Multiple Anticholinergic Medication Use and Risk of Hospital Admission for Confusion or Dementia

Ellett, Lisa M. Kalisch; Pratt, Nicole; Ramsay, Emmae; Barratt, John D.; Roughead, Elizabeth E.

doi:10.1111/jgs.13054

Cited by 107 publications

(81 citation statements)

References 26 publications

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“…Clinical guidelines typically focus on a single disease, and adherence to these guidelines could result in adverse interactions between drugs and diseases . Failure to manage specific chronic conditions optimally (e.g., cardiovascular disease or diabetes mellitus) or to take into account the different medications used in treatment of these conditions in an individual could contribute to risk of cognitive impairment …”

Section: Discussionmentioning

confidence: 99%

Multimorbidity and Risk of Mild Cognitive Impairment

Vassilaki

Aakre

Ruth

et al. 2015

J American Geriatrics Society

158

153

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OBJECTIVES To determine the association of multiple chronic conditions with risk of incident mild cognitive impairment (MCI)/dementia. DESIGN Prospective cohort study SETTING Olmsted County, Minnesota. PARTICIPANTS Cognitively normal individuals (N=2,176) enrolled in the Mayo Clinic Study of Aging (MCSA). MEASUREMENTS Participants were randomly selected from the community and evaluated by a study coordinator, a physician, and underwent neuropsychometric testing at baseline and at 15-month intervals to assess diagnoses of MCI and dementia. We electronically captured information on International Classification of Diseases, ninth revision (ICD-9) codes for chronic conditions in the five years prior to enrollment using the Rochester Epidemiology Project medical records linkage system. We defined multimorbidity as having two or more chronic conditions and examined the association of multimorbidity with MCI/dementia using Cox proportional hazards models. RESULTS Among 2,176 cognitively normal participants (mean [±SD] age 78.5 [±5.2] years; 50.6% men), 1,884 (86.6%) had multimorbidity. The risk of MCI/dementia was elevated in persons with multimorbidity (hazard ratio [HR]: 1.38; 95% confidence interval [CI], 1.05–1.82). The HR was stronger in persons with ≥4 conditions (HR: 1.61; 95%CI, 1.21–2.13) compared to persons with only 0 or 1 conditions, and for men (HR: 1.53, 95% CI, 1.01– 2.31) than for women (HR: 1.20, 95% CI, 0.83– 1.74). CONCLUSION In older adults, having multiple chronic conditions is associated with an increased risk of MCI/dementia. This is consistent with the hypothesis that multiple etiologies may contribute to MCI and late-life dementia. Preventing chronic diseases may be beneficial in delaying or preventing MCI or dementia.

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Section: Discussionmentioning

confidence: 99%

Multimorbidity and Risk of Mild Cognitive Impairment

Vassilaki

Aakre

Ruth

et al. 2015

J American Geriatrics Society

158

153

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“…Furthermore, ADEs are frequently a causative or contributory factor to hospitalisation in older adults [29]. Anticholinergic burden, a measure of a patient’s cumulative exposure to medicines with anticholinergic properties, has been shown to be associated with an increased risk of hospitalisation for confusion or dementia [30]. Falls, which may also be a manifestation of an ADE, are of particular concern amongst institutionalised older adults, as they are directly responsible for significant morbidity and mortality in this population [31].…”

Section: Discussionmentioning

confidence: 99%

Development of a core outcome set for effectiveness trials aimed at optimising prescribing in older adults in care homes

Millar

Daffu-O’Reilly

Hughes

et al. 2017

Trials

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BackgroundPrescribing medicines for older adults in care homes is known to be sub-optimal. Whilst trials testing interventions to optimise prescribing in this setting have been published, heterogeneity in outcome reporting has hindered comparison of interventions, thus limiting evidence synthesis. The aim of this study was to develop a core outcome set (COS), a list of outcomes which should be measured and reported, as a minimum, for all effectiveness trials involving optimising prescribing in care homes. The COS was developed as part of the Care Homes Independent Pharmacist Prescribing Study (CHIPPS).MethodsA long-list of outcomes was identified through a review of published literature and stakeholder input. Outcomes were reviewed and refined prior to entering a two-round online Delphi exercise and then distributed via a web link to the CHIPPS Management Team, a multidisciplinary team including pharmacists, doctors and Patient Public Involvement representatives (amongst others), who comprised the Delphi panel. The Delphi panellists (n = 19) rated the importance of outcomes on a 9-point Likert scale from 1 (not important) to 9 (critically important). Consensus for an outcome being included in the COS was defined as ≥70% participants scoring 7–9 and <15% scoring 1–3. Exclusion was defined as ≥70% scoring 1–3 and <15% 7–9. Individual and group scores were fed back to participants alongside the second questionnaire round, which included outcomes for which no consensus had been achieved.ResultsA long-list of 63 potential outcomes was identified. Refinement of this long-list of outcomes resulted in 29 outcomes, which were included in the Delphi questionnaire (round 1). Following both rounds of the Delphi exercise, 13 outcomes (organised into seven overarching domains: medication appropriateness, adverse drug events, prescribing errors, falls, quality of life, all-cause mortality and admissions to hospital (and associated costs)) met the criteria for inclusion in the final COS.ConclusionsWe have developed a COS for effectiveness trials aimed at optimising prescribing in older adults in care homes using robust methodology. Widespread adoption of this COS will facilitate evidence synthesis between trials. Future work should focus on evaluating appropriate tools for these key outcomes to further reduce heterogeneity in outcome measurement in this context.

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“…A number of studies have established that there is a relationship between anticholinergic burden and outcomes such as cognitive decline 39,40 , delirium 3,41 , falls 1,42 , and mortality 43–45 . However, there is a substantial amount of heterogeneity in terms of the ways in which exposure to medications with anticholinergic properties is defined, and few studies actually address whether there is a difference in the risk for adverse events specifically between individuals with high-level versus low-level anticholinergic burden 40,41,45 . Interestingly, no studies have investigated whether there is a difference in the risk for adverse events for high-level anticholinergic burden due to a cumulative effect versus the effect of one medication with high-level anticholinergic activity.…”

Section: Discussionmentioning

confidence: 99%

Anticholinergic Prescribing in Medicare Part D Beneficiaries Residing in Nursing Homes: Results from a Retrospective Cross-Sectional Analysis of Medicare Data

et al. 2017

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Background Prescribing of medications with anticholinergic properties in older nursing home residents is relatively common, despite an association with increased risk for falls, delirium and other outcomes. Few studies have investigated what factors influence different levels of prescribing of these agents. Objectives The primary objective was to identify factors associated with low- and high-level anticholinergic burden in nursing home residents. A secondary objective was to examine in detail the contribution of different medications to low versus high burden, to aid in determining drugs to target in interventions. Design Retrospective, cross-sectional analysis. Setting National sample of 2009–2010 Medicare Part A and B claims, Part D prescription drug events, and Minimum Data Set (MDS) v2.0 assessments. Participants The cohort included 4730 Medicare beneficiaries age ≥65 with continuous Medicare Parts A, B, and D enrollment, admitted for non-skilled stays ≥14 days between 01/01/2010–09/30/2010. Measurements Anticholinergic burden was defined using the Anticholinergic Cognitive Burden(ACB) scale. Medication scores were summed at the patient-level and categorized as high (score ≥3), low (score 1–2), or none. Baseline predisposing (age, sex, race/ethnicity), enabling (prior year hospital, emergency department, primary care, specialist visits; region; Medicaid/low-income subsidy), and medical need factors (dementia severity, anti-dementia medication, Charlson co-morbidity index [CCI], select comorbidities) were evaluated for association with anticholinergic burden using multinomial logistic regression. Results Overall, 29.6% had high-level anticholinergic burden, and 35.2% had low-level burden. High-level burden was most often (72%) due to one highly anticholinergic medication rather than cumulative effect. In adjusted analyses, factors associated with increased risk of both low and high anticholinergic burden included: comorbidity, antidementia medication, depression, hypertension, and prior year hospitalization. Older age was associated with decreased odds of high anticholinergic burden. Urinary incontinence and prior year specialist visit were associated with increased odds of high anticholinergic burden. Severe and non-severe dementia were associated with decreased odds of low-level burden, but increased odds of high-level burden. Conclusion Almost two-thirds of nursing home patients have some degree of anticholinergic burden. Several medical need variables are significantly associated with increased risk for low-level and high-level anticholinergic burden. Interventions should be developed to optimize prescribing for residents at increased risk of receiving medications with anticholinergic properties. Future study is needed to evaluate the difference in the risk of adverse outcomes associated with various levels of anticholinergic burden.

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Multiple Anticholinergic Medication Use and Risk of Hospital Admission for Confusion or Dementia

Abstract: Taking more anticholinergic medications is associated with greater risk of hospitalization for confusion or dementia. Strategies to reduce anticholinergic medication burden are likely to translate into significant health benefits.

Cited by 107 publications

References 26 publications

Multimorbidity and Risk of Mild Cognitive Impairment

Multimorbidity and Risk of Mild Cognitive Impairment

Development of a core outcome set for effectiveness trials aimed at optimising prescribing in older adults in care homes

Anticholinergic Prescribing in Medicare Part D Beneficiaries Residing in Nursing Homes: Results from a Retrospective Cross-Sectional Analysis of Medicare Data

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