Increasing anticholinergic burden and delirium in palliative care inpatients

Zimmerman, Kristin; Salow, Marci; Skarf, Lara M.; Kostas, Tia; Paquin, Allison M; Simone, Mark; Rudolph, James L.

doi:10.1177/0269216314522105

Cited by 48 publications

(64 citation statements)

References 25 publications

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“…Our finding that anticholinergic drug exposure measured with the ARS is associated with delirium, is in agreement with the results of previous studies performed in critically ill patients (Wolters et al 2015), palliative care patients (Zimmerman et al 2014), patients with Parkinson's disease (Crispo et al 2016) and older nursing home residents (Landi et al 2014). Also, previous studies found no association between anticholinergic drug exposure, measured with the ACB or the Anticholinergic Drug Scale, and delirium in older hospitalized patients (Moorey et al 2016;Campbell et al 2011;Wolters et al 2015).…”

Section: Discussionsupporting

confidence: 92%

Anticholinergic drug exposure is associated with delirium and postdischarge institutionalization in acutely ill hospitalized older patients

Egberts

Craats

Wijk

et al. 2017

Pharmacology Res & Perspec

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Several studies investigated the possible association between anticholinergic drugs and diverse clinical outcomes in older persons, but the results are inconsistent. The aim of this study was to investigate whether anticholinergic drug exposure is associated with delirium on admission, length of hospital stay, postdischarge institutionalization and in‐hospital mortality in acutely ill hospitalized older patients. In this observational chart review study, we included acutely ill patients aged 65 and older who were admitted to the geriatric ward of the Erasmus University Medical Center, Rotterdam, The Netherlands, between 2012 and 2015 (n = 905). Anticholinergic drug exposure on admission was defined as the use of anticholinergic drugs, total number of anticholinergic drugs and anticholinergic drug burden score (ADB), quantified with the Anticholinergic Risk Scale (ARS), the Anticholinergic Cognitive Burden scale (ACB) and the list of Chew et al. (Chew). Logistic regression analyses were performed to investigate possible associations between anticholinergic drug exposure and the aforementioned outcomes. Analyses were adjusted for age, sex, comorbidities, non‐anticholinergic drugs and delirium, where appropriate. Moderate and high ADB measured with the ARS were associated with delirium on admission with odds ratios (OR) of 1.70 (95% confidence interval (CI) = 1.16–2.49) and 1.83 (95% CI = 1.06–3.15), respectively. High ADB measured with the ARS was also associated with postdischarge institutionalization (OR = 2.43, 95% CI = 1.24–4.75). No associations were found using the ACB and Chew. Future studies are warranted to investigate the clinical usefulness of the ARS in reducing complications in older persons.

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Section: Discussionsupporting

confidence: 92%

Anticholinergic drug exposure is associated with delirium and postdischarge institutionalization in acutely ill hospitalized older patients

Egberts

Craats

Wijk

et al. 2017

Pharmacology Res & Perspec

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“…Furthermore effective treatments should be accessible and amenable to administration with minimal burden, thus ensuring no increased distress to the patient. A medication profile review and an increase in the Anticholinergic Risk Scale will assist in identifying potential deliriogenic medications that can be dose-reduced or discontinued (50,51). Apart from the imminently dying context (last hours of life), an opioid switch (with a reduction in opioid equianalgesic dose by 30-50%) also may be appropriate if signs of opioid-induced neurotoxicity are present, although there remains a lack of high level evidence for this strategy in delirious patients (52,53).…”

Section: Delirium Reversibility In End-of-life Carementioning

confidence: 99%

End-of-Life Delirium: Issues Regarding Recognition, Optimal Management, and the Role of Sedation in the Dying Phase

Bush

Leonard

Agar

et al. 2014

Journal of Pain and Symptom Management

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Context. In end-of-life care, delirium is often not recognized and poses unique management challenges, especially in the case of refractory delirium in the terminal phase.Objectives. To review: delirium in the terminal phase context, specifically in relation to recognition issues; the decision-making processes and management strategies regarding its reversibility; the potential refractoriness of delirium to symptomatic treatment; and the role of sedation in refractory delirium. Methods.We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant electronic database literature searches (Ovid Medline, Embase, PsycINFO and CINAHL) to inform this narrative review.Results. The overall management strategy for delirium at the end of life is directed by the patient's prognosis in association with the patient's goals of care. As symptoms of delirium are often refractory in the terminal phase, especially in the case of agitated delirium, the judicious use of palliative sedation is frequently required. However, there remains a lack of high level evidence for the management of delirium in the terminal phase, including the role of antipsychotics and optimal sedation strategies. For the family and health care staff, clear communication, education and emotional support are vital components to assist with decision making and direct the treatment care plan. Conclusion.Further research on the effectiveness of delirium management strategies in the terminal phase for patients and their families is required. Further validation of assessment tools for diagnostic screening and severity measurement are needed in this patient population.

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“…For example, delirium in palliative care patients is rarely attributed to medications,21 despite the fact that increasing numbers of symptom-specific medications as death approaches have been shown to be the biggest contributing factor to anticholinergic load 2 22. At the very end of life, such medication combinations are even more likely to lead to clinically apparent drug interactions 23…”

Section: Introductionmentioning

confidence: 99%

Analysis of drug interactions at the end of life

Morgan

Rowett

Currow

2015

BMJ Support Palliat Care

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Potential drug-drug interactions are common for this group of patients. Some interactions may be recognised as an acceptable risk when the prescription is written. Further research is necessary to determine the best way to improve recognition of potential drug-drug interactions and the rates of morbidity or accelerated mortality associated with this. It is likely that palliative care services will need to implement multiple strategies including greater use of computerised prescribing software, and greater closer liaison with clinical pharmacists.

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Increasing anticholinergic burden and delirium in palliative care inpatients

Cited by 48 publications

References 25 publications

Anticholinergic drug exposure is associated with delirium and postdischarge institutionalization in acutely ill hospitalized older patients

Anticholinergic drug exposure is associated with delirium and postdischarge institutionalization in acutely ill hospitalized older patients

End-of-Life Delirium: Issues Regarding Recognition, Optimal Management, and the Role of Sedation in the Dying Phase

Analysis of drug interactions at the end of life

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