Prasad S. Nishtala

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.

Psychotropic Prescribing in Long-Term Care Facilities : Impact of Medication Reviews and Educational Interventions

The objective of this literature review was to evaluate the evidence pertaining to the impact of medication reviews and/or educational interventions on psychotropic drug use in long-term care facilities. A computerized search was conducted using MEDLINE, Cochrane Central Register of Control Trials, CINAHL, EMBASE, International Pharmaceutical Abstracts and PsycINFO, from January 1980 to April 2007. Controlled studies or randomized controlled studies were included for review. The authors identified 26 studies evaluating the impact of medication reviews and/or educational interventions on psychotropic drug use in long-term care facilities. Eleven studies met the inclusion criteria for this review and the data from six of these studies were included in a meta-analysis. The pooled odds ratio (OR) from five studies on hypnotic prescribing showed a decrease in use postintervention (OR = 0.57, 95% confidence intervals [CI] = 0.41-0.79). The pooled OR from five studies on prevalence of antipsychotic prescribing postintervention was not significant (OR = 0.81, 95% CI = 0.63-1.04). Medication reviews and/or educational interventions are effective at reducing psychotropic drug prescribing. However, research on the benefits of these interventions in reducing psychotropic drug use on total health care costs and resident health outcomes is lacking.

Drug Burden Index and Potentially Inappropriate Medications in Community-Dwelling Older People The Impact of Home Medicines Review

BackgroundA significant problem in older people (aged ≥65 years) is the use of potentially inappropriate medications (PIMs), including those with sedative and anticholinergic properties. However, effective intervention strategies have yet to be identified. The Drug Burden Index (DBI) is an evidence-based tool that measures a person’s total exposure to medications with sedative and anticholinergic properties and has been shown to be independently associated with impairment in cognitive and physical function.ObjectiveThe main aim of the study was to investigate whether Home Medicines Review (HMR) services by pharmacists for community-dwelling older people would lead to an improvement in the use of medications, as measured by a decrease in the DBI score. The study also aimed to investigate the (i) distribution of DBI scores and PIMs among older people living in the community, and (ii) impact of pharmacists’ recommendations on DBI scores and PIMs.MethodsA retrospective analysis of medication reviews was performed for 372 community-dwelling older people (aged ≥65 years) who received an HMR service from the pharmacist. The main outcome measure was the total DBI score at baseline and post-HMR. The data were also examined to determine the extent of PIM use (2003 Beers’ criteria), and the number and nature of pharmacists’ recommendations.ResultsOverall, medications contributing to the DBI (i.e. medications with sedative or anticholinergic properties) and PIMs were identified in 60.5% (n = 225) and 39.8% (n=148) of the patients, respectively. Following pharmacist recommendations during the HMR service, medications contributing to the DBI were identified in 51.6% (n = 192) of the patients. A statistically significant reduction in the sum total of DBI scores for all patients was observed following pharmacists’ recommendations during the HMR service (206.9 vs 157.3, p < 0.001). Pharmacists’ recommendations also led to a decrease in the use of PIMs, which were identified in 28.2% (n= 105) of the patients following the HMR service.ConclusionWhen the DBI is used for evaluation, pharmacists’ recommendations during HMR services, if acted upon, may effect changes in the prescribing of sedative and anticholinergic medications, thereby substantially reducing the patient’s drug burden. Future studies should focus on whether such a decrease may translate into functional improvements. The study also showed a positive influence of HMR services on the prescribing of PIMs.

Impact of Residential Medication Management Reviews on Drug Burden Index in Aged-Care Homes: A Retrospective Analysis

BackgroundThe Drug Burden Index (DBI) is an evidence-based tool that associates medication exposure with functional outcomes in older people. Accredited clinical pharmacists performing medication reviews could consider including the DBI in their medication reviews to optimize prescribing in older people.ObjectiveTo examine the impact of residential medication management reviews (RMMRs) performed by accredited clinical pharmacists on DBI in older people living in aged-care homes.MethodsA retrospective analysis was performed of a random sample of 500 de-identified RMMR reports from residents aged (mean±SD) 84±9.0 years who had medication reviews conducted by ten accredited clinical pharmacists from 1 January 2008 through 30 June 2008. The data on medication use were collected over 8 months across 62 aged-care homes. DBI scores were calculated at baseline, after the recommendations had been made by the pharmacist and after uptake of pharmacist recommendations by the general practitioner (GP).ResultsA statistically significant decrease (p<0.001) in median DBI score was observed as a result of uptake of pharmacist recommendations by the GP. GPs were more likely to take up recommendations made by pharmacists that resulted in a decrease in DBI score than recommendations that resulted in an increase in DBI score (60.7% vs 34.6%, respectively). The mean decrease in DBI as a result of pharmacist recommendations was 0.12 (95% CI 0.09, 0.14) representing a 20% decrease in mean baseline DBI for residents. When GPs implemented pharmacists’ recommendations, DBI decreased by a mean of 12% from baseline (mean decrease 0.07; 95% CI 0.05, 0.08). Most of the recommendations proposed by the pharmacists involved withdrawing benzodiazepines or reducing antipsychotic drug dosage.ConclusionsThis is the first study in which DBI has been used as a tool to evaluate the impact of RMMRs conducted by accredited clinical pharmacists. The study demonstrates that pharmacist-conducted medication reviews can reduce prescribing of sedative and anticholinergic drugs in older people, resulting in a significant decrease in the DBI score.

Comparison of anticholinergic risk scales and associations with adverse health outcomes in older people

To investigate whether anticholinergic burden scores from nine published anticholinergic scales are associated with adverse health outcomes, including hospital admissions, hospitalizations for falls, hospital length of stay (LOS), and more visits to general practitioners (GPs).

Associations of drug burden index with falls, general practitioner visits, and mortality in older people.

On a population level in people aged ≥65 years old living in New Zealand, the aim of this study is to quantify each individuals cumulative exposure to anticholinergic and sedative medicines using the Drug Burden Index (DBI) and examine the impact of DBI on fall‐related hospitalisations, general practitioner (GP) visits, and all‐cause mortality.

Determinants of antipsychotic medication use among older people living in aged care homes in Australia

To investigate determinants of antipsychotic medication use among older people living in aged care homes in Australia.

Anticholinergic Activity of Commonly Prescribed Medications and Neuropsychiatric Adverse Events in Older People

This study sought to determine whether the presence of in vitro anticholinergic activity (AA) among different drugs is associated with reporting of neuropsychiatric adverse events (NPAEs) and whether age affects this relationship. Retrospective case/noncase analyses using Australias spontaneous Adverse Drug Reaction System (ADRS) database containing 150 475 reports determined crude and adjusted reporting odds ratios (RORs) for NPAEs for 23 drugs with various reported in vitro AA. Covariates were age (treated as a dichotomous variable [≥65 years]), gender, and concomitant use of antipsychotics, benzodiazepines, tricyclic antidepressants, and drugs with recognized inherent anticholinergic properties (anticholinergic drugs). The interaction effect between these covariates and each drug exposure category was examined. Age (≥65 years) has a significant association with greater odds relative to younger age for reporting NPAEs. Drugs with reported significant AA in vitro were not always associated with RORs greater than 1 for reporting NPAEs, highlighting a dissonance between the in vitro AA index and ADRS observations. Significant interactions were observed between age (≥65 years) and exposure to cimetidine, anticholinergic drugs, antipsychotics, and tricyclic antidepressants in modifying odds for reporting NPAEs, reinforcing the need for cautious use and monitoring of drugs with AA in older people.

Potentially inappropriate medicines in a cohort of community‐dwelling older people in New Zealand

To examine independent factors associated with potentially inappropriate medicines (PIM) among 316 community‐dwelling people aged ≥75 years living in Dunedin.

Temporal Trends in Polypharmacy and Hyperpolypharmacy in Older New Zealanders over a 9-Year Period: 2005-2013

Background: Polypharmacy and hyperpolypharmacy are proxy indicators for inappropriate medicine use. Inappropriate medicine use in older people leads to adverse clinical outcomes. Objective: The objectives of this study were to investigate the prevalence and trends of polypharmacy and hyperpolypharmacy in older people in New Zealand from 2005 to 2013, analyzing the pharmaceutical collections maintained by the Ministry of Health. Methods: A repeated cross-sectional analysis of population-level dispensing data was conducted from January 1, 2005 to December 31, 2013. Polypharmacy and hyperpolypharmacy in individuals were defined as the use of 5-9 medicines and ≥10 medicines, respectively, dispensed concurrently for a period of ≥90 days. Differences in polypharmacy and hyperpolypharmacy between 2005 and 2013 were examined. A multinomial regression model was used to predict sociodemographic characteristics associated with polypharmacy and hyperpolypharmacy. Results: Polypharmacy and hyperpolypharmacy were found to be higher in 2013 compared to 2005 (polypharmacy: 29.5 vs. 23.4%, p < 0.001; hyperpolypharmacy: 2.1 vs. 1.3%, p < 0.001). The risk of polypharmacy and hyperpolypharmacy was higher in females, in those aged 80-84 years, in the Māori population (for polypharmacy) and the Middle Eastern, Latin American, or African population (for hyperpolypharmacy), in people living in the Southern-district health board, and in individuals with increasing deprivation. Conclusion: The population of New Zealand is aging and the number of older people with multiple chronic conditions is increasing. The proportion of older people exposed to polypharmacy and hyperpolypharmacy has increased in 2013 compared to 2005. Our study provides important information to alert health policy makers, researchers, and clinicians about the dire need to reduce the medication burden in older New Zealanders.