.6% (n = 84) were prescribed 2 DAPs, 1.6% (n = 20) were prescribed 3 DAPs, and 0.08% (n = 1) were prescribed 4 DAPs. The majority of patients prescribed a DAP had an ACB score of 3 (n = 359, 75.4%) and an average ACB score of 3.8. The most common DAPs prescribed in patients with an ACB score of 2 or higher were quetiapine (n = 202, 42.4%), atropine (n = 155, 32.6%), hyoscyamine (n = 61, 12.8%), olanzapine (n = 46, 9.6%), and scopolamine (n = 35, 7.4%). Due to the limited benefit and increased harms with the use of DAPs, providers should aim to maximize nonpharmacologic options. By reducing the use of the top 5 DAPs identified in this study, the quality of life and care for EOL patients with dementia can potentially be improved.

Anticholinergic burden in the Japanese elderly population: Use of antimuscarinic medications for overactive bladder patients.

To assess anticholinergic use, especially the use of antimuscarinics, in the elderly (aged ≥65years) Japanese overactive bladder and non-overactive bladder populations. Patient records were sourced from a large, nationwide Japanese pharmacy claims database. Anticholinergic use on a random day in 2016 (index date) was investigated through the Anticholinergic Cognitive Burden scale (primary scale), the Anticholinergic Drug Scale, the Anticholinergic Risk Scale and Beers criteria. The prevalence of anticholinergic use and anticholinergic scores at the index date were summarized descriptively. The overactive bladder population was defined as patients who had at least one prescription record for any antimuscarinic (fesoterodine, imidafenacin, oxybutynin, propiverine, solifenacin or tolterodine) or the β3-adrenoreceptor agonist, mirabegron, within the 1-year pre-index period. Among 1216126 outpatients, 35138 (2.9%) were included in the overactive bladder group. In total, 112 (68.7%) of the anticholinergics listed in the scales were identified. In those who received any Anticholinergic Cognitive Burden scale-listed anticholinergic, the mean scores were higher in overactive bladder patients versus non-overactive bladder patients (3.2±1.3 and 1.6±1.1, respectively). Similarly, overactive bladder patients who received antimuscarinics had higher Anticholinergic Cognitive Burden scores (3.3±1.2) than patients who received mirabegron only (1.7±1.1). In 58.8% of the overactive bladder patients, ≥80% of the total Anticholinergic Cognitive Burden score was exclusively attributable to antimuscarinics. Anticholinergic use was higher in overactive bladder patients versus non-overactive bladder patients. This increased use was largely attributable to antimuscarinics. The alternative use of mirabegron could therefore be considered to reduce the burden experienced by patients in Japan.

Anticholinergic Burden is Associated With Increased Mortality in Older Patients With Dependency Discharged From Hospital

ObjectivesTo determine whether anticholinergic burden may predict differently 1-year mortality in older patients discharged from acute care hospitals with or without dependency in basic activities of daily living (BADL). DesignProspective observational study. Setting and participantsOur series consisted of 807 patients aged 65 years or older consecutively discharged from 7 acute care geriatric wards throughout Italy between June 2010 and May 2011. MeasuresOverall anticholinergic burden was assessed by the anticholinergic cognitive burden (ACB) score. Dependency was rated by BADL, and dependency in at least 1 BADL was considered as a potential mediator in the analysis. The study outcome was all-cause mortality during 12-months of follow-up. ResultsPatients included in the study were aged 81.0 ± 7.4 years, and 438 (54.3%) were female. During the follow-up period, 177 out of 807 participants (21.9%) died. After adjusting for potential confounders, discharge ACB score = 2 or more was significantly associated with the outcome among patients with dependency in at least 1 BADL [hazard ratio (HR) 2.25 95% confidence (CI) 1.22‒4.14], but not among independent ones (HR 1.06 95% CI 0.50‒2.34). The association was confirmed among dependent patients after adjusting for the number of lost BADL at discharge (HR 2.20 95% CI 1.18‒4.04) or ACB score at 3-month follow-up (HR 2.18 95% CI 1.20‒3.98), as well as when considering ACB score as a continuous variable (HR 1.28 95% CI 1.11‒1.49). The interaction between ACB score at discharge and BADL dependency was highly significant (P < .001). Conclusions/ImplicationsACB score at discharge may predict mortality among older patients discharged from an acute care hospital carrying at least 1 BADL dependency. Hospital physicians should be aware that prescribing anticholinergic medications in this population may have negative prognostic implications and they should try to reduce anticholinergic burden at discharge whenever possible.

Anticholinergic medications in patients admitted with cognitive impairment or falls (AMiCI). The impact of hospital admission on anticholinergic cognitive medication burden. Results of a multicentre observational study.

Drugs with anticholinergic properties increase the risk of falls, delirium, chronic cognitive impairment, and mortality and counteract procholinergic medications used in the treatment of dementia. Medication review and optimisation to reduce anticholinergic burden in patients at risk is recommended by specialist bodies. Little is known how effective this review is in patients who present acutely and how often drugs with anticholinergic properties are used temporarily during an admission. The aim of the study was to describe the changes in the anticholinergic cognitive burden (ACB) in patients admitted to hospital with a diagnosis of delirium, chronic cognitive impairment or falls and to look at the temporary use of anticholinergic medications during hospital stay. This is a multi-centre observational study that was conducted in seven different hospitals in the UK, Finland, The Netherlands and Italy. 21.1% of patients had their ACB score reduced by a mean of 1.7%, 19.7% had their ACB increased by a mean of 1.6%, 22.8% of DAP naïve patients were discharged on anticholinergic medications. There was no change in the ACB scores in 59.2% of patients. 54.1% of patients on procholinergics were taking anticholinergics. Out of the 98 medications on the ACB scale, only 56 were seen. Medications with a low individual burden were accounting for 64.9% of the total burden. Anticholinergic drugs were used temporarily during the admission in 21.9% of all patients. A higher number of DAPs used temporarily during admission was associated with a higher risk of ACB score increase on discharge (OR=1.82, 95% CI for OR: 1.36-2.45, P<.001). There was no reduction in anticholinergic cognitive burden during the acute admissions. This was the same for all diagnostic subgroups. The anticholinergic load was predominantly caused by medications with a low individual burden. More than 1 in 5 patients not taking anticholinergics on admission were discharged on them and similar numbers saw temporary use of these medications during their admission. More than half of patients on cholinesterase-inhibitors were taking anticholinergics at the same time on admission, potentially directly counteracting their effects.

Anticholinergic drugs and risk of dementia: case-control study

ObjectivesTo estimate the association between the duration and level of exposure to different classes of anticholinergic drugs and subsequent incident dementia.DesignCase-control study.SettingGeneral practices in the UK contributing to the Clinical...

Medication Profiles of Patients with Cognitive Impairment and High Anticholinergic Burden.

Drugs with anticholinergic properties are considered potentially inappropriate in patients with cognitive impairment because harms-including delirium, falls, and fractures-may outweigh benefits. To highlight opportunities to improve clinical decision making and care for patients with cognitive impairment and multiple chronic conditions, we identified distinct subgroups of patients with mild cognitive impairment (MCI) and dementia who had high cumulative anticholinergic burden and specific patterns of anticholinergic use. We conducted a retrospective cohort study in a not-for-profit, integrated delivery system. Participants included community-dwelling adults aged 65years and older (n=13,627) with MCI or dementia and at least two other chronic diseases. We calculated the Anticholinergic Cognitive Burden (ACB) score for each participant from pharmacy and electronic health record (EHR) data. Among individuals with a mean 12-month ACB score≥2, we used agglomerative hierarchical clustering to identify groups or clusters of individuals with similar anticholinergic prescription patterns. Twenty-four percent (3257 participants) had high anticholinergic burden, defined as an ACB score≥2. Clinically meaningful clusters based upon anchoring medications or drug classes included a cluster of cardiovascular medications (n=1497; 46%); two clusters of antidepressant medications (n=633; 20%); and a cluster based on use of bladder antimuscarinics (n=431; 13%). Several clusters comprised multiple central nervous system (CNS)-active drugs. Cardiovascular and CNS-active medications comprise a substantial portion of anticholinergic burden in people with cognitive impairment and multiple chronic conditions. Antidepressants were highly prevalent. Clinical profiles elucidated by these clusters of anticholinergic medications can inform targeted approaches to care.

Anticholinergic burden and 1-year mortality among older patients discharged from acute care hospital.

The association between anticholinergic burden and mortality is controversial. We aimed to investigate whether the anticholinergic cognitive burden (ACB) score predicts 1-year mortality in older patients discharged from acute care hospitals. Our series consisted of 807 hospitalized patients aged ≥65 years. Patients were followed up for 12 months after discharge. All-cause mortality was the outcome of the study. The ACB score at discharge (0, 1, ≥2) and increasing ACB score from admission to discharge (no increase, +1, +2 or more) were calculated and used as exposure variables. Cox proportional hazards models adjusted for potential confounders were used for the analysis. Interactions between the ACB score and cognitive impairment or history of falls were also investigated. During the follow-up period, 177 out of 807 participants (21.9%) died. After adjusting for potential confounders, a discharge ACB score of ≥2 (HR 1.69, 95% CI 1.09-2.65) was significantly associated with the outcome, whereas the association between increasing ACB score of +2 or more and mortality was weaker (HR 1.30, 95% CI 0.95-1.92). The interaction between the ACB score at discharge or increasing ACB score and cognitive impairment was statistically significant (P = 0.003 and P = 0.004, respectively), whereas that between the ACB score and falls was not. The ACB score at discharge and, to a lesser extent, an increasing ACB score during hospital stay are associated with an increased risk of 1-year mortality in older patients discharged from hospital. Such an association is stronger among patients with cognitive impairment. Geriatr Gerontol Int 2018; 18: 705-713.

Anticholinergic Burden and Risk of Stroke and Death in People with Different Types of Dementia.

Anticholinergic burden is associated with poorer cognitive and functional outcomes in people with dementia. However, the impact of anticholinergics on significant adverse outcomes such as stroke has not been studied previously. To investigate the association between total anticholinergic cognitive burden (ACB) and risk of stroke and death in people with different dementia subtypes. This was a cohort study of 39,107 people with dementia and no prior history of stroke registered in the Swedish Dementia Registry (SveDem) from 2008-2014. Data were extracted from the Swedish Prescribed Drug Register, the Swedish National Patient Register, and the Swedish Total Population Register. Competing risk regression models were used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between time-varying ACB score and risk of stroke and all-cause mortality. During a mean follow-up period of 2.31 (standard deviation 1.66) years, 11,224 (28.7%) individuals had a stroke or died. Compared with non-users of anticholinergic medications, ACB score of 1 (HR 1.09, 95% CI 1.04-1.14) and ACB score of ≥2 (HR 1.20, 95% CI 1.14-1.26) increased the risk of developing the composite outcome of stroke and death. When stratifying by dementia disorder, the association remained significant in Alzheimer's disease, mixed dementia, and vascular dementia. The use of anticholinergic medicines may be associated with an increased risk of stroke and death in people with dementia. A dose-response relationship was observed. Careful consideration should be made when prescribing medications with anticholinergic properties to people with dementia.