High Anticholinergic Activity Research Articles

Development of the Swedish anticholinergic burden scale (Swe-ABS)

BackgroundDrugs with anticholinergic properties are associated with cognitive adverse effects, especially in patients vulnerable to central muscarinic antagonism. A variety of drugs show weak, moderate or strong anticholinergic effects. Therefore, the cumulative anticholinergic burden should be considered in patients with cognitive impairment. This study aimed to develop a Swedish Anticholinergic Burden Scale (Swe-ABS) to be used in health care and research.MethodsA systematic literature review was conducted in PubMed and Ovid Embase to identify previously published tools quantifying anticholinergic drug burden (i.e., exposure). Drugs and grading scores (0–3, no to high anticholinergic activity) were extracted from identified lists. Enteral and parenteral drugs authorized in Sweden were included. Drugs with conflicting scores in the existing lists were assessed by an expert group. Two drugs that were not previously assessed were also added to the evaluation process.ResultsThe systematic literature search identified the following nine anticholinergic burden scales: Anticholinergic Activity Scale, Anticholinergic Burden Classification, updated Anticholinergic Cognitive Burden scale, Anticholinergic Drug Scale, Anticholinergic Load Scale, Anticholinergic Risk Scale, updated Clinician-rated Anticholinergic Scale, German Anticholinergic Burden Scale and Korean Anticholinergic Burden Scale. A list of drugs with significant anticholinergic effects provided by The Swedish National Board of Health and Welfare was included in the process. The suggested Swe-ABS consists of 104 drugs scored as having weak, moderate or strong anticholinergic effects. Two hundred and fifty-six drugs were listed as having no anticholinergic effects based on evaluation in previous scales. In total, 62 drugs were assessed by the expert group.ConclusionsSwe-ABS is a simplified method to quantify the anticholinergic burden and is easy to use in clinical practice. Publication of this scale might make clinicians more aware of drugs with anticholinergic properties and patients’ total anticholinergic burden. Further research is needed to validate the Swe-ABS and evaluate anticholinergic exposure versus clinically significant outcomes.

'Worrying' rise in number of patients with a high anticholinergic burden

The number of patients taking two or more medicines with moderate or high anticholinergic activity increased by around 10% at the beginning of the COVID-19 pandemic and has not returned to pre-pandemic levels, show NHS data analysed by The Pharmaceutical Journal. In a trend that experts have described as “worrying”, between January–March 2020 and April–June […]

Decrease of Anticholinergic Drug Use in Nursing Home Residents in the United States, 2009 to 2017.

To investigate the time course of anticholinergic drug use in nursing home residents and assess if any temporal change in anticholinergic use varied by nursing home quality rating. Retrospective repeated cross-sectional analysis of Medicare enrollment, Parts A, B, and D, claims data linked to the Minimum Data Set from 2009 to 2017. Medicare-certified nursing homes. Long-term residents 65 years or older with nursing home stay of at least 100 consecutive days within a given calendar year. Estimates of anticholinergic drug prescription rates between 2009 and 2017 were based on a binary variable indicating whether a resident received a drug with high anticholinergic activity, as defined by the Anticholinergic Cognitive Burden scale, for at least 1 day during the initial 100 consecutive days of nursing home stay in a given calendar year. We used mixed effects logistic regression models to determine adjusted rates of anticholinergic use each year and test the interaction between nursing home quality rating and year, while adjusting for patient and nursing home characteristics. The cohort included 786,858 100-day nursing home stays (299,354 unique residents) in 6,703 nursing homes for the years 2009 to 2017. Prescription rates were stable at approximately 34% to 35% between 2009 and 2011, then gradually decreased to 24.3% in 2017 (P < .0001), with the decline being more pronounced in nursing homes having high quality ratings (P < .0001). Rates for anticholinergic drugs in nursing homes with 4 to 5 star quality rating (33.7% in 2011 to 23.3% in 2017) showed a steeper decline over time relative to nursing homes with 1 to 2 star quality rating (34.2% in 2011 to 25.2% in 2017) (P < .0001). The use of drugs with high anticholinergic activity has declined from 2009 to 2017, with a greater decline in higher-quality nursing homes.

Impact of anticholinergic load on functioning and cognitive performances of persons with psychosis referred to psychosocial rehabilitation centers.

Few studies have explored whether high-anticholinergic load may hamper rehabilitation in persons with schizophrenia. We aim to explore the associations between anticholinergic load of psychotropic treatment and functioning or cognitive performances of persons with psychosis engaged in psychosocial rehabilitation. The study was performed using data collected at baseline assessment in the REHABase cohort including persons referred to a French network of psychosocial rehabilitation centers. The composite-rating scale developed by Salahudeen et al. was used to rate the anticholinergic load of psychotropic drugs prescribed at baseline assessment. The associations between total anticholinergic load score (categorized as 'low' <3 v. 'high' ⩾3) and functioning or cognitive characteristics were explored using multivariate analyses. Of the 1012 participants with schizophrenia spectrum disorders identified in the REHABase, half used at least two psychotropic drugs with anticholinergic activity and one out of three was prescribed at least one psychotropic drug with high-anticholinergic activity. High-anticholinergic load was significantly associated with lower stage of recovery [odds ratio (OR) = 1.70, 95% confidence interval (CI) 1.05-2.76, p = 0.03], poor mental well-being (OR = 1.55, 95% CI 1.02-2.33, p = 0.04) and poor self-rated medication adherence (OR = 2.14, 95% CI 1.29-3.53, p = 0.003). Regarding cognition, a high-anticholinergic score was associated with poorer delayed-episodic memory (OR = 1.69, 95% CI 1.01-2.85, p = 0.05) and at the trend level with faster completion time on the test exploring executive performance (OR = 0.67, 95% CI 0.43-1.04, p = 0.07). The psychosocial rehabilitation plan of persons with psychosis should integrate optimization of psychotropic treatment in order to lessen the functional and cognitive impact of high-anticholinergic load.

Development of a Brazilian anticholinergic activity drug scale.

ABSTRACTObjective To develop a scale of anticholinergic activity drugs used in Brazil, to be applied in health care and pharmacoepidemiology research.Methods We performed a literature review on PubMed/MEDLINE® to identify previously published scales of anticholinergic drugs. This scale started with anticholinergic drugs, and those with known anticholinergic activity as per the 4th level, chemical-therapeutic subgroup, of the Anatomical Therapeutic Chemical classification. We also included drugs with high anticholinergic activity, as described in a list of potentially inappropriate medications for use in older adults, according to the 2015 American Geriatrics Society Beers Criteria. Drugs listed in at least two anticholinergic scales were added. Then we verified which drugs in the previous steps were marketed in Brazil. We assigned a score of 1, 2 and 3, based on their anticholinergic action.Results A total of 273 anticholinergic drugs were identified, of which 125 were included in the scale. We identified 45 (36.0%) drugs with a score of 3, 13 (10.4%) with a score of 2, and 67 (53.6%) with a score of 1. Drugs for the nervous and respiratory systems were the most frequent in the scale. Eight drugs were not present in previous scales.Conclusion The methodology used for development of the Brazilian anticholinergic activity scale is simple, systematized, reproducible and easy to update. The scale allows evaluating the impact of anticholinergic burden on health outcomes, and can potentially contribute to pharmacoepidemiology research, leading to more accurate measurements of anticholinergic activity.

Anticholinergic Burden and Cognitive Impairment in Patients with Heart Failure

Purpose Cognitive impairment (CI) in heart failure pts. may affect performance of everyday activities that impact ability to manage chronic illness. Anticholinergic drugs are a risk factor for CI. Higher anticholinergic burden (ACB) can occur with specific medications with high anticholinergic activity or an accumulation of drugs with low, medium, and high anticholinergic burden. The ACB of drugs in HF pts. may be a factor contributing to a high prevalence of CI; however, no studies have compared ACB and CI based on severity of HF. This study aims to compare CI and ACB in pts. with Class II vs. Class III/IV HF. Methods 113 adult pts. were recruited from a HF/Transplant Program. Exclusion criteria included diagnosis of dementia, LVAD or total artificial heart. Demographic data were obtained using a self-report questionnaire; clinical data were retrieved using a medical record review. Cognitive function was measured with the MOS Cognitive Function Scale. ACB was calculated using the Anticholinergic Cognitive Burden Scoring Scale. Comorbidity was measured with the Charlson Index. Polypharmacy (>=5 drugs) was determined using a medication count. Data were analyzed using mean (SD) for continuous variables f (%) for categorical variables. Significant differences between groups were examined using Chi Square and independent t-tests. Results Participants (Class II=48, Class III/IV=65) were 62% male, 50% AA, and 56 years old. There were no sig, differences between groups based on EF (p=.116), comorbidity (p=.485), evaluation for transplant (p=.235), IV inotrope therapy (p=.132), or ACB (Class II=2.47 vs Class III/IV-2.67; p=.811). There were between group differences based on age (p=.006), listed for transplant (p=.001), evaluation for MCS (p=.007), ICD (p=.002), polypharmacy ( n=105; Class II=9.5 vs 10.03, p=.034), and CI (Class II=11.06 vs Class III/IV-16.3, p=.035). Conclusion Findings support significant CI and ACB in NYHA Class II-IV pts. with greater CI in Class III/IV pts. Pts. with HF have substantial polypharmacy that may lead to high anticholinergic drug exposure which has been correlated with increased risk for CI. Future studies should target factors influencing CI in patients with greater severity of HF.

Pharmacologic Considerations in the Elderly Surgical Patient

The most rapidly growing segment of the elderly population corresponds to persons age 85 and over. As of 2006, elderly patients accounted for 35.3% of the inpatient and 32.1% of the outpatient surgical procedures occurring in the United States. Because age-related changes occur in each organ system in all elderly individuals, this population merits special consideration when undergoing surgical procedures. Furthermore, there is a high probability that older adults will have multiple chronic medical problems, which may present a complex medication management challenge. This review covers the pharmacologic impact of physiologic changes associated with aging, preoperative assessment, preoperative medication management, delirium and the impact of perioperative medications in the elderly, anesthesia and related medications, and specific drug classes and their use in the elderly surgical patient. Figures show an overview of the management of the elderly surgical patient, and preoperative medication management. Tables list medications that should be avoided in older patients with reduced renal function, drugs that exhibit additive adverse effects, medications with high anticholinergic activity, medications that inhibit and induce the CYP450 system, herbal supplements, 2015 Beers Criteria summary of potentially inappropriate medication use in older adults, drugs associated with postoperative delirium, risk factors for postoperative delirium, and clinical pharmacology of commonly used anesthetic agents. This review contains 2 highly rendered figures, 9 tables, and 61 references

Association Between Anticholinergic Medication Use and Cognition, Brain Metabolism, and Brain Atrophy in Cognitively Normal Older Adults.

The use of anticholinergic (AC) medication is linked to cognitive impairment and an increased risk of dementia. To our knowledge, this is the first study to investigate the association between AC medication use and neuroimaging biomarkers of brain metabolism and atrophy as a proxy for understanding the underlying biology of the clinical effects of AC medications. To assess the association between AC medication use and cognition, glucose metabolism, and brain atrophy in cognitively normal older adults from the Alzheimer's Disease Neuroimaging Initiative (ADNI) and the Indiana Memory and Aging Study (IMAS). The ADNI and IMAS are longitudinal studies with cognitive, neuroimaging, and other data collected at regular intervals in clinical and academic research settings. For the participants in the ADNI, visits are repeated 3, 6, and 12 months after the baseline visit and then annually. For the participants in the IMAS, visits are repeated every 18 months after the baseline visit (402 cognitively normal older adults in the ADNI and 49 cognitively normal older adults in the IMAS were included in the present analysis). Participants were either taking (hereafter referred to as the AC+ participants [52 from the ADNI and 8 from the IMAS]) or not taking (hereafter referred to as the AC- participants [350 from the ADNI and 41 from the IMAS]) at least 1 medication with medium or high AC activity. Data analysis for this study was performed in November 2015. Cognitive scores, mean fludeoxyglucose F 18 standardized uptake value ratio (participants from the ADNI only), and brain atrophy measures from structural magnetic resonance imaging were compared between AC+ participants and AC- participants after adjusting for potential confounders. The total AC burden score was calculated and was related to target measures. The association of AC use and longitudinal clinical decline (mean [SD] follow-up period, 32.1 [24.7] months [range, 6-108 months]) was examined using Cox regression. The 52 AC+ participants (mean [SD] age, 73.3 [6.6] years) from the ADNI showed lower mean scores on Weschler Memory Scale-Revised Logical Memory Immediate Recall (raw mean scores: 13.27 for AC+ participants and 14.16 for AC- participants; P = .04) and the Trail Making Test Part B (raw mean scores: 97.85 seconds for AC+ participants and 82.61 seconds for AC- participants; P = .04) and a lower executive function composite score (raw mean scores: 0.58 for AC+ participants and 0.78 for AC- participants; P = .04) than the 350 AC- participants (mean [SD] age, 73.3 [5.8] years) from the ADNI. Reduced total cortical volume and temporal lobe cortical thickness and greater lateral ventricle and inferior lateral ventricle volumes were seen in the AC+ participants relative to the AC- participants. The use of AC medication was associated with increased brain atrophy and dysfunction and clinical decline. Thus, use of AC medication among older adults should likely be discouraged if alternative therapies are available.

Pharmacologic Considerations in the Elderly Surgical Patient

The most rapidly growing segment of the elderly population corresponds to persons age 85 and over. As of 2006, elderly patients accounted for 35.3% of the inpatient and 32.1% of the outpatient surgical procedures occurring in the United States. Because age-related changes occur in each organ system in all elderly individuals, this population merits special consideration when undergoing surgical procedures. Furthermore, there is a high probability that older adults will have multiple chronic medical problems, which may present a complex medication management challenge. This review covers the pharmacologic impact of physiologic changes associated with aging, preoperative assessment, preoperative medication management, delirium and the impact of perioperative medications in the elderly, anesthesia and related medications, and specific drug classes and their use in the elderly surgical patient. Figures show an overview of the management of the elderly surgical patient, and preoperative medication management. Tables list medications that should be avoided in older patients with reduced renal function, drugs that exhibit additive adverse effects, medications with high anticholinergic activity, medications that inhibit and induce the CYP450 system, herbal supplements, 2015 Beers Criteria summary of potentially inappropriate medication use in older adults, drugs associated with postoperative delirium, risk factors for postoperative delirium, and clinical pharmacology of commonly used anesthetic agents. This review contains 2 highly rendered figures, 9 tables, and 61 references

Examination and Estimation of Anticholinergic Burden: Current Trends and Implications for Future Research.

It is postulated that minimizing anticholinergic burden in older people may result in improved short-term memory and behavior, reduced confusion and delirium, and enhanced quality of life and daily functioning. The purpose of this opinion article was to investigate the current trends and future implications relating to the examination and estimation of anticholinergic burden in older people. Current evidence linking medicines with anticholinergic activity and cognitive impairment is derived mostly from observational data. Further research with larger trials or cohort studies with adequate power and appropriate follow-up periods is required to confirm associations between anticholinergic burden and adverse outcomes. This article provides insights into different approaches for the estimation of anticholinergic burden. Network-based systems pharmacology models could be an effective way of understanding anticholinergic drug-induced adverse effects. The emphasis on mechanistic models may open new opportunities for researchers to understand adverse drug effects in clinical practice. In the interim, medicines with high anticholinergic activity should be avoided in older people, unless considered clinically essential. In this instance, they should be used at a low/titrated dose and for the shortest duration possible. It is therefore important to reinforce the clinical significance of reviewing anticholinergic medicines in older people.

Profiling cognitive impairment in treatment-resistant schizophrenia patients

The aim of this study was to compare cognitive performance between schizophrenia patients with and without treatment resistance (TRS and non-TRS patients) taking into account psychopathological symptoms and antipsychotic treatment. The following cognitive tests were administered to 53 TRS patients and 32 non-TRS subjects: Rey Auditory Verbal Learning Test (RAVLT), Trail Making Tests (TMT-A and TMT-B), verbal fluency tests (FAS test and Supermarket), as well as selected Wechsler Adults Intelligence Scale (WAIS-R-PI) subtests: Digit Symbol Coding Test, Digit Span Forward and Backward and Similarities. TRS patients performed significantly worse in comparison with non-TRS patients on the measures of processing speed (TMT-A, Stroop test, FAS test, Supermarket test, Digit Symbol Coding test), verbal fluency (FAS test, Supermarket test), cognitive flexibility and executive functions (Stroop test) after controlling for age, illness duration, clinical symptoms severity, the number of years of completed education and antipsychotics’ dose. Cognitive performance was associated with negative and general symptomatology. Anticholinergic activity of antipsychotics had debilitating effect on cognitive functioning in non-TRS patients (FAS test) and in TRS patients (TMT-B test, Stroop test, RAVLT subtests, Digit Coding test and Similarities test), while low anticholinergic activity of antipsychotics was associated with better cognitive performance in non-TRS patients (Backward Digit Span test) and in TRS patients (Similarities test). Results of this study indicate that cognitive deficits are more robust in TRS patients than in non-TRS subjects, and are associated with clinical symptoms as well as the treatment with antipsychotics that exert high anticholinergic activity.

Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review.

BackgroundThe cumulative effect of taking multiple medicines with anticholinergic properties termed as anticholinergic burden can adversely impact cognition, physical function and increase the risk of mortality. Expert opinion derived risk scales are routinely used in research and clinical practice to quantify anticholinergic burden. These scales rank the anticholinergic activity of medicines into four categories, ranging from no anticholinergic activity (= 0) to definite/high anticholinergic activity (= 3). The aim of this systematic review was to compare anticholinergic burden quantified by the anticholinergic risk scales and evaluate associations with adverse outcomes in older people.MethodsWe conducted a literature search in Ovid MEDLINE, EMBASE and PsycINFO from 1984-2014 to identify expert opinion derived anticholinergic risk scales. In addition to this, a citation analysis was performed in Web of Science and Google Scholar to track prospective citing of references of selected articles for assessment of individual scales for adverse anticholinergic outcomes. The primary outcomes of interest were functional and cognitive outcomes associated with anticholinergic burden in older people. The critical appraisals of the included studies were performed by two independent reviewers and the data were extracted onto standardised forms.ResultsThe primary electronic literature search identified a total of 1250 records in the 3 different databases. On the basis of full-text analysis, we identified 7 expert-based anticholinergic rating scales that met the inclusion criteria. The rating of anticholinergic activity for medicines among these rating scales was inconsistent. For example, quetiapine was rated as having high anticholinergic activity in one scale (n = 1), moderate in another scale (n = 1) and low in two other scales (n = 2). Citation analysis of the individual scales showed that the Anticholinergic Cognitive Burden (ACB) scale was the most frequently validated expert based anticholinergic scale for adverse outcomes (N = 13).ConclusionsIn conclusion, there is not one standardised tool for measuring anticholinergic burden. Cohort studies have shown that higher anticholinergic burden is associated with negative brain effects, poorer cognitive and functional outcomes.Electronic supplementary materialThe online version of this article (doi:10.1186/s12877-015-0029-9) contains supplementary material, which is available to authorized users.

Abstracts of the 62nd Annual and Scientific Meeting Science for Healthy & Active Ageing. October 9-11, 2014. Galway, Ireland.

Background: Anticholinergic medications may be associated with adverse clinical outcomes, including acute impairments in cognition and anticholinergic side effects, the risk of adverse outcomes increasing with increasing anticholinergic exposure. Older people with intellectual disability may be at increased risk of exposure to anticholinergic medicines due to their higher prevalence of comorbidities. We sought to determine anticholinergic burden in ageing people with intellectual disability. Methods: Medication data (self-report/proxy-report) was drawn from Wave 1 of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA), a study on the ageing of 753nationally representative people with an IDC40 years randomly selected from the National Intellectual Disability Database. Each individual’s cumulative exposure to anticholinergic medications was calculated using the Anticholinergic Cognitive Burden Scale (ACB) amended by a multi-disciplinary group with independent advice to account for the range of medicines in use in this population. Results: Overall, 70.1 % (527) reported taking medications with possible or definite anticholinergic properties (ACBC1), with a mean (±SD) ACB score of 4.5 (±3.0) (maximum 16). Of those reporting anticholinergic exposure (n=527), 41.3 % (217) reported an ACB score o fC5. Antipsychotics accounted for 36.4 % of the total cumulative ACB score followed by anticholinergics (16 %) and antidepressants (10.8 %). The most frequently reported medicine with anticholinergic activity was carbamazepine 16.8 % (127). The most frequently reported medicine with high anticholinergic activity (ACB 3) was olanzapine13.4 % (101). There was a significant association between higher anti-cholinergic exposure and multimorbidity, particularly mental health morbidity, and some anticholinergic adverse effects such as constipation and day-time drowsiness but not self-rated health. Conclusion: Using simple cumulative measures proved an effective means to capture total burden and helped establish that anticholinergic exposure in the study population was high. The finding highlights the need for comprehensive reviews of medications.

Effects of psychotropic drugs on memory: Part 2.

In these two columns, we have briefly reviewed the research on the effects on memory of lithium, anticonvulsants, anticholinergics, neuroleptics, antidepressants, beta blockers, and benzodiazepines. Evidence suggests that all classes of psychotropic medication may have some deleterious effect on memory. However, the clinician must weigh the risk of memory loss due to psychotropic drugs against the risk that certain emotional illnesses, such as depression and severe anxiety, may themselves impair memory function if not treated. Clinically significant effects on memory are most often seen when using drugs or combinations of drugs with high anticholinergic activity and when using short-acting benzodiazepines. Clinical evidence and some research suggest that geriatric patients are more sensitive to the potential memory impairment caused by psychotropic drugs, but more research data are needed.