Association of anticholinergic cognitive load with the appointment of potentially not recommended drugs and the frequency of hospitalization of elderly and senile patients

Actuality. The pharmacotherapy practice in elderly and senile patients is characterized by a widespread use of drugs with anticholinergic properties. Available data indicate that the combined anticholinergic cognitive burden correlates with the risk of adverse events and may serve as a factor in increasing the frequency of hospitalization in elderly patients.

Objective. To examine the prevalence of anticholinergic medications and factors associated with anticholinergic cognitive burden in this study population.

Methods. A retrospective pharmacoepidemiological analysis of medical records of 401 patients >65 years of age, hospitalized in Moscow in the period from 1st of June to 30th of December, 2017, was performed. Anticholinergic drugs were identified using Anticholinergic Cognitive Burden Scale (ACB) [Anticholinergic cognitive burden scale. Aging Brain Care. 2012 Update Developed by the Aging Brain Program of the Indiana University Center for Aging Research]. Binary logistic regression was applied to identify significantly the factors associated with anticholinergic medication use in the study population. Data were presented using odds ratios with 95 % confidence intervals.

Results. Four hundred one patients were included in the analysis, with a mean age of 77.4 (±7.2) years, 72.1 % were female, the median (IQR) of comorbidities per patient was 3 (0-5), the median of the number of prescribed medications per patient was 2 (0-4). The most common pathological conditions included chronic heart failure, hypertension, cerebrovascular disease, coronary heart disease. Polypharmacy was observed in 36.7% of patients. according to the ACB scale, 41.9 % of patients were exposed to ACB-contributing medicines (95 % CI: 41.1-42.7). Mean ACB score was 0.71 ± 0.06 (IQR 1-7). The most commonly prescribed ACB- contributing medications were cardiovascular agents — 51.47 %; and oral anticoagulants — 23.4 %. The odds of ACB exposure was 1.47 (CI 95 % = 1.33-1.63). The prescription of drugs with anticholinergic burden was not associated with an increase in the frequency of hospitalization (OR: 0.83, p = 0.089). Patients with ACB>0 had higher levels of potentially inappropriate medications (PIMs) (OR: 1.29, p = 0.02). An association of polypharmacy with high ACB scores was found (p = 0.001). No association was observed between potentially prescribing omission (PPOs), age and gender with Anticholinergic burden (ACB).

Conclusions. Pharmacotherapy analysis of elderly and senile patients showed high prevalence rates of prescribing drugs with potential anticholinergic effects of level 1 according to ACB scale). There was no association between prescribing anticholinergics with an increased risk of hospitalization and the number of concomitant diseases.

1. Chew ML, Mulsant BH, Pollock BG, et al. Anticholinergic activity of 107 medications commonly used by older adults. JAm Geriatr Soc. 2008;56:1333-41.

2. Cancelli I, Beltrame M, Gigli GL, Valente M. Drugs with anticholinergic properties: cognitive and neuropsychiatric side-effects in elderly patients. Neurol Sci. 2009;30:87-92.

3. Mintzer J, Burns A. Anticholinergic side effects of drugs in elderly people. JR Soc Med. 2000;93(9):457-62. pmid:11089480.

4. Han L, Agostini JV, Allore HG. Cumulative anticholinergic exposure is associated with poor memory and executive function in older men. J Am Geriatr Soc. 2008;56:2203-2210.

5. Quan H, Li B, Couris CM, et al. Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol. 2011;173:676-682.

6. Klarin I, Wimo A, Fastbom J. The association of inappropriate drug use with hospitalisation and mortality. Drugs Aging. 2005;22:69-82.

7. Kay GG, Abou-Donia MB, Messer WS, et al. Antimuscarinic drugs for overactive bladder and their potential effects on cognitive function in older patients. J Am Geriatr Soc. 2005;53:2195-2201.

8. Hopcroft P, Peel NM, Poudel A, et al. Prescribing for older people discharged from the acute sector to residential aged-care facilities. Intern Med J. 2014;44:1034-7.

9. Patterson SM, Cadogan CA, Kerse N, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2014: CD008165.

10. Block CK, Logue E, Thaler NS, et al. The interaction between medical burden and anticholinergic cognitive burden on neuropsychological function in a geriatric primary care sample. Arch Clin Neuropsychol. 2015;30(2):105-113.

11. Murray AM, Levkoff SE, Wetle TT, et al. Acute delirium and functional decline in the hospitalized elderly patient. J Gerontol. 1993;48:M181-6.

12. Campbell N, Boustani M, Limbil T, et al. The cognitive impact of anticholinergics: a clinical review. Clin Interv Aging. 2009;4:225-33.

13. American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616-31.

14. Gallagher P, Ryan C, Byrne S, et al. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72-83.

15. Shuichi W, Takahide F, Kosuke K. Risk of hospitalization associated with anticholinergic medication for patients with dementia. Psychogeriatrics. 2018;18:57-63

16. Lowry E, Woodman R, Soiza R, et al. Drug burden index, physical function, and adverse outcomes in older hospitalized patients. J Clin Pharmacol. 2012;52:1584-1591.

17. Boustani M, Campbell N, Maidment I, Fox C. Impact of anticholinergics on the aging brain: a review and practical application. Aging Health. 2008;4(3):311-20.

18. Aging Brain Care. Anticholinergic Cognitive Burden Scale—2012 Update. Available: www.agingbraincare.org/uploads/products/ACB_scale_-_legal_size.pdf.

19. O’Mahony D, O’Sullivan D, Byrne S, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2. Age Ageing. 2015;44:213-218.

20. Espino DV, Bazaldua OV, Palmer RF, et al. Suboptimal medication use and mortality in an older adult community-based cohort: results from the Hispanic EPESE Study. J Gerontol A Biol Sci Med Sci. 2006;61:170-5.

21. Pozzi C, Lapi F, Mazzaglia G, et al. Is suboptimal prescribing a risk factor for poor health outcomes in community-dwelling elders? The ICARe Dicomano study. Pharmacoepidemiol Drug Saf. 2010;19:954-60.

22. Bhattacharya R, Chatterjee S, Carnahan RM, Aparasu RR. Prevalence and predictors of anticholinergic agents in elderly outpatients with dementia. Am J Geriatr Pharmacother. 2011;9:434-441.

23. Weichert I, Romero R, Tolonen J, Lebus C, et al. Anticholinergic medications in patients admitted with cognitive impairment or falls (AMiCI). The impact of hospital admission on anticholinergic cognitive medication burden. J Clin Pharm Ther. 2018 Oct;43(5):682-694. doi: 10.1111/jcpt.12694. Epub 2018 May 4.

24. Remillard AJ. A pharmacoepidemiological evaluation of anticholinergic prescribing patterns in the elderly. Pharmacoepidemiol Drug Saf. 1996 May;5(3):155-64

25. Sujita WN, Sarah NH, Simon H, Prasad SN. Anticholinergic Component of the Drug Burden Index and the Anticholinergic Drug Scale as Measures of Anticholinergic Exposure in Older People in New Zealand: A Population-Level Study. Drugs & Aging. 2013;11:927-934.

26. Ziere G, Dieleman JP, Hofman A, et al. Polypharmacy and falls in the middle age and elderly population. Br J Clin Pharmacol. 2006;61:218-223.

27. Satabdi C, Sandhya M, Jeffrey TS, Rajender RA. Prevalence and Predictors of Anticholinergic Medication Use in Elderly Nursing Home Residents with Dementia. Drugs and aging. 2010;12:987-997.

28. Salahudeen MS, Hilmer SN, Nishtala PS. Comparison of anticholinergic risk scales and associations with adverse health outcomes in older people. J Am Geriatr Soc. 2015;63:85-90.

29. Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The Anticholinergic Risk Scale and anticholinergic adverse effects in older persons. Arch Intern Med. 2008;168: 508-513.

30. Singh S, Loke YK, Enright P, Furberg CD. Pro-arrhythmic and proischaemic effects of inhaled anticholinergic medications. Thorax. 2013;68:114-116.

31. Jyrkka J, H Enlund, P Lavikainen, et al. Association of polypharmacy with nutritional status, functional ability and cognitive capacity over a three-year period in an elderly population. Pharmacoepidemiol Drug Saf. 20(2011), pp. 514-522.