Preoperative Comparison of Three Anticholinergic Drug Scales in Older Adult Patients and Development of Postoperative Delirium: A Prospective Observational Study

Heinrich, Martina; Müller, Ann-Kristin; Cvijan, Andela; Mörgeli, Rudolf; Kruppa, Jochen; Winterer, Georg; Slooter, Arjen J. C.; Spies, Claudia

doi:10.1007/s40266-021-00839-5

Cited by 12 publications

(9 citation statements)

References 33 publications

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“…Pasina et al also used the Anticholinergic Cognitive Burden Scale in their recently published study and did not find a clear association between anticholinergic burden and delirium in patients admitted to an acute geriatric ward (44). Also, in contrast to our findings, a recently published study by Heinrich et al found no association between preoperative anticholinergic load and POD using the Anticholinergic Cognitive Burden Scale, the Anticholinergic Drug Score and the ARS (24). However, compared to our study, these patients were significantly younger (POD: 74 years, no POD: 71 years in median) and patients with more than mild cognitive impairment (Mini-Mental State Examination score ≤ 23 points) were excluded.…”

Section: Discussioncontrasting

confidence: 99%

“…Anticholinergic burden has been associated with delirium in several settings (18,20,21), although results were conflicting (22). Studies on the effect of DAPs on POD are less frequent, and their results were also inconsistent, with one positive (23) and two negatives studies (24,25). Different results could be caused by the use of different scores calculating anticholinergic burden, small sample sizes, and different definitions of delirium.…”

Section: Introductionmentioning

confidence: 99%

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Anticholinergic Drug Exposure Increases the Risk of Delirium in Older Patients Undergoing Elective Surgery

et al. 2022

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IntroductionPostoperative delirium (POD) is a common and serious adverse event of surgery in older people. Because of its great impact on patients' safety and quality of life, identification of modifiable risk factors could be useful. Although preoperative medication intake is assumed to be an important modifiable risk factor, the impact of anticholinergic drugs on the occurrence of POD seems underestimated in elective surgery. The aim of this study was to investigate the association between preoperative anticholinergic burden and POD. We hypothesized that a high preoperative anticholinergic burden is an independent, potentially modifiable predisposing and precipitating factor of POD in older people.MethodsBetween November 2017 and April 2019, 1,470 patients of 70 years and older undergoing elective orthopedic, general, cardiac, or vascular surgery were recruited in the randomized, prospective, multicenter PAWEL trial. Anticholinergic burden of a sub-cohort of 899 patients, who did not receive a multimodal intervention for preventing POD, was assessed by two different tools at hospital admission: The established Anticholinergic Risk Scale (ARS) and the recently developed Anticholinergic Burden Score (ABS). POD was detected by confusion assessment method (CAM) and a validated post discharge medical record review. Logistic regression analyses were performed to evaluate the association between anticholinergic burden and POD.ResultsPOD was observed in 210 of 899 patients (23.4%). Both ARS and ABS were independently associated with POD. The association persisted after adjustment for relevant confounding factors such as age, sex, comorbidities, preoperative cognitive and physical status, number of prescribed drugs, surgery time, type of surgery and anesthesia, usage of heart-lung-machine, and treatment in intensive care unit. If a patient was taking one of the 56 drugs listed in the ABS, risk for POD was 2.7-fold higher (OR = 2.74, 95% CI = 1.55–4.94) and 1.5-fold higher per additional point on the ARS (OR = 1.54, 95% CI = 1.15–2.02).ConclusionPreoperative anticholinergic drug exposure measured by ARS or ABS was independently associated with POD in older patients undergoing elective surgery. Therefore, identification, discontinuation or substitution of anticholinergic medication prior to surgery may be a promising approach to reduce the risk of POD in older patients.

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Section: Discussioncontrasting

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Anticholinergic Drug Exposure Increases the Risk of Delirium in Older Patients Undergoing Elective Surgery

et al. 2022

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“…Our ndings on the association between delirium and exposure to anticholinergics and sedatives are unique. One possible explanation for these ndings, as a neurotransmitter hypothesis, is the deterioration of cholinergic neurotransmission and expansion of neuroin ammation due to activation of microglial cells in patients with dementia [39,40]. Because of these pathological changes, patients may be more susceptible to the possible adverse effects of drugs.…”

Section: Discussionmentioning

confidence: 99%

Impact of drug burden index on delirium in community-dwelling older adults with dementia: A longitudinal observational study

Katipoğlu

Demircan

Naharcı

2022

Preprint

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Background The Drug Burden Index (DBI) is a validated tool for assessing the dose-dependent cumulative exposure to sedative and anticholinergic medications. However, the increased risk of delirium superimposed dementia (DSD) with high DBI levels has not yet been investigated. Aim This study aimed to examine the longitudinal association between high DBI levels and delirium in community-dwelling older adults with dementia. Method A total of 1105 participants with cognitive impairment underwent a comprehensive geriatric assessment. Experienced geriatricians made the final diagnosis of delirium based on DSM-IV-TR and DSM-V. We calculated the DBI as the sum of all sedatives and anticholinergics taken continuously for at least four weeks before admission. We classified the participants as having no exposure (DBI=0), low exposure (0<DBI<1), and high exposure (DBI≥1). Results Of the 721 patients with dementia, the mean age was 78.3±6.7 years, and the majority were female (64.4%). In the whole sample, low and high exposures to anticholinergic and sedative medications at admission were 34.1% (n=246) and 38.1% (n=275), respectively. Patients in the high-exposure group had higher physical impairment (p=0.01), higher polypharmacy (p=0.01), and higher DBI scores (p=0.01). In the multivariate Cox regression analysis, high exposure to anticholinergic and sedative medications increased the risk of delirium 4.09-fold compared to the no exposure group (HR=4.09, CI: 1.63-10.27, p=0.01). Conclusion High exposure to drugs with sedative and anticholinergic properties was common in community-dwelling older adults. A high DBI was associated with DSD, highlighting the need for an optimal prescription in this vulnerable population. Trial registration The trial was retrospectively registered at ClinicalTrials.gov. Identifier: NCT04973709 Registered on 22 July 2021.

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“…Within the study, further publications with other questions have been published. Worth mentioning here seem the manuscripts, which investigate the association between preoperative medication use and development of POD and POCD [ 22 ] or between three Anticholinergic Drug Scales and development of POD [ 23 ] and between radiological, chemical and pharmacological cholinergic system parameters and preoperative neurocognitive disorder [ 21 ].…”

Section: Methodsmentioning

confidence: 99%

“…POD was assessed daily through a validated delirium screening (using the Nursing Delirium Screening Scale, Confusion Assessment Method and a patient chart review) until the 7th postoperative day. For a detailed description of the assessment, please refer to previous publications [ 22 , 23 ].…”

Section: Methodsmentioning

confidence: 99%

Association between genetic variants of the cholinergic system and postoperative delirium and cognitive dysfunction in elderly patients

et al. 2021

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Background Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are frequent and serious complications after surgery. We aim to investigate the association between genetic variants in cholinergic candidate genes according to the Kyoto encyclopedia of genes and genomes - pathway: cholinergic neurotransmission with the development of POD or POCD in elderly patients. Methods This analysis is part of the European BioCog project (www.biocog.eu), a prospective multicenter observational study with elderly surgical patients. Patients with a Mini-Mental-State-Examination score ≤ 23 points were excluded. POD was assessed up to seven days after surgery using the Nursing Delirium Screening Scale, Confusion Assessment Method and a patient chart review. POCD was assessed three months after surgery with a neuropsychological test battery. Genotyping was performed on the Illumina Infinium Global Screening Array. Associations with POD and POCD were analyzed using logistic regression analysis, adjusted for age, comorbidities and duration of anesthesia (for POCD analysis additionally for education). Odds ratios (OR) refer to minor allele counts (0, 1, 2). Results 745 patients could be included in the POD analysis, and 452 in the POCD analysis. The rate of POD within this group was 20.8% (155 patients), and the rate of POCD was 10.2% (46 patients). In a candidate gene approach three genetic variants of the cholinergic genes CHRM2 and CHRM4 were associated with POD (OR [95% confidence interval], rs8191992: 0.61[0.46; 0.80]; rs8191992: 1.60[1.22; 2.09]; rs2067482: 1.64[1.10; 2.44]). No associations were found for POCD. Conclusions We found an association between genetic variants of CHRM2 and CHRM4 and POD. Further studies are needed to investigate whether disturbances in acetylcholine release and synaptic plasticity are involved in the development of POD. Trial registration: ClinicalTrials.gov: NCT02265263.

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Preoperative Comparison of Three Anticholinergic Drug Scales in Older Adult Patients and Development of Postoperative Delirium: A Prospective Observational Study

Cited by 12 publications

References 33 publications

Anticholinergic Drug Exposure Increases the Risk of Delirium in Older Patients Undergoing Elective Surgery

Anticholinergic Drug Exposure Increases the Risk of Delirium in Older Patients Undergoing Elective Surgery

Impact of drug burden index on delirium in community-dwelling older adults with dementia: A longitudinal observational study

Association between genetic variants of the cholinergic system and postoperative delirium and cognitive dysfunction in elderly patients

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