Anticholinergic Medication Burden Research Articles

Anticholinergic Medication Burden-Associated Cognitive Impairment in Schizophrenia.

Many psychotropic medications used to treat schizophrenia have significant anticholinergic properties, which are linked to cognitive impairment and dementia risk in healthy subjects. Clarifying the impact of cognitive impairment attributable to anticholinergic medication burden may help optimize cognitive outcomes in schizophrenia. The aim of this study was to comprehensively characterize how this burden affects functioning across multiple cognitive domains in schizophrenia outpatients. Cross-sectional data were analyzed using inferential statistics and exploratory structural equation modeling to determine the relationship between anticholinergic medication burden and cognition. Patients with a diagnosis of schizophrenia or schizoaffective disorder (N=1,120) were recruited from the community at five U.S. universities as part of the Consortium on the Genetics of Schizophrenia-2. For each participant, prescribed medications were rated and summed according to a modified Anticholinergic Cognitive Burden (ACB) scale. Cognitive functioning was assessed by performance on domains of the Penn Computerized Neurocognitive Battery (PCNB). ACB score was significantly associated with cognitive performance, with higher ACB groups scoring worse than lower ACB groups on all domains tested on the PCNB. Similar effects were seen on other cognitive tests. Effects remained significant after controlling for demographic characteristics and potential proxies of illness severity, including clinical symptoms and chlorpromazine-equivalent antipsychotic dosage. Anticholinergic medication burden in schizophrenia is substantial, common, conferred by multiple medication classes, and associated with cognitive impairments across all cognitive domains. Anticholinergic medication burden from all medication classes-including psychotropics used in usual care-should be considered in treatment decisions and accounted for in studies of cognitive functioning in schizophrenia.

Staff Awareness of Anti-Cholinergic Burden (ACB) - A Qualitative Cross-Sectional Study in a Tertiary Care Hospital.

Introduction and hypothesisAnticholinergics are commonly used for a variety of conditions including urinary incontinence. Many studies show the ill effects of anticholinergics on cognition resulting in increased morbidity and mortality. However, the interaction of anticholinergic medications and cumulative anti-cholinergic burden (ACB) of different medications are not well known in general population and amongst health care professionals. Our aim is to study the extent of current awareness of ACB amongst health care professionals which plays a crucial role in educating patients and avoiding these morbidities.MethodsA single centre cross-sectional study of 50 health care professionals who participated voluntarily. A questionnaire was designed to assess the knowledge, beliefs and attitudes towards anticholinergic burden and participants were also asked to choose the ACB score for 17 commonly used medications.ResultsA total of 74% participants admitted to have no understanding of the term ACB, 48% participants prescribe anticholinergics in their daily role, 44% knew that cognition was adversely affected by anticholinergics, and 16% participants were aware of scoring system. Only 16% participants routinely counsel women of cognitive side effects when anticholinergics are started. 86% reported that they would avoid prescribing medications which might affect cognition if possible. If given choice as a patient, 94% would avoid these medications if they were informed of the specific side effects like impaired cognition, physical decline, falls, hospital admissions and increased mortality.ConclusionAnticholinergic burden (ACB) is a serious phenomenon associated with increased morbidity and mortality in the general population as well as elderly population. It is evident from this study that the knowledge and awareness of ACB in our health care staff are still lacking.

A Cohort Study of Anticholinergic Medication Burden and Incident Dementia and Stroke in Older Adults.

Anticholinergic medications may increase risk of dementia and stroke, but prospective studies in healthy older people are lacking. Compare risk of incident dementia and stroke by anticholinergic burden among initially healthy older people. Prospective cohort study. Primary care (Australia and USA). 19,114 community-dwelling participants recruited for the ASPREE trial, aged 70+ years (65+ if US minorities) without major cardiovascular disease, dementia diagnosis, or Modified Mini-Mental State Examination score below 78/100. Baseline anticholinergic exposure was calculated using the Anticholinergic Cognitive Burden (ACB) score. Dementia was adjudicated using Diagnostic and Statistical Manual of Mental Disorders volume IV criteria, and stroke using the World Health Organization definition. At baseline, 15,000 participants (79%) had an ACB score of zero, 2930 (15%) a score of 1-2, and 1184 (6%) a score of ≥ 3 (indicating higher burden). After a median follow-up of 4.7 years and adjusting for baseline covariates, a baseline ACB score of ≥ 3 was associated with increased risk of ischemic stroke (adjusted HR 1.58, 95% CI 1.06, 2.35), or dementia (adjusted HR 1.36, 95% CI 1.01, 1.82), especially of mixed etiology (adjusted HR 1.53, 95% CI 1.06, 2.21). Results were similar for those exposed to moderate/highly anticholinergic medications. Residual confounding and reverse causality are possible. Assessment of dose or duration was not possible. High anticholinergic burden in initially healthy older people was associated with increased risk of incident dementia and ischemic stroke. A vascular effect may underlie this association. These findings highlight the importance of minimizing anticholinergic exposure in healthy older people.

Effects of anticholinergic medication use on brain integrity in persons living with HIV and persons without HIV.

This study examined relationships between anticholinergic medication burden and brain integrity in people living with HIV (PLWH) and people without HIV (HIV-). Neuropsychological performance z-scores (learning, retention, executive function, motor/psychomotor speed, language domains, and global cognition), and neuroimaging measures (brain volumetrics and white matter fractional anisotropy) were analyzed in PLWH (n = 209) and HIV- (n = 95) grouped according to the Anticholinergic Cognitive Burden (ACB) scale (0 = no burden, 1-3 = low burden, >3 = high burden). Neuropsychological performance and neuroimaging outcomes were compared between HIV- and PLWH with high anticholinergic burden. Within a cohort of PLWH (n = 90), longitudinal change in ACB score over ∼2 years was correlated to the rate of change per month of study interval in neuropsychological performance and neuroimaging measures. A higher number of anticholinergic medications and ACB was observed in PLWH compared with HIV- (P < 0.05). A higher ACB was associated with worse motor/psychomotor performance, smaller occipital lobe, putamen, subcortical gray matter and total gray matter volumes in HIV-; and poorer executive function, retention and global cognition, smaller brain volumes (frontal, parietal and temporal lobes, hippocampus, amygdala, cortex, subcortical gray matter and total gray matter), and reduced fractional anisotropy (posterior corpus callosum, perforant pathway) in PLWH. PLWH with high anticholinergic burden performed worse on tests of learning and executive function compared with HIV- with high anticholinergic burden. Longitudinally, PLWH who reduced their ACB over time had better neuropsychological performance and neuroimaging measures. Anticholinergic medications were associated with worse neuropsychological performance and reduced structural brain integrity, and these effects were more widespread in PLWH. Use of anticholinergic medications should be carefully monitored in older adults with deprescription considered whenever possible.

Anticholinergic drug use and risk of mortality for people with dementia in Northern Ireland

Objective Anticholinergic burden refers to the cumulative effect of medications which contain anticholinergic properties. We assessed how anticholinergic burden and different types of anticholinergic medications influence mortality rates among people with dementia in Northern Ireland. Our secondary aim was to determine what demographic characteristics predict the anticholinergic burden of people with dementia. Methods Data were extracted from the Enhanced Prescribing database for 25,418 people who were prescribed at least one dementia management medication between 2010 and 2016. Information was also extracted on the number of times each available anticholinergic drug was prescribed between 2010 and 2016, allowing the calculation of an overall anticholinergic burden. Cox proportional hazard models were used to determine how anticholinergic burden influenced mortality whilst multilevel model regression determined what demographic characteristics influence overall anticholinergic burden. Results Of the 25,418 people with dementia, only 15% (n = 3880) had no anticholinergic burden. Diazepam (42%) and risperidone (18%) were the two most commonly prescribed drugs. Unadjusted Cox proportional hazard models indicated that higher anticholinergic burden was associated with significantly higher mortality rates in comparison to people with dementia who had no anticholinergic burden (HR = 1.59: 95% CI = 1.07-2.36). In particular, urological (HR = 1.20: 95% CI = 1.05-1.38) and respiratory (HR = 1.17: 95% CI = 1.08-1.27) drugs significantly increased mortality rates. People with dementia living in areas with low levels of deprivation had significantly lower anticholinergic burden (HR=-.39: 95% CI=-.47:-30). Conclusions Reducing anticholinergic burden is essential for people with dementia. Further research should address the unfavourable prognosis of people living with dementia in highly deprived areas.

Impact of Anticholinergic Medication Burden on Mobility and Falls in the Lifestyle Interventions for Elders (LIFE) Study

Anticholinergic cognitive burden (ACB) may be associated with detrimental effects on mobility and physical independence in older adults. We evaluated the incidence of major mobility disability (MMD), persistent major mobility disability (PMMD), and injurious falls among participants within the Lifestyle Interventions for Elders (LIFE) trial according to varied anticholinergic burden levels. Participants aged 70–89 years were randomized to a physical activity (PA) or successful aging (SA) intervention and evaluated by ACB medication use as a summed score of a previously developed ACB scale. Confounders included demographic characteristics, physical function, cognitive function, and fall history. Average participant follow-up was 2.6 years and included outcome assessment for MMD, PMMD, and injurious falls every six months. Adjusted proportional hazards models evaluated the independent effects of ACB scores as well as interaction effects with the intervention. Of the 1635 participants, 986 (60%) used ≥1 anticholinergic medication. Compared to those with no burden, participants with an ACB score of 1 demonstrated increased MMD (HR = 1.42 [1.13–1.78]), PMMD (HR = 1.53 [1.12–2.09]), and injurious falls (HR = 1.60 [1.10–2.32]). Results similar in magnitude were observed for all other ACB levels versus the no burden group. Stepwise dose–response comparisons between ACB groupings did not demonstrate significant differences in outcomes. Stratification by PA or SA interventions demonstrated few differences from the combined overall trial results. Compared to those not taking anticholinergic medications, participants taking anticholinergic medications generally demonstrated increased risk of MMD, PMMD, and injurious falls. Total anticholinergic burden was not associated with a stepwise dose–response relationship in mobility disability and may lack sensitivity to capture varied responses.

Multimorbidity and Frailty: Tackling Complexity in Parkinson's Disease.

Parkinson’s disease (PD) is a condition that predominantly affects older people. It is imperative that clinical management considers the other significant illnesses that people with PD accumulate as they age in conjunction with their resilience to cope with physiological change. Multimorbidity and frailty act synergistically to heighten the risk of adverse outcomes for older people with PD. These states are associated with increased likelihood of hospitalization, polypharmacy, adverse drug effects including the anticholinergic burden of medications, drug-disease and drug-drug interactions. Management should be integrated, holistic and individualised to meticulously balance the risks of interventions considering the vulnerability of the individual to recover from disturbance to their environmental, physical and cognitive equilibrium.

Impact of Anticholinergic Medication Burden on Cognition in Schizophrenia in the Consortium on the Genetics of Schizophrenia (COGS-2) Study

Anticholinergic medications are associated with increased dementia risk in longitudinal studies of cognitively normal older adults. While psychotropic medications commonly used in the treatment of schizophrenia (SZ), including antipsychotics, mood stabilizers, antidepressants, and sedative/hypnotics have variable anticholinergic properties their cumulative effect in SZ has not been comprehensively characterized. Since cognitive impairment is a core feature of SZ, excessive anticholinergic medication burden may further compromise cognitive functioning. This study examined the relationship between anticholinergic medication burden and cognition in a large cohort of SZ patients.

One-Year Evaluation of a Targeted Medication Therapy Management Intervention for Older Adults.

Older adults are especially susceptible to adverse effects of inappropriate medication therapy, and anticholinergic medications are common culprits for cognitive dysfunction due to their action on the central nervous system. Medication therapy management (MTM) interventions can aid in deprescribing and reducing inappropriate medication use in older adults. However, there is sparse literature on the long-term sustainability of these interventions. To (a) investigate whether the deprescribing of anticholinergic medications during an 8-week randomized controlled trial (RCT) of a targeted MTM intervention is sustained at 1-year postintervention follow-up and (b) compare anticholinergic utilization trends in the study population with a large sample of similar individuals not exposed to the intervention. Participants in the targeted MTM (tMTM) RCT had normal cognition or mild cognitive impairment and were recruited from enrollees in a longitudinal study at the University of Kentucky Alzheimer's Disease Center (ADC) and thus have pertinent medical information gathered approximately annually. In this posttrial observational follow-up, sustainability of the anticholinergic deprescribing intervention was assessed in participants in the RCT, and anticholinergic medication use trends were described from the RCT baseline (which occurred immediately following an ADC visit) to the next annual visit in all participants. Mean change in anticholinergic burden from RCT baseline to the next annual visit was estimated using analysis of covariance, and participants were compared with 2 external samples. Anticholinergic burden was measured using the Anticholinergic Drug Scale (ADS). The odds of decreasing baseline anticholinergic burden and number of total and strong anticholinergic medications at the follow-up study time point was assessed using logistic regression. Of the deprescribing changes made during the initial RCT, 50% were sustained after 1 year. Participants in the tMTM trial reported decreases in the use of anticholinergic antihistamines and bladder agents (-6.5 and -4.4%, respectively), but there was no change in the use of anticholinergic agents targeted at the central nervous system. While the anticholinergic burden of RCT participants decreased over 1 year (adjusted mean ADS change [95% CI] = -0.33 [-0.72, 0.07]), it was not different than the change observed in 2 external samples at the trial center (-0.20 [-0.42, 0.02]) and nationally (-0.33 [-0.39, -0.26]). There were no statistically significant differences between trial participants and external samples in the odds of decreasing anticholinergic burden nor in decreasing the number of total, or strongly anticholinergic, medications at the 1-year follow-up. This study demonstrates that the sustainability of deprescribing is limited to the period of intervention, rather than affording lasting effects even over periods as short as 1 year, which was demonstrated not only in the small group of RCT participants but also by comparison with external groups. Future work should extend the duration of intervention and follow-up periods for MTM interventions to allow further insights regarding the sustainability of deprescribing efforts in older adults. The original trial was supported by a pilot study award from the University of Kentucky Center for Clinical and Translational Sciences (UL1TR000117). Additional support for this study was provided by the National Institutes of Health/National Institute on Aging (R01 AG054130). Jicha reports contract research for Esai, Biohaven, Alltech, Suven, Novartis, and Lilly. The other authors have nothing to disclose.

Medication burden and frailty in older adults with intellectual disability: An observational cross-sectional study.

Recently, efforts have been made to quantify frailty among older adults with intellectual disability (ID). Medication exposure is associated with frailty among older adults without ID. However, there is little research on this association among older adults with ID. The aim of this study was to examine specifically in people with ID the association between frailty and medication exposure, including anticholinergic and sedative medication exposure. Data were drawn from Wave 2 (2013/2014) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA), a nationally representative study of older adults with ID in Ireland. A modified version of Fried's frailty phenotype was constructed. Drug burden measures were polypharmacy, Drug Burden Index (DBI), Anticholinergic Cognitive Burden (ACB) and Sedative Load Model. Multinomial logistic regression was used to calculate odds ratios (ORs) and identify associations between frailty and drug burden. This study included 570 participants with ID. Excessive polypharmacy (use of ≥10 medications) was significantly associated with being pre-frail (P = .017; OR = 2.56; 95% confidence interval [CI] 1.19-5.50) and frail (P < .001; OR 7.13; 95% CI 2.81-18.12), but DBI, ACB or Sedative Load score were not significantly associated with frailty status (P > .05). This is the first study to examine frailty and its association with medication use including anticholinergic and sedative medication burden among older adults with ID. Further research is required to investigate frailty as measured by other frailty models in relation to medication burden in older adults with ID.

P.027 Relation between functional and cognitive impairments in remitted patients with bipolar disorder and suggestions for trials targeting cognition

Targeted cognitive training (TCT) has been reported to improve verbal learning deficits in patients with schizophrenia (SZ). Despite positive findings, it is not clear whether demographic factors and clinical characteristics contribute to the success of TCT on an individual basis. Medication-associated anticholinergic burden has been shown to impact TCT-associated verbal learning gains in SZ outpatients, but the role of anticholinergic medication burden on TCT gains in treatment refractory SZ patients has not been described. In this study, SZ patients mandated to a locked residential rehabilitation center were randomized to treatment as usual (TAU; n = 22) or a course of TAU augmented with TCT (n = 24). Anticholinergic medication burden was calculated from medication data at baseline and follow-up using the Anticholinergic Cognitive Burden (ACB) Scale. MATRICS Consensus Cognitive Battery Verbal Learning domain scores were used as the primary outcome variable. The TAU and TCT groups were matched in ACB at baseline and follow-up. While baseline ACB was not associated with verbal learning in either group, increases in ACB over the course of the study were significantly associated with deterioration of verbal learning in the TAU group (r = −0.51, p = 0.02). This was not seen in subjects randomized to TCT (r = −0.13, p = 0.62). Our results suggest that TCT may blunt anticholinergic medication burden associated reduction in verbal learning in severely disabled SZ inpatients.

Impact of anticholinergic burden on cognitive impairment, disability and malnutrition: a cross-sectional study among hospitalized older patients

The anticholinergic burden (ACB) is known to be associated with the worsening of functional and cognitive status. This study aims at demonstrating a correlation between the ACB and the malnutrition, given the widespread effect on the digestive tract of anticholinergic medications. From 2012 to 2018, 2843 patients were recruited among the new admissions to our Geriatric Unit. For each patient the activities of daily living (ADL), the instrumental activities of daily living (IADL), the mini mental state examination (MMSE), the cumulative illness rating scale (CIRS), the mini nutritional assessment (MNA) and the ACB of medications were evaluated. The correlations between the ACB and the ADL (P&lt;0.001), the IADL (P&lt;0.001), the MMSE (P&lt;0.001) scores were confirmed, and a significant correlation was also found between the ACB and the MNA (P&lt;0.001) score. The CIRS and the ACB scores resulted to be independent predictors of all outcomes considered, in a linear regression model adjusted for age, sex, comorbidity and number of prescribed drugs. Therefore, ACB seems to have by itself an impact on physical and cognitive functions and on nutritional status.

Verbal learning deficits associated with increased anticholinergic burden are attenuated with targeted cognitive training in treatment refractory schizophrenia patients

Targeted cognitive training (TCT) has been reported to improve verbal learning deficits in patients with schizophrenia (SZ). Despite positive findings, it is not clear whether demographic factors and clinical characteristics contribute to the success of TCT on an individual basis. Medication-associated anticholinergic burden has been shown to impact TCT-associated verbal learning gains in SZ outpatients, but the role of anticholinergic medication burden on TCT gains in treatment refractory SZ patients has not been described. In this study, SZ patients mandated to a locked residential rehabilitation center were randomized to treatment as usual (TAU; n=22) or a course of TAU augmented with TCT (n=24). Anticholinergic medication burden was calculated from medication data at baseline and follow-up using the Anticholinergic Cognitive Burden (ACB) Scale. MATRICS Consensus Cognitive Battery Verbal Learning domain scores were used as the primary outcome variable. The TAU and TCT groups were matched in ACB at baseline and follow-up. While baseline ACB was not associated with verbal learning in either group, increases in ACB over the course of the study were significantly associated with deterioration of verbal learning in the TAU group (r=−0.51, p=0.02). This was not seen in subjects randomized to TCT (r=−0.13, p=0.62). Our results suggest that TCT may blunt anticholinergic medication burden associated reduction in verbal learning in severely disabled SZ inpatients.

Anticholinergic medication burden in pediatric prolonged critical illness: a potentially modifiable risk factor for delirium

目的 介绍并理解危重症合并谵妄的流行及危险因素很重要。因为抗胆碱能药物可能增加PICU内谵妄的发生，本研究旨在量化长期住院患儿抗胆碱能药物应用情况。本研究采用抗胆碱能药物评分(anticholinergic drug scale, ADS)量化该药物负担等级及程度。 设计 回顾性队列研究，2011年1月至2015年12月。 场所 单家学院型医疗中心PICU。 对象 需要机械通气的18岁以下患儿且PICU住院时间≥15 d。 干预措施 无 方法与主要结果 88例入组患儿于入PICU 15 d内每日行ADS评分(共1 320 PICU日)，评估其与人口统计学数据、疾病严重度以及用药的关系。每日ADS评分中位值5(IQR 3，7)分。ADS评分与年龄、性别、既往用药史、现疾病评分严重度、PICU住院时间、机械通气小时数或住院病死率无关。与ADS高评分最相关的药物为低效价抗胆碱能药物如吗啡、咪达唑仑、万古霉素、皮质激素及呋塞米，但不包括雷米替丁(ADS 2分)。大剂量输注咪达唑仑患儿ADS评分显著高于低剂量或未输注咪达唑仑患儿。 结论 PICU长期机械通气患儿常输注多种有抗胆碱能作用的药物。此类药物暴露明显高于成人ICU患者报道。抗胆碱能药物暴露与谵妄有关，对PICU患儿此类暴露尚需进一步研究。

Anticholinergic Medication Burden in Pediatric Prolonged Critical Illness: A Potentially Modifiable Risk Factor for Delirium.

Objectives:It is important to describe and understand the prevalence and risk factors for the syndrome of delirium in critical illness. Since anticholinergic medication may contribute to the development of delirium in the PICU, we have sought to quantify anticholinergic medication exposure in patients with prolonged admission. We have used Anticholinergic Drug Scale scores to quantify the magnitude or extent of this burden.Design:Retrospective cohort study, January 2011 to December 2015.Setting:Single academic medical center PICU.Patients:Children under 18 years old with a PICU admission of 15 days or longer, requiring mechanical ventilation.Interventions:None.Measurements and Main Results:Daily Anticholinergic Drug Scale scores for the first 15 days of admission, in each of 88 subjects (total of 1,320 PICU days), were collected and assessed in relation to demographic data, severity of illness, and medication use. Median (interquartile range) of daily Anticholinergic Drug Scale score was 5 (interquartile range, 3–7). Anticholinergic Drug Scale score was not associated with age, sex, medical history, presenting Severity of Illness score, PICU length of stay, ventilator hours, or hospital mortality. Medications most frequently associated with high Anticholinergic Drug Scale score were low potency anticholinergic drugs such as morphine, midazolam, vancomycin, steroids, and furosemide, with the exception of ranitidine (Anticholinergic Drug Scale score 2). Patients receiving high doses of midazolam infusion had significantly higher Anticholinergic Drug Scale scores compared with those receiving lower or no midazolam dosing.Conclusions:A high number of medications with anticholinergic effects are administered to PICU patients receiving prolonged mechanical ventilation. These exposures are much higher than those reported in adult intensive care patients. Since anticholinergic drug exposure is associated with delirium, further study of this exposure in PICU patients is needed.

PMU22 - ANTICHOLINERGIC BURDEN IN OLDER PATIENTS: PHARMACIST INTERVENTION

To analyse the anticholinergic risk (AR) in elderly nursing home patients. Anticholinergic drugs in elderly people have been associated with some serious side-effects, ranging from dry mouth, constipation, and visual impairments to confusion, delirium, and severe cognitive decline. The toxicity is often the result of the cumulative anticholinergic burden of multiple prescription medications and metabolites rather than of a single compound. A cross-sectional study including all elderly patients residing in a nursing home in May 2018. Age, sex and pharmacotherapy were collected for each patient. AR was calculated using an Anticholinergic Burden web tool Calculator which includes 10 different Anticholinergic scales described in a systematic review. The scales offer final AR scores classified in three groups: low, medium and high, according to the risk categorisation made by the authors of each scale. Higher scores are associated with increased AR. We analysed 111 patients; mean age:73.93±8.35 years, 79.28% males. Mean prescribed drugs: 7.39±3.94. There were 16 patients (14.41%) without risk; 35 (31.53%) with medium risk and 35 (31.53%) with high risk. Twenty-five patients (22.52%) did not receive any anticholinergic drug.According to AR score, 70 patients (58.3%) were taking at least one anticholinergic drug, 39 drugs were involved.We identified 39 drugs with anticholinergic potency being the most common: alprazolam (43.6%), mirtazapine (25.6%), lorazepam (23.1%), sertraline (20.5%). Regarding ATC code, drugs from “N05 psycholeptics” group were mainly involved (30.63%); followed by “N06. Psychoanaleptics” (10.81%)and “A10. Drugs used in diabetes”(9.9%). A high proportion of elderly patients are at risk of anticholinergics adverse events because of their prescribed treatment. In consequence, detection of AR can be an important strategy for optimising treatment in these patients, particularly in those suffering from dementia. Pharmaceutical care in elderly nursing home enables the optimisation of pharmacotherapy, improving patient safety. REFERENCES AND/OR ACKNOWLEDGEMENTS All staff of Geriatric-Healthcare Centre.

206Audit of Anticholinergic Medication Burden in Nursing Home Residents and Associated Falls Risk

206Audit of Anticholinergic Medication Burden in Nursing Home Residents and Associated Falls Risk

A high anticholinergic burden is associated with a history of falls in the previous year in middle-aged women: findings from the Aberdeen Prospective Osteoporosis Screening Study

PurposeTo examine the cross-sectional association between anticholinergic medication burden (ACB) and a history of falls, bone mineral density, and low trauma fractures in middle-aged women aged under 65 years from the Aberdeen Prospective Osteoporosis Screening Study. MethodsACB (0 = none, 1 = possible, ≥2 = definite) was calculated from medication use for 3883 Caucasian women [mean age (SD) = 54.3 (2.3) years] attending the second Aberdeen Prospective Osteoporosis Screening Study visit (1997–2000). Outcomes were examined using logistic regression. Model adjustments were selected a priori based on expert opinion. ResultsOf 3883 participants, 3293 scored ACB = 0, 328 scored ACB = 1, and 262 scored ACB ≥2. High ACB burden (≥2) was associated with increased odds (ACB = 0 reference) for falls (fully adjusted odds ratio [95% confidence intervals] = 1.81 [1.25–2.62]; P = 0.002) and having low bone mineral density (lowest quintile-20%) at Ward's triangle (3.22 [1.30–7.99]; P = 0.01). A history of falls over the year prior to the study visit in participants with ACB score ≥2 was 32 per 100. For ACB categories 1 and 0, a history of falls per 100 was 21 and 22, respectively. ConclusionsThe risk of falling associated with ACB observed in older age may also extend to middle-aged women.

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.

Reducing Anticholinergic Medication Burden in Patients With Psychotic or Bipolar Disorders.

Anticholinergic medications are prescribed to treat extrapyramidal side effects (EPS) associated with antipsychotics. Anticholinergic medications cause several side effects and can often be withdrawn during the maintenance phase of antipsychotic treatment without EPS reemergence. The purpose of this quality improvement (QI) project was to reduce anticholinergic medication burden and improve quality of life in patients with severe mental illness. Patients with DSM-IV-TR-diagnosed schizophrenia, schizoaffective disorder, and bipolar disorders in an outpatient psychiatric clinic who were prescribed benztropine were identified, screened for anticholinergic side effects by the treating psychiatrist, and referred to an on-site clinical pharmacist for a comprehensive medication review. Anticholinergic side effects, cognitive impairment, and impact on quality of life were assessed using a Likert scale. Recommendations for potential medication changes were discussed with the prescriber. Initial and follow-up assessments were conducted over 1-8 months to identify improvements in side effects and quality of life. Twenty-nine patients were assessed from November 2014 to December 2015. Patients were receiving from 1 to 6 medications with anticholinergic properties (median = 3 medications). Of the 29 patients, 19 were recommended for a medication change, with 13 having 1 or more anticholinergic medications discontinued and 6 having the dose decreased. A significant reduction in anticholinergic side effects and improvements in memory and quality of life were observed for these patients (P ≤ .05). In this interdisciplinary, collaborative QI project, patients whose anticholinergic burden was reduced experienced a significant improvement in side effects, memory, and quality of life.