Anticholinergic Risk Scale Research Articles

Expert‐based drug lists to measure anticholinergic burden: similar names, different results

Scoring scales such as the Anticholinergic Drug Scale (ADS), the Anticholinergic Risk Scale (ARS), and the Anticholinergic Cognitive Burden Scale (ACB) provide an estimation of total anticholinergic burden. Not all the lists include the same drugs, and the points given for certain drugs differ among them. Whether these discrepancies present important differences in the estimation of anticholinergic burden for an individual patient is unknown. Therefore, the aim of this study is to assess agreement among the three scales. Anticholinergic burden was measured with the three scales in 83 patients aged ≥65 years in a medium- and long-stay psychiatric hospital. Subsequently, patients were categorized into three risk categories: low risk (0 points), medium risk (1-2 points) or high risk (3 or more points). The chance-corrected measures of agreement for the different scores were determined with the k-statistic (kappa). Values for kappa were: 0.19 for Anticholinergic Risk Scale-Anticholinergic Drug Scale, 0.21 for ACB-Anticholinergic Drug Scale and 0.25 for Anticholinergic Risk Scale-ACB. The mean anticholinergic burden measured with ACB was 3.28. There is poor agreement among the three scales. These lists cannot be directly applied to different settings in which drug availability differs substantially, and they require periodic updates. Anticholinergic burden in our setting (psychogeriatric inpatients) was particularly high.

Measures of Anticholinergic Drug Exposure, Serum Anticholinergic Activity, and All-cause Postdischarge Mortality in Older Hospitalized Patients with Hip Fractures

To assess possible associations between anticholinergic drug exposure and serum anticholinergic activity (SAA) and their capacities to predict all-cause mortality in older hospitalized patients. Academic medical center. Data on clinical characteristics, full medication exposure, SAA, and 4 anticholinergic drug scoring systems (ADSSs: Anticholinergic Risk Scale [ARS], Anticholinergic Drug Scale, Anticholinergic Burden scale, and anticholinergic component of the Drug Burden Index) were collected in 71 older hospitalized patients (age 84 ± 6 years) awaiting surgical repair after hip fractures. The median (range) SAA was 2.8 (1.1-4.9) pmol/mL. Age (ρ= 0.25, p=0.03), Katz Index of Independence in Activities of Daily Living score (ρ= 0.39, p= 0.001), in-hospital delirium (ρ= 0.29, p= 0.01), preadmission cognitive impairment (ρ= 0.31, p= 0.01), and the number of nonanticholinergic drugs (n-NA, ρ=-0.27, p= 0.02) were associated with SAA. No significant associations were detected between ADSSs and SAA. Cognitive impairment (β= 2.1, 95% confidence interval [CI]: 0.7 to 2.5, p= 0.005) and n-NA (β=-0.3, 95% CI:-0.5 to-0.03, p= 0.03) were independently associated with SAA. Cognitive impairment (hazard ratio [HR]: 6.7, 95% CI: 1.1 to 40.3, p= 0.04) and higher ARS scores (HR: 2.2, 95% CI: 1.2 to 3.7, p= 0.006) independently predicted 3-month mortality whereas in-hospital delirium (HR: 3.6, 95% CI: 1.3 to 10.3, p= 0.02), living at home (HR: 0.2, 95% CI: 0.0 to 0.9, p= 0.03), and length of hospital stay (HR: 1.1, 95% CI: 1.0 to 1.2, p= 0.004) independently predicted 1-year mortality after adjustment for age, gender, and Charlson comorbidity index. Cognitive impairment and n-NA, but not ADSSs, are independently associated with SAA in older hospitalized patients. The ARS score, together with cognitive impairment, in-hospital delirium, place of residence, and length of hospital stay, predicts all-cause mortality in this group.

Association of Anticholinergic Burden with Cognitive and Functional Status in a Cohort of Hospitalized Elderly: Comparison of the Anticholinergic Cognitive Burden Scale and Anticholinergic Risk Scale

Drugs with anticholinergic effects are associated with adverse events such as delirium and falls as well as cognitive decline and loss of independence. The aim of the study was to evaluate the association between anticholinergic burden and both cognitive and functional status, according to the hypothesis that the cumulative anticholinergic burden, as measured by the Anticholinergic Cognitive Burden (ACB) Scale and Anticholinergic Risk Scale (ARS), increases the risk of cognitive decline and impairs activities of daily living. This cross-sectional, prospective study (3-month telephone follow-up) was conducted in 66 Italian internal medicine and geriatric wards participating in the Registry of Polytherapies SIMI (Società Italiana di Medicina Interna) (REPOSI) study during 2010. The sample included 1,380 inpatients aged 65 years or older. Cognitive status was rated with the Short Blessed Test (SBT) and physical function with the Barthel Index. Each patient's anticholinergic burden was evaluated using the ACB and ARS scores. The mean SBT score for patients treated with anticholinergic drugs was higher than that for patients receiving no anticholinergic medications as also indicated by the ACB scale, even after adjustment for age, sex, education, stroke and transient ischaemic attack [9.2 (95 % CI 8.6-9.9) vs. 8.5 (95 % CI 7.8-9.2); p = 0.05]. There was a dose-response relationship between total ACB score and cognitive impairment. Patients identified by the ARS had more severe cognitive and physical impairment than patients identified by the ACB scale, and the dose-response relationship between this score and ability to perform activities of daily living was clear. No correlation was found with length of hospital stay. Drugs with anticholinergic properties identified by the ACB scale and ARS are associated with worse cognitive and functional performance in elderly patients. The ACB scale might permit a rapid identification of drugs potentially associated with cognitive impairment in a dose-response pattern, but the ARS is better at rating activities of daily living.

Anticholinergic Drugs and Functional Outcomes in Older Patients Undergoing Orthopaedic Rehabilitation

BackgroundMedications with anticholinergic (antimuscarinic) effects negatively affect physical and cognitive function in community-dwelling older patients. However, it is unknown if anticholinergic drugs exert detrimental effects in older patients undergoing rehabilitation. ObjectiveThe purpose of our study was to assess the effect of anticholinergic drug exposure on functional outcomes in older patients undergoing rehabilitation. We speculated that higher anticholinergic drug exposure would be associated with reduced functional outcomes in this group. MethodsData on clinical characteristics, full medication, anticholinergic drug exposure (total number of anticholinergic drugs [tAD] and Anticholinergic Risk Scale [ARS] score), and Barthel index (BI) score were collected on admission and discharge in a consecutive series of 117 older patients (age 79 [7] years) admitted to the orthopaedic rehabilitation unit of a teaching hospital between July 2010 and March 2011. Outcome measures were BI changes (BI on discharge – BI on admission) during rehabilitation (primary outcome) and length of stay (secondary outcome). ResultsAnticholinergic drugs were prescribed in 38 patients (32.5%). Median and interquartile range for tAD = 0 (0–1); for ARS = 0 (0–1). Poisson regression showed that higher tAD (incidence rate ratio [IRR] = 0.92; 95% CI, 0.88–0.97; P = 0.003) and ARS scores (IRR = 0.97; 95% CI, 0.95–0.99; P = 0.008) on admission independently predicted lower BI changes. Being a woman (IRR = 0.87; 95% CI, 0.78–0.97; P = 0.01), lower Abbreviated Mental Test scores (IRR = 0.94; 95% CI, 0.91–0.97; P < 0.001), and lower BI on admission (IRR = 0.98; 95% CI, 0.97–0.98; P < 0.001), but not tAD or ARS scores, independently predicted increasing length of stay. ConclusionsHigher anticholinergic drug exposure on admission independently predicts reduced functional outcomes, but not length of stay, in older patients undergoing orthopaedic rehabilitation.

Analysis of iatrogenic risk related to anticholinergic effects using two scales in acute geriatric inpatient unit

Anticholinergic medications are responsible for most frequent adverse drug effects. Two scales have been elaborated as tools for prescribers: the Anticholinergic Drug Scale (ADS) of Carnahan et al., and the Anticholinergic Risk Scale (ARS) of Rudolph et al. The objective of this study was to analyze the diagnostic performance of both scales for predicting signs related to an anticholinergic effect. Medical records of 1379 patients aged 75 years or older hospitalized in a geriatric acute care unit between 2002 and 2005 were studied. The analyze was made retrospectively, but data were collected prospectively. Risk of appearance of total anticholinergic signs (ADS : OR 1,45, CI 95% [1,03-2,03], p=0,037 and ARS : OR 1,98, CI 95% [1,19-3,28] p<0,01) and peripheral signs (ADS: OR 1,66, CI 95% [1,22-2,26], p<0,01 and ARS : OR 1,81, CI 95% [1,19-2,75], p<0,01) increased when score was ≥ 3 with both scales, which wasn't the case for central signs. Both scales permitted to detect an increased risk of appearance of total and peripheral anticholinergic signs, but not the centrals as delirium. Interest of total anticholinergic burden remains to be demonstrated, especially for delirium risk assessment.

Anticholinergic Medications and Cognition

The concept that anticholinergic drugs could have negative effects on cognition was brought to the fore in the 1980s when anticholinergic drugs used to treat parkinsonism were shown to induce delirium 1 Agnoli A. Martucci N. Manna V. et al. Effect of cholinergic and anticholinergic drugs on short-term memory in Alzheimer’s dementia: A neuropsychological and computerized electroencephalographic study. Clin Neuropharmacol. 1983; 6: 311-323 Crossref PubMed Scopus (81) Google Scholar and drug-induced “alzheimerism.” 2 Kurlan R. Como P. Drug-induced alzheimerism. Arch Neurol. 1988; 45: 356-357 Crossref PubMed Scopus (19) Google Scholar These findings were brought full circle by the recent article in the Journal by Lowry et al. 3 Lowry E. Woodman R.J. Soiza R.L. et al. Associations between the Anticholinergic Risk Scale score and physical function: Potential implications for adverse outcomes in older hospitalized patients. J Am Med Dir Assoc. 2011; ([Oct]) Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar showing that patients with a high anticholinergic risk score was negatively associated with a number of components of the Barthel Index. This study highlights the risk of functional decline in the frail elderly residing in nursing homes. 4 Abellan van Kan G. Rolland Y.M. Morley J.E. et al. Frailty: Toward a clinical definition. J Am Med Dir Assoc. 2008; 9: 71-72 Abstract Full Text Full Text PDF PubMed Scopus (410) Google Scholar , 5 Rockwood K. Abeysundera M.J. Mitnitski A. How should we grade frailty in nursing home patients?. J Am Med Dir Assoc. 2007; 8: 595-603 Abstract Full Text Full Text PDF PubMed Scopus (200) Google Scholar , 6 Gobbens R.J. van Assen M.A. Luijkx K.G. et al. Determinants of frailty. J Am Med Dir Assoc. 2010; 11: 356-364 Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar , 7 Morley J.E. Anabolic steroids and frailty. J Am Med Dir Assoc. 2010; 11: 533-536 Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar , 8 Abellan van Kan G. Rolland Y. Bergman H. et al. The I.A.N.A. Task Force on frailty assessment of older people in clinical practice. J Nutr Health Aging. 2008; 12: 29-37 Crossref PubMed Scopus (645) Google Scholar

Associations Between the Anticholinergic Risk Scale Score and Physical Function: Potential Implications for Adverse Outcomes in Older Hospitalized Patients

The anticholinergic risk scale (ARS) score is associated with the number of anticholinergic side effects in older outpatients. We tested the hypothesis that high ARS scores are negatively associated with "global" parameters of physical function (Barthel Index, primary outcome) and predict length of stay and in-hospital mortality (secondary outcomes) in older hospitalized patients. Prospective study in 2 acute geriatric units. Three hundred sixty-two consecutive patients (age 83.6 ± 6.6 years) admitted between February 1, 2010, and June 30, 2010. Clinical and demographic characteristics, Barthel Index, full medication exposure, and ARS score were recorded on admission. Data on length of stay and in-hospital mortality were obtained from electronic records. After adjustment for age, gender, dementia, institutionalization, Charlson Comorbidity Index, admission site, and number of nonanticholinergic drugs, a unit increase in ARS score was associated with a 29% reduction in the odds of being in a higher Barthel quartile than a lower quartile (odds ratio 0.71, 95% confidence interval [CI] 0.59-0.86, P = .001). The Barthel components mostly affected were bathing (P < .001), grooming (P < .001), dressing (P < .001), transfers (P =.005), mobility (P < .001), and stairs (P < .001). Higher ARS scores predicted in-hospital mortality among patients with hyponatremia (hazard ratio [HR] 3.66, 95% CI 1.70-7.89, P = .001) but not those without hyponatremia (HR 1.04, 95% CI 0.70-1.54, P = .86). The ARS score did not significantly predict length of stay (HR 1.02, 95% CI 0.88-1.17, P = .82). High ARS scores are negatively associated with various components of the Barthel Index and predict in-hospital mortality in the presence of hyponatremia among older patients. The ARS score may be useful in the acute setting to improve risk stratification.

Assessment of inappropriate prescribing in the elderly subject during acute care hospitalisation

Inappropriate prescribing in elderly is considered as common (40% of subjects from community from the 3CStudy in France had a inappropriate prescription, using Beer's criteria), and can lead to severe issues. Few studies have assessed inappropriate prescribing for elderly inpatients in acute care, with multiple tools. Our study was designed to assess outcome prescriptions concordance of elderly inpatients, for potentially inappropriate medication use. A retrospective study based on a random sample of 170 inpatients in 2009 was performed at Nantes University Hospital. We used standardized tools, especially general prescriptions rules of the "Collège professionnel des gériatres français", Beers's criteria, the Anticholinergic Risk Scale, concordance for renal function, and search for medication with tight therapeutic edge. Mean age of inpatients was 85.2 ± 4.1 years. Median numbers of prescribing drugs was eight. General prescriptions rules were followed up to 90% of inpatients: no forbidden drug-drug interaction was found. However, more than two psychotropic medications were prescribed for 3.9% of inpatients. At least one drug listed in Beers's criteria were found for 41 (27.0%) inpatients: amiodarone (18 inpatients) and long-term benzodiazepines (seven inpatients). A medication from the anticholinergic risk scale was found for 28 subjects (18.6%): however, for only seven of them, the score was higher than 3. Concordance for renal function was required for 126 inpatients (82.9%) for at least one prescription, 9 (7.1%) patients have a medication overdose according to their renal impairment. Medications with tight therapeutic edge were prescribed for 52 subjects (34.2%): mostly oral anticoagulants (27 subjects). In 15 cases, the dose was underneath the recommended level. Some potentially inappropriate medication uses were revealed by our study. It is essential to spread out results for clinicians, for a better knowledge of these risks.

Clinical and Demographic Factors Associated with Antimuscarinic Medication Use in Older Hospitalized Patients

Background: Antimuscarinic drug prescribing scoring systems might better identify patients at risk of adverse drug reactions. The recently developed Anticholinergic Risk Scale (ARS) score is significantly associated with the number of antimuscarinic side effects in older outpatients. We sought to identify the clinical and demographic patient-level correlates of the ARS, including a modified version adjusted for daily dose, in elderly hospitalized patients. Methods: Clinical and demographic patient characteristics known to be associated with antimuscarinic prescribing, ARS and dose-adjusted ARS scores, and full medication exposure on admission were recorded in 362 consecutive patients (aged 83.6 ± 6.6 years) admitted to 2 geriatric units (NHS Grampian, Aberdeen, Scotland, UK) between February 1, 2010 and June 30, 2010. Results: Each year of increasing age was associated with reduced number of antimuscarinic drugs (incidence rate ratio [IRR], 0.963; 95% confidence interval [CI], 0.948–0.980; P < 0.001), non-antimuscarinic drugs (IRR, 0.991; 95% CI, 0.985–0.997; P = 0.006), and total number of drugs (IRR, 0.988; 95% CI, 0.983–0.994; P < 0.001). Multivariate Poisson regression showed that increasing age and history of dementia were negatively associated with the ARS score (IRR, 0.97; 95% CI, 0.94–0.99; P = 0.001 and IRR, 0.62; 95% CI, 0.41–0.92; P = 0.019, respectively). By contrast, institutionalization (IRR, 1.32; 95% CI, 1.00–1.74; P = 0.050), Charlson comorbidity index (IRR, 1.06; 95% CI, 1.01–1.11; P = 0.015), and total number of non-antimuscarinic drugs (IRR, 1.13; 95% CI, 1.08–1.18; P < 0.001) were all positively associated with the ARS score. Similar results were observed for the dose-adjusted ARS score. Conclusion: Institutionalization, comorbidities, and non-antimuscarinic polypharmacy show independent positive associations with the ARS and dose-adjusted ARS scores in older hospitalized patients. Increasing age and dementia are negatively associated with the ARS score.

Anticholinergic Drug Use and Mortality Among Residents of Long-Term Care Facilities: A Prospective Cohort Study

Few studies have investigated the possible association between use of anticholinergic drugs and mortality. The objectives of this study were to investigate the prevalence and determinants of anticholinergic drug use and the possible association between anticholinergic drug use and mortality. Data were obtained from 53 long-term care wards in Helsinki, Finland, in 2003. Medication, diagnostic, and mortality data were available for 1004 residents. Each resident's anticholinergic load was calculated using the Anticholinergic Risk Scale (ARS). Cox proportional hazards models were used to investigate the risk of death among users with a mild anticholinergic load (ARS score 1-2) and high load (ARS score ≥3) compared with nonusers of anticholinergic drugs. Age, sex, and nutritional status were used as covariates. Among the 1004 residents, 455 (45%) were nonusers of anticholinergic drugs, 363 (36%) had a mild anticholinergic load, and 186 (19%) had a high anticholinergic load. One-year all-cause mortality rates were 28%, 29%, and 27%, respectively. Higher ARS scores were not associated with mortality (ARS score 1-2: hazard ratio 1.08; 95% confidence interval, 0.84-1.41; ARS score ≥3: hazard ratio 1.05; 95% confidence interval, 0.75-1.46). Anticholinergic drug use was common; however, high ARS scores were not associated with mortality. Further research is needed using alternative models and among different resident populations.

Limitations of the Anticholinergic Risk Scale—Reply

Limitations of the Anticholinergic Risk Scale—Reply

The Anticholinergic Risk Scale and Anticholinergic Adverse Effects in Older Persons

Adverse effects of anticholinergic medications may contribute to events such as falls, delirium, and cognitive impairment in older patients. To further assess this risk, we developed the Anticholinergic Risk Scale (ARS), a ranked categorical list of commonly prescribed medications with anticholinergic potential. The objective of this study was to determine if the ARS score could be used to predict the risk of anticholinergic adverse effects in a geriatric evaluation and management (GEM) cohort and in a primary care cohort. Medical records of 132 GEM patients were reviewed retrospectively for medications included on the ARS and their resultant possible anticholinergic adverse effects. Prospectively, we enrolled 117 patients, 65 years or older, in primary care clinics; performed medication reconciliation; and asked about anticholinergic adverse effects. The relationship between the ARS score and the risk of anticholinergic adverse effects was assessed using Poisson regression analysis. Higher ARS scores were associated with increased risk of anticholinergic adverse effects in the GEM cohort (crude relative risk [RR], 1.5; 95% confidence interval [CI], 1.3-1.8) and in the primary care cohort (crude RR, 1.9; 95% CI, 1.5-2.4). After adjustment for age and the number of medications, higher ARS scores increased the risk of anticholinergic adverse effects in the GEM cohort (adjusted RR, 1.3; 95% CI, 1.1-1.6; c statistic, 0.74) and in the primary care cohort (adjusted RR, 1.9; 95% CI, 1.5-2.5; c statistic, 0.77). Higher ARS scores are associated with statistically significantly increased risk of anticholinergic adverse effects in older patients.