Anticholinergic Risk Scale Score Research Articles

Exploring the impact of anticholinergic burden on urinary independence: insights from a post-stroke cohort of older adults.

Anticholinergic burden is associated with adverse events in the older adults. However, there is a lack of evidence regarding its effect on urinary independence in stroke patients. This study examined the association between increased anticholinergic burden during hospitalization and urinary independence in post-stroke patients undergoing rehabilitation. This observational cross-sectional study included stroke patients admitted to a post-acute rehabilitation hospital between 2020 and 2022 who were not independently urinating. The degree of urinary independence was assessed using the Functional Independence Measure-Bladder (FIM-Bladder), a subscale of the motor domain of the FIM, and urinary independence was defined as FIM-Bladder ≥ 6. Anticholinergic burden was assessed using the anticholinergic risk scale (ARS), and changes in ARS during hospitalization were calculated by subtracting the value at admission from the value at discharge. The study outcome was urinary independence at discharge. Logistic regression analysis was used to examine whether change in ARS score was independently associated with the outcome. Statistical significance was set at P < 0.05. Of the 573 patients enrolled, 312 patients (mean age 77.5years, 51.9% male) were included in the analysis. ARS increased during hospitalization in 57 patients (18.3%). Change in ARS score was independently associated with urinary independence (odds ratio: 0.432, 95% confidence interval: 0.247-0.756, P = 0.003). Increased anticholinergic burden in post-stroke patients who require assistance with urination is significantly associated with less independent urination. Anticholinergic agents may need to be introduced cautiously in patients who require assistance with urination.

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 Burden, Polypharmacy, and Cognition in Parkinson’s Disease Patients with Mild Cognitive Impairment: A Cross-Sectional Observational Study

Introduction: Anticholinergic burden may be an important risk factor for the cognitive impairment. Especially in polypharmacy, even drugs with low anticholinergic effects may contribute to a significant anticholinergic burden. The drugs with anticholinergic effects are used in treatment of motor and nonmotor symptoms of Parkinson’s disease (PD). Therefore, it is important to screen for polypharmacy and anticholinergic burden in PD patients with mild cognitive impairment (MCI). Methods: This cross-sectional study was conducted with 58 patients with PD. PD-MCI was diagnosed according to MDS Level 2 Comprehensive Assessment. Cognitive performance (attention – working memory, executive functions, language, memory, and visuospatial functions) of patients was evaluated. The anticholinergic burden was scored by Anticholinergic Cognitive Burden (ACB) Scale, Anticholinergic Risk Scale (ARS), and Anticholinergic Drug Scale (ADS). Results: There was no significant difference in anticholinergic burden between PD-MCI and PD-normal cognition. A significant concordance was observed between ACB, ARS, and ADS scores (p < 0.001; Kendall’s W = 0.653). While the variable predicting anticholinergic burden was the total number of drugs for ACB and ADS scales, it was the number of antiparkinson drugs for ARS scale. Conclusion: Patients with PD are at high risk for polypharmacy and anticholinergic burden. Anticholinergic burden should be considered in the selection of drugs, especially for comorbidities in patients with PD. No significant correlation was found between the cognition and anticholinergic burden in patients with PD-MCI. Although the risk scores of antiparkinson and other drugs were different among the 3 scales, significant concordance was observed between scales.

Anticholinergic burden in older adult inpatients: patterns from admission to discharge and associations with hospital outcomes.

Background:Anticholinergic medications are associated with adverse outcomes in older adults and should be prescribed cautiously. We describe the Anticholinergic Risk Scale (ARS) scores of older inpatients and associations with outcomes.Methods:We included all emergency, first admissions of adults ⩾65 years old admitted to one hospital over 4 years. Demographics, discharge specialty, dementia/history of cognitive concern, illness acuity and medications were retrieved from electronic records. ARS scores were calculated as the sum of anticholinergic potential for each medication (0 = limited/none; 1 = moderate; 2 = strong and 3 = very strong). We categorised patients based on admission ARS score [ARS = 0 (reference); ARS = 1; ARS = 2; ARS ⩾ 3] and change in ARS score from admission to discharge [admission and discharge ARS = 0 (reference); same; decreased; increased]. We described anticholinergic prescribing patterns by discharge specialty and explored multivariable associations between ARS score categories and mortality using logistic regression [odds ratios (ORs), 95% confidence intervals (CIs)].Results:From 33,360 patients, 10,183 (31%) were prescribed an anticholinergic medication on admission. Mean admission ARS scores were: Cardiology and Stroke = 0.56; General Medicine = 0.78; Geriatric Medicine = 0.83; Other medicine = 0.81; Trauma and Orthopaedics = 0.66; Other Surgery = 0.65. Mean ARS did not increase from admission to discharge in any specialty but reductions varied significantly, from 4.6% (Other Surgery) to 27.7% (Geriatric Medicine) (p < 0.001). The odds of both 30-day inpatient and 30-day post-discharge mortality increased with admission ARS = 1 (OR = 1.21, 95% CI 1.01–1.44 and OR = 1.44, 1.18–1.74) but not with ARS = 2 or ARS ⩾ 3. The odds of 30-day post-discharge mortality were higher in all ARS change categories, relative to no anticholinergic exposure (same: OR = 1.45, 1.21–1.74, decreased: OR = 1.27, 1.01–1.57, increased: OR = 2.48, 1.98–3.08).Conclusion:The inconsistent dose–response associations with mortality may be due to confounding and measurement error which may be addressed by a prospective trial. Definitive evidence for this prevalent modifiable risk factor is required to support clinician behaviour-change, thus reducing variation in anticholinergic deprescribing by inpatient speciality.Plain language summary We describe how commonly medicines which block the chemical acetylcholine are prescribed to older adults admitted to hospital as an emergency and explore links between these medicines and death during or soon after hospital admission Backgroud: Medicines which block the chemical acetylcholine are commonly prescribed to treat symptoms such as itch and difficulty sleeping or to treat medical conditions such as depression. However, some studies in older adults have found potential links between these medicines and confusion and falls. Therefore, doctors are recommended to prescribe these drugs cautiously in adults aged 65 years and over.Methods: In our paper we use data collected as part of routine medical care at one university hospital to describe how often these medicines are prescribed in a large sample of older adults admitted to hospital as an emergency. We look at the medicines patients are prescribed on admission to the hospital and also when they are later discharged.Results: We find that these medicines are frequently prescribed. We also find that, in general, patients are prescribed fewer of these potentially harmful medicines on hospital discharge compared with hospital admission. This suggests that clinicians are aware of advice to prescribe acetylcholine blocking medicines cautiously and they are more often stopped in hospital than started. However, we find a lot of variation in practice depending on which hospital specialty was caring for the patient during their inpatient stay. We also find potential links with these medicines and death during the admission or soon after hospital discharge, but these potential links are not always consistent.Conclusion: Further study is needed to fully understand links between medicines that block acetylcholine and late life health. This will be important to reduce variation in prescribing practices.

Relationship between Anticholinergic Burden and Health-Related Quality of Life among Residents in Long-Term Care

ObjectivesAnticholinergic burden defined by the Anticholinergic Risk Scale (ARS) has been associated with cognitive and functional decline. Associations with health-related quality of life (HRQoL) have been scarcely studied. The aim of this study was to examine the association between anticholinergic burden and HRQoL among older people living in long-term care. Further, we investigated whether there is an interaction between ARS score and HRQoL in certain underlying conditions.Design and participantsCross-sectional study in 2017. Participants were older people residing in long-term care facilities (N=2474) in Helsinki.MeasurementsData on anticholinergic burden was assessed by ARS score, nutritional status by Mini Nutritional Assessment, and HRQoL by the 15D instrument.ResultsOf the participants, 54% regularly used ARS-defined drugs, and 22% had ARS scores ≥2. Higher ARS scores were associated with better cognition, functioning, nutritional status and higher HRQoL. When viewing participants separately according to a diagnosis of dementia, nutritional status or level of dependency, HRQoL was lower among those having dementia, worse nutritional status, or being dependent on another person’s help (adjusted for age, sex, comorbidities). Significant differences within the groups according to ARS score were no longer observed. However, interactions between ARS score and dementia and dependency emerged.ConclusionIn primary analysis there was an association between ARS score and HRQoL. However, this relationship disappeared after stratification by dementia, nutritional status and dependency. The reasons behind the interaction concerning dementia or dependency remain unclear and warrant further studies.

Association of Preoperative Anticholinergic Medication Exposure With Postoperative Healthcare Resource Use and Outcomes: A Population-based Cohort Study.

The aim of this study was to measure the association of preoperative anticholinergic exposure with length of stay (LOS) and other outcomes in older people having elective noncardiac surgery. Anticholinergic medications are associated with adverse events in nonsurgical populations; the association of anticholinergic medications with outcomes in elective surgery patients is poorly described. We conducted a retrospective, population-based cohort study using linked administrative data in Ontario, Canada. We identified all people >65 years old, from 2003 to 2014, having major, elective noncardiac surgery. Anticholinergic medication exposure was quantified using the Anticholinergic Risk Scale (ARS). Multilevel, multivariable modeling measured the adjusted association of ARS with LOS (primary outcome), institutional discharge, readmissions, costs, and survival (secondary outcomes). Of 245,410 individuals, 71,569 had anticholinergic exposure (ARS 1-2, 15.6%; ARS ≥3, 13.6%). Median LOS was 5 days (interquartile range 3-7). Using proportional hazards analysis to model time to discharge, adjusting for in-hospital death as a competing risk, and surgical risk, demographic characteristics, and comorbidities, higher ARS scores were associated with longer LOS [smaller hazard ratios (HRs) mean longer LOS; ARS 1-2: adjusted HR 0.94, 95% confidence interval (CI), 0.93-0.95, P < 0.0001; ARS ≥3: adjusted HR 0.93, 95% CI, 0.91-0.95, P < 0.0001]. Similar associations were observed for all secondary outcomes. Increasing ARS scores were associated with increased LOS, decreased survival, higher rates of institutional discharge and readmission, and higher costs of care. Perioperative interventional research to reduce the anticholinergic exposure in older surgical patients is likely warranted.

Temporal Trends in the Use of Anticholinergic Drugs Among Older People Living in Long-Term Care Facilities in Helsinki.

BackgroundThe use of drugs with anticholinergic properties (DAPs) is common among older adults despite their known adverse effects, such as cognitive decline. Professionals should pay attention to DAPs, since evidence on their adverse effects has been accumulating during the last decade. However, to our knowledge previous studies exploring temporal trends in the use of DAPs are scarce.ObjectiveThe aim of this study was to assess temporal trends in the use of DAPs from 2003 to 2017 in long-term care facilities in Helsinki.MethodsFour cross-sectional studies were conducted in 2003, 2007, 2011, and 2017. Participants included older people (≥ 65 years) living in nursing homes (NHs) in 2003 (n = 1979), 2011 (n = 1568), and 2017 (n = 750), and in assisted living facilities (ALFs) in 2007 (n = 1336), 2011 (n = 1556), and 2017 (n = 1673) in Helsinki, Finland. Data on demographics, medication use, and diagnoses were collected by structured questionnaires. The assessments were conducted as a point prevalence over 1 day. The use of DAPs and the total anticholinergic burden were defined by the Anticholinergic Risk Scale (ARS).ResultsIn ALFs, there has been an increasing trend in the use of DAPs over a 10-year period (41.2% in 2007 and 53.7% in 2017). In NHs, by contrast, the use of DAPs remained quite stable (52.3% in 2003 and 52.4% in 2017). The burden of DAPs measured by ARS score decreased in NHs and remained stable in ALFs. Marked changes occurred in the DAPs used; antidepressants, especially mirtazapine, increased in both settings, whereas the use of hydroxyzine and urinary antispasmodics nearly disappeared. The proportion of users of DAP antipsychotics increased in ALFs. Participants with dementia had a lower anticholinergic burden than those without dementia, in both settings.ConclusionsDespite increased knowledge of the harms of DAPs, they remain widely used. Physicians seem to be aware of the harms of DAPs among people with dementia, and some other favorable trends in prescribing were also observed. Clinicians should especially consider the indications behind the use of DAP antidepressants and antipsychotics, and carefully weigh their potential benefits and harms.

Anticholinergic Load and Nutritional Status in Older Individuals.

The association between anticholinergic load-based Anticholinergic Risk Scale scores and nutritional status is unclear in Japanese patients. The aim of this study was to establish whether anticholinergic load affects the nutritional status of geriatric patients in convalescent stages. Retrospective longitudinal cohort study. Convalescent rehabilitation wards. Of the 1490 patients aged ≥65 years who were discharged from convalescent rehabilitation wards between July 2010 and October 2018, 908 patients met the eligibility criteria. They were categorized according to the presence or absence of increased anticholinergic load from admission to discharge. Demographic data, laboratory data, the Functional Independence Measure were analyzed between the groups. The primary outcome was Geriatric Nutritional Risk Index (GNRI) at discharge. Multiple linear regression analysis was performed to analyze the relationship between anticholinergic load and GNRI at discharge. Multiple linear regression analysis after adjusting for confounding factors revealed that anticholinergic load was independently and negatively correlated with GNRI at discharge. Particularly, the use of chlorpromazine, hydroxyzine, haloperidol, metoclopramide, risperidone, etc. increased significantly from admission to discharge. Increased anticholinergic load during hospitalization may be a predictor of nutritional status in geriatric patients.

Impact of anticholinergic burden on emergency department visits among older adults in Korea: A national population cohort study

ObjectivesThis study aimed to evaluate the impact of high anticholinergic burden on overall emergency department (ED) visits and ED visits related to adverse effects of anticholinergic drugs among older adults. MethodsFor this retrospective cohort study, we used claims data from older adults with high representativeness. The average daily Anticholinergic Risk Scale (ARS) score was calculated based on the dosage, treatment duration, and potency of anticholinergic drugs during three months. A high-exposure group (ARS ≥ 2) and a non-exposure group were included in this analysis. The primary outcome was the first ED visit during the follow-up period. Anticholinergic ED visits were defined as ED visits with a main diagnosis of a fall, fracture, dizziness, delirium, constipation, or urinary retention. ResultsIn total, 118,750 subjects (43.6% male) were included in this study. The mean age was 75.4 ± 6.6 years. The adjusted hazard ratios (aHRs) for all-cause and anticholinergic ED visits among those with high ARS scores were 1.28 (95% CI: 1.20–1.36) and 1.55 (95% CI: 1.38–1.74), respectively. The high-exposure group was at higher risk than the non-exposure group for ED visits for falls or fractures (aHR: 1.31, 95% CI: 1.07–1.60), dizziness (aHR: 1.71, 95% CI: 1.36–2.14), delirium (aHR: 2.05, 95% CI: 1.13–3.73), constipation (aHR: 1.65, 95% CI: 1.35–2.02) and urinary retention (aHR: 1.66, 95% CI: 1.30–2.12). ConclusionsThis study demonstrated that a high anticholinergic burden in older adults increased the risk of all-cause ED visits, anticholinergic ED visits and specific-cause ED visits.

Anticholinergic drugs use and risk of hip fracture in geriatric patients.

Limited research exists regarding the effect of anticholinergic drugs on fracture in geriatric Japanese patients. The aim of the present study was to establish whether anticholinergic load affects hip fracture and to clarify the risk based on the Anticholinergic Risk Scale score among geriatric patients in a convalescent rehabilitation setting. The present nested case-control study included consecutive geriatric patients admitted and discharged from the convalescent rehabilitation ward between 2010 and 2016. Participants were divided based on the presence or absence of hip fracture during hospitalization. Demographic data, laboratory data and the Functional Independence Measure were analyzed between groups. The primary outcome was the presence of hip fracture. Multiple logistic regression analysis was carried out to analyze the relationship between anticholinergic drug use and hip fracture. In total, 601 participants (210 men, 391 women; interquartile range 73-85 years) were included in the present study. Multiple logistic regression analysis of hip fracture, adjusting for confounding factors, showed that anticholinergic drug use was independently and positively correlated with hip fracture. In particular, an increase in the Anticholinergic Risk Scale score by 2 points correlates with a 2.86-fold greater risk for hip fracture, and an increase of ≥3 points results in a 4.21-fold greater risk, both being statistically significant results. Increased anticholinergic load during hospitalization might be a predictor of increased hip fracture in geriatric patients. Geriatr Gerontol Int 2018; 18: 1340-1344.

Anticholinergic load negatively correlates with recovery of cognitive activities of daily living for geriatric patients after stroke in the convalescent stage.

Anticholinergic drugs are associated with risks of falls, confusion and cognitive dysfunction. However, the effect of anticholinergic drug use on rehabilitation outcomes after a stroke is poorly documented. We therefore aimed to establish whether the anticholinergic load was associated with functional recovery among geriatric patients convalescing after stroke. Consecutive geriatric stroke patients admitted and discharged from a convalescence rehabilitation ward between 2010 and 2016 were included in this retrospective cohort study. Anticholinergic load was assessed by the Anticholinergic Risk Scale (ARS), and functional recovery was assessed by the Functional Independence Measure (FIM). The primary outcome was cognitive FIM (FIM-C) gain, but we also assessed the interaction of other putative factors identified from univariate analysis. Multivariate analyses were performed, adjusting for confounding factors. We included 418 participants (171 males, 247 females) with a median age of 78years (interquartile range, 72-84years). Multiple regression analysis revealed that ARS change, length of stay, and epilepsy were independently and negatively correlated with cognitive FIM gain. Multiple logistic regression analysis indicated that the "Comprehension" and "Memory" items of the cognitive FIM gain were independently and negatively associated with anticholinergic load. A causal relationship cannot be established, but increased ARS scores during hospitalization may predict limited cognitive functional improvement in geriatric patients after stroke. Alternatively, cognitive impairment may lead to increased use of anticholinergic drugs.

Is cognitive impairment associated with antipsychotic dose and anticholinergic equivalent loads in first-episode psychosis?

Cognitive deficits are a core feature of early stages in schizophrenia. However, the extent to which antipsychotic (AP) have a deleterious effect on cognitive performance remains under debate. We aim to investigate whether anticholinergic loadings and dose of AP drugs in first episode of psychosis (FEP) in advanced phase of remission are associated with cognitive impairment and the differences between premorbid intellectual quotient (IQ) subgroups. Two hundred and sixty-six patients participated. The primary outcomes were cognitive dimensions, dopaminergic/anticholinergic load of AP [in chlorpromazine equivalents (Eq-CPZ) and the Anticholinergic Risk Scale (ARS), respectively]. Impairments in processing speed, verbal memory and global cognition were significantly associated with high Eq-CPZ and verbal impairment with high ARS score. Moreover, this effect was higher in the low IQ subgroup. Clinicians should be aware of the potential cognitive impairment associated with AP in advanced remission FEP, particularly in lower premorbid IQ patients.

Evaluation of a pharmacist-led pilot service based on the anticholinergic risk scale

ObjectivesTo determine primary care physician (PCP) acceptance rates of electronic medication therapy recommendations based on anticholinergic burden for high-risk elderly patients, and to evaluate potential associations between recommendation acceptance and patient-provider characteristics. SettingTwo medical clinics within Dean Health System, an integrated health care organization comprising ambulatory surgery centers, medical clinics, community pharmacies, specialty pharmacies, a health plan, and a pharmacy benefits management company. Practice InnovationIn this pilot service, the medical records of patients at least 60 years old who met the following criteria were evaluated bimonthly: 1) PCP visit within 2 weeks; (2) three or more inpatient hospitalizations or emergency department visits in the past year; and (3) ten or more active medications. Anticholinergic Risk Scale (ARS) scores of eligible patients were calculated, and medication therapy recommendations were sent electronically to PCPs for patients with an ARS score greater than 3. Post-visit recommendation outcomes were recorded. EvaluationDescriptive statistics were utilized to characterize patients, physicians, and recommendations. A generalized linear mixed effects model with physician specific random effects was employed to evaluate recommendation acceptance rates, and odds ratios were calculated to quantify associations between baseline patient/provider characteristics and the likelihood of recommendation acceptance. Changes in aggregate ARS scores were evaluated with the use of a paired t test. ResultsFifty-nine patients were included in this pilot, with 89 medication therapy recommendations made to 21 PCPs. An overall recommendation acceptance rate of 50% (95% confidence interval [CI] 37%–63%) was observed. There were no significant associations identified between baseline patient/provider characteristics and medication recommendation acceptance. ConclusionHigh recommendation acceptance rates were achieved with the combination of objective anticholinergic risk assessment and algorithm-driven medication therapy recommendations. The lack of identified associations between patient/provider characteristics and recommendation acceptance supports the future scalability of this novel service.

Associations between Anticholinergic Burden and Adverse Health Outcomes in Parkinson Disease.

BackgroundElderly adults should avoid medications with anticholinergic effects since they may increase the risk of adverse events, including falls, delirium, and cognitive impairment. However, data on anticholinergic burden are limited in subpopulations, such as individuals with Parkinson disease (PD). The objective of this study was to determine whether anticholinergic burden was associated with adverse outcomes in a PD inpatient population.MethodsUsing the Cerner Health Facts® database, we retrospectively examined anticholinergic medication use, diagnoses, and hospital revisits within a cohort of 16,302 PD inpatients admitted to a Cerner hospital between 2000 and 2011. Anticholinergic burden was computed using the Anticholinergic Risk Scale (ARS). Primary outcomes were associations between ARS score and diagnosis of fracture and delirium. Secondary outcomes included associations between ARS score and 30-day hospital revisits.ResultsMany individuals (57.8%) were prescribed non-PD medications with moderate to very strong anticholinergic potential. Individuals with the greatest ARS score (≥4) were more likely to be diagnosed with fractures (adjusted odds ratio (AOR): 1.56, 95% CI: 1.29–1.88) and delirium (AOR: 1.61, 95% CI: 1.08–2.40) relative to those with no anticholinergic burden. Similarly, inpatients with the greatest ARS score were more likely to visit the emergency department (adjusted hazard ratio (AHR): 1.32, 95% CI: 1.10–1.58) and be readmitted (AHR: 1.16, 95% CI: 1.01–1.33) within 30-days of discharge.ConclusionsWe found a positive association between increased anticholinergic burden and adverse outcomes among individuals with PD. Additional pharmacovigilance studies are needed to better understand risks associated with anticholinergic medication use in PD.

Prevalence of Anticholinergic Medication Use in the Program of All-Inclusive Care for the Elderly.

Evaluate the prevalence of anticholinergic medication use in the Program of All-Inclusive Care for the Elderly (PACE). Cross-sectional, retrospective chart review. The Basics at Jan Werner PACE, Amarillo, Texas. PACE participants (n = 128) and long-term care residents (n = 105) 65 years of age and older. The primary outcome was percentage of prescribed medications with anticholinergic properties and risk factors associated with prescribing: study site, gender, race, age, and creatinine clearance. Anticholinergic medication prescribing was significantly lower in the PACE program (2.3% of total medications vs. 3.9%; P < 0.05) as well as total medication use (12.1 medications per subject vs. 20.8; P < 0.05 in the long-term care environment). Only the long-term care study site had a significant association with anticholinergic prescribing (odds ratio = 5.04, confidence interval 2.71-9.38). PACE participants also had lower Anticholinergic Risk Scale scores (score of 0, 60.2% PACE vs. 16.2%), reduced fall rates (23.8 per month PACE vs. 66.9), and similar hospitalization rates (5.4 per month PACE vs. 5.7). PACE participants were prescribed fewer medications and had lower anticholinergic burden, which potentially lowers their risk of adverse effects. These data support the PACE interdisciplinary model by demonstrating the benefit of team care in appropriate use of medications. It provides a potential blueprint to organizations aimed at reducing potentially inappropriate medication prescribing in older adults.

Impact of anticholinergic load on bladder function.

Our aim was to evaluate the impact of anticholinergic load on urinary retention based on postvoid residual (PVR) on micturition study. Secondary objectives were to assess the effect of anticholinergic load on other urodynamic parameters. This was a retrospective cohort study of women who underwent urodynamics (UDS) at one academic institution. All medications being taken by the women at the time of UDS were scored using the anticholinergic risk scale (ARS). This validated scale assigns rank scores to each medication based on its anticholinergic potential. Women were dichotomized into two anticholinergic cohorts: low (0-1) or high (≥2) ARS scores. During the study period, 599 women underwent UDS. ARS scores ranged from 0 to 8, with 440 (73.5 %) having low (≤1) and 159 (26.5 %) having high (≥2) scores. For our primary outcome of micturition PVR, there was no difference between low and high ARS groups (66.8 ± 108.6 ml vs. 78.6 ± 121.0 ml, p = 0.25). There was also no difference between ARS groups in other voiding function parameters. Sensitivity analyses did demonstrate a difference in micturition PVR, with ARS 0-4 (n = 583) vs. ARS ≥ 5 (n = 16): 68.3 ± 109.1 ml vs. 127.5 ± 185.7 (p < 0.01) ,as well as maximum cystometric capacity (MCC): 420.8 ± 181.3 ml vs. 526.1 ± 252.4 ml (p = 0.02). Despite the prevalence and risks associated with the use of medications with anticholinergic properties, a cumulative effect on bladder function was only demonstrated with very high anticholinergic risk scores of ≥5.

Perioperative anticholinergic medications and risk of catheterization after urogynecologic surgery.

This study aimed to examine how anticholinergic medication exposure affects the risk of failed postoperative void trial (VT) in women undergoing urogynecologic surgery. We conducted a retrospective cohort study of women undergoing outpatient prolapse or incontinence surgery. We evaluated perioperative anticholinergic exposure via the validated anticholinergic risk scale (ARS). Total ARS score was calculated by summing the individual ARS for each medication used during the following periods: at home before surgery, in preoperative holding, intraoperatively, and in postoperative recovery. The "low anticholinergic exposure" cohort (total ARS, ≤7) was compared to the "high anticholinergic exposure" cohort (total ARS, ≥8) to assess our primary outcome: failed postoperative VT on day of surgery. Of 125 women in the study, 98 (78%) had low anticholinergic exposure and 27 (22%) had high anticholinergic exposure. Overall, 28 (22%) patients failed the postoperative VT. Women in the high anticholinergic group had a significantly higher risk of a failed VT (41% vs 17%, P = 0.01 for high vs low anticholinergic groups, respectively). In logistic regression analysis, adjusting for age, body mass index, diabetes, midurethral sling and anterior repair, high anticholinergic exposure (AOR, 4.15; 95% confidence interval, 1.49-11.57), and anterior repair (AOR, 3.15; 95% CI, 1.15-8.61) remained significantly associated with failed postoperative VT. Higher exposure to perioperative anticholinergic medications increases the risk of a failed postoperative VT after outpatient urogynecologic surgery.

Drug Burden Index Score and Anticholinergic Risk Scale as Predictors of Readmission to the Hospital

Determine the association between different measures of drug exposure such as an increased Drug Burden Index (DBI) and a higher Anticholinergic Risk Scale (ARS) score in vulnerable elders and risk of readmission to the hospital. The study is a retrospective cohort comparing ARS and DBI between patients readmitted and not readmitted to the hospital within 30 days of initial admission. Data collected included drugs considered to have anticholinergic, sedative, or both types of properties (Appendix 1), medication strengths, doses per day, patient age, Vulnerable Elders Survey (VES-13) score upon admission, patient diagnoses, and rates of admission. Nonprofit, 838-bed, regional health system of four hospitals. Patients were included in the study if they were admitted to a hospital floor, were 65 years of age or older, were assessed using VES-13, and did not have routinely visiting family to engage them as observed by floor nurses. None; retrospective study. Readmission rate. The mean difference in DBI and ARS scores were higher in the readmitted group. Hydrocodone and hydroxyzine were the most commonly used drugs in the readmitted group that were considered when determining DBI. There is a role for screening and clinical intervention in vulnerable elders using DBI and ARS to help identify those at greatest risk for readmission to the hospital.

Polypharmacy, Drug–Drug Interactions, and Potentially Inappropriate Medications in Older Adults with Human Immunodeficiency Virus Infection

To describe the frequency of medication-related problems in older adults with human immunodeficiency virus (HIV) infection. Retrospective chart review. Community. HIV-positive individuals aged 60 and older and age- and sex-matched HIV-negative individuals. Total number of medications, potentially inappropriate medications (PIMs) according to the modified Beers Criteria, anticholinergic drug burden according to the Anticholinergic Risk Scale (ARS), and drug-drug interactions using the Lexi-Interact online drug interactions database. Of 89 HIV-positive participants, most were Caucasian (91%) and male (94%), with a median age of 64 (range 60-82). Common comorbidities included hyperlipidemia, hypertension, and depression. Participants were taking a median of 13 medications (range 2-38), of which only a median of four were antiretrovirals. At least one PIM was prescribed in 46 participants (52%). Sixty-two (70%) participants had at least one Category D (consider therapy modification) drug-drug interaction, and 10 (11%) had a Category X (avoid combination) interaction. One-third of these interactions were between two nonantiretroviral medications. Fifteen participants (17%) had an ARS score of 3 or greater. In contrast, HIV-negative participants were taking a median of six medications, 29% had at least one PIM, and 4% had an ARS score of 3 or greater (P < .05 for each comparison, except P = .07 for anticholinergic burden). HIV-positive older adults have a high frequency of medication-related problems, of which a large portion is due to medications used to treat comorbid diseases. These medication issues were substantially higher than HIV-negative participants. Attention to the principles of geriatric prescribing is needed as this population ages in order to minimize complications from multiple medication use.

Minimizing anticholinergic drug prescribing in older hospitalized patients: a full audit cycle.

Anticholinergic drugs are associated with poor outcomes in older patients but no specific intervention strategies aimed at reducing anticholinergic drug exposure have been described. To identify whether a consultant-led medication review targeting anticholinergics would reduce anticholinergic drug exposure [number of anticholinergic drugs and Anticholinergic Risk Scale (ARS) score]. The first phase of the audit included 70 consecutive admissions (mean age 84 years, 53 women). ARS score was calculated on admission and after initial consultant review. Re-audit was undertaken on another 70 consecutive admissions (mean age 83 years, 43 women) after introducing a system of informing the responsible consultant of the ARS score at their first review. Drugs with anticholinergic effects (n = 53) were prescribed preadmission to 45/140 (32%) of patients. Consultant geriatrician review reduced ARS scores (p = 0.01), especially following the introduction of the information system (p = 0.002). In the first arm of the audit, 51 (73%) patients had ARS of 0 after a consultant's review compared with 47 (67%) patients on admission, whilst 67 (96%) patients had ARS of 2 or less after a consultant's review compared with 63 (90%) patients on admission. In the second arm of the audit, 59 (84%) patients had ARS of 0 after a consultant's review compared with 48 (69%) patients on admission, whilst 70 (100%) patients had ARS of 2 or less after a consultant's review compared with 69 (99%) patients on admission. Anticholinergic drugs were either stopped, or their dose reduced, in 35% of patients in the first arm of the audit and in 73% of patients in the re-audit (odds ratio 5.0, 95% confidence interval 1.4-17.8). Consultant-led medication review (standard practice) was effective at reducing anticholinergic drug exposure in the acute setting. A system of alerting clinicians to patients prescribed anticholinergic medications further reduced anticholinergic drug exposure.