Stephanie Munger

The cognitive impact of anticholinergics:a clinical review

Context: The cognitive side effects of medications with anticholinergic activity have been documented among older adults in a variety of clinical settings. However, there has been no systematic confirmation that acute or chronic prescribing of such medications lead to transient or permanent adverse cognitive outcomes. Objective: Evaluate the existing evidence regarding the effects of anticholinergic medications on cognition in older adults. Data sources: We searched the MEDLINE, OVID, and CINAHL databases from January, 1966 to January, 2008 for eligible studies. Study selection: Studies were included if the anticholinergic activity was systematically measured and correlated with standard measurements of cognitive performance. Studies were excluded if they reported case studies, case series, editorials, and review articles. Data extraction: We extracted the method used to determine anticholinergic activity of medications and its association with cognitive outcomes. Results: Twenty-seven studies met our inclusion criteria. Serum anticholinergic assay was the main method used to determine anticholinergic activity. All but two studies found an association between the anticholinergic activity of medications and either delirium, cognitive impairment or dementia. Conclusions: Medications with anticholinergic activity negatively affect the cognitive performance of older adults. Recognizing the anticholinergic activity of certain medications may represent a potential tool to improve cognition.

Impact of anticholinergics on the aging brain: a review and practical application

Objective: in an effort to enhance medication prescribing for older adults and reduce the burden of cognitive impairment, this paper reviews the literature regarding the negative impact of anticholinergics on cognitive function and provides clinicians with a practical guidance for anticholinergic use in older adults. Methods: a Medline search identified studies evaluating the use of anticholinergics and the relationship between anticholinergics and cognitive impairment. Results: prescribing anticholinergics for older adults leads to acute cognitive impairment and, possibly, chronic cognitive deficits. Assessing anticholinergic burden with a simple scale may represent a useful noninvasive tool to optimize geriatric pharmacotherapy. Conclusion: more studies are needed to validate the Anticholinergic Cognitive Burden scale and establish therapeutic guidelines in the presence of cognitive anticholinergic adverse effects.

Implementing Innovative Models of Dementia Care: The Healthy Aging Brain Center

Background: Recent randomized controlled trials have demonstrated the effectiveness of the collaborative dementia care model targeting both the patients suffering from dementia and their informal caregivers. Objective: To implement a sustainable collaborative dementia care program in a public health care system in Indianapolis. Methods: We used the framework of Complex Adaptive System and the tool of the Reflective Adaptive Process to translate the results of the dementia care trial into the Healthy Aging Brain Center (HABC). Results: Within its first year of operation, the HABC delivered 528 visits to serve 208 patients and 176 informal caregivers. The mean age of HABC patients was 73.8 (standard deviation, SD 9.5), 40% were African-Americans, 42% had less than high school education, 14% had normal cognitive status, 39% received a diagnosis of mild cognitive impairment, and 46% were diagnosed with dementia. Within 12 months of the initial HABC visit, 28% of patients had at least one visit to an emergency room (ER) and 14% were hospitalized with a mean length of stay of five days. The rate of a one-week ER revisit was 14% and the 30-day rehospitalization rate was 11%. Only 5% of HABC patients received an order for neuroleptics and only 16% had simultaneous orders for both definite anticholinergic and anti-dementia drugs. Conclusion: The tools of ‘implementation science’ can be utilized to translate a health care delivery model developed in the research laboratory to a practical, operational, health care delivery program.

Comorbidity Profile and Healthcare Utilization in Elderly Patients with Serious Mental Illnesses

OBJECTIVES Patients with serious mental illness are living longer. Yet, there remain few studies that focus on healthcare utilization and its relationship with comorbidities in these elderly mentally ill patients. DESIGN Comparative study. Information on demographics, comorbidities, and healthcare utilization was taken from an electronic medical record system. SETTING Wishard Health Services senior care and community mental health clinics. PARTICIPANTS Patients age 65 years and older-255 patients with serious mental illness (schizophrenia, major recurrent depression, and bipolar illness) attending a mental health clinic and a representative sample of 533 nondemented patients without serious mental illness attending primary care clinics. RESULTS Patients having serious mental illness had significantly higher rates of medical emergency department visits (p = 0.0027) and significantly longer lengths of medical hospitalizations (p <0.0001) than did the primary care control group. The frequency of medical comorbidities such as diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, thyroid disease, and cancer was not significantly different between the groups. Hypertension was lower in the mentally ill group (p <0.0001). Reported falls (p <0.0001), diagnoses of substance abuse (p = 0.02), and alcoholism (p = 0.0016) were higher in the seriously mentally ill. The differences in healthcare utilization between the groups remained significant after adjusting for comorbidity levels, lifestyle factors, and attending primary care. CONCLUSIONS Our findings of higher rates of emergency care, longer hospitalizations, and increased frequency of falls, substance abuse, and alcoholism suggest that seriously mentally ill older adults remain a vulnerable population requiring an integrated model of healthcare.

Selecting a change and evaluating its impact on the performance of a complex adaptive health care delivery system

Complexity science suggests that our current health care delivery system acts as a complex adaptive system (CAS). Such systems represent a dynamic and flexible network of individuals who can coevolve with their ever changing environment. The CAS performance fluctuates and its members’ interactions continuously change over time in response to the stress generated by its surrounding environment. This paper will review the challenges of intervening and introducing a planned change into a complex adaptive health care delivery system. We explore the role of the “reflective adaptive process” in developing delivery interventions and suggest different evaluation methodologies to study the impact of such interventions on the performance of the entire system. We finally describe the implementation of a new program, the Aging Brain Care Medical Home as a case study of our proposed evaluation process.

Connecting research discovery with care delivery in dementia: the development of the Indianapolis Discovery Network for Dementia.

Background The US Institute of Medicine has recommended an integrated, locally sensitive collaboration among the various members of the community, health care systems, and research organizations to improve dementia care and dementia research. Methods Using complex adaptive system theory and reflective adaptive process, we developed a professional network called the “Indianapolis Discovery Network for Dementia” (IDND). The IDND facilitates effective and sustainable interactions among a local and diverse group of dementia researchers, clinical providers, and community advocates interested in improving care for dementia patients in Indianapolis, Indiana. Results The IDND was established in February 2006 and now includes more than 250 members from more than 30 local (central Indiana) organizations representing 20 disciplines. The network uses two types of communication to connect its members. The first is a 2-hour face-to-face bimonthly meeting open to all members. The second is a web-based resource center (http://www.indydiscoverynetwork.org ). To date, the network has: (1) accomplished the development of a network website with an annual average of 12,711 hits per day; (2) produced clinical tools such as the Healthy Aging Brain Care Monitor and the Anticholinergic Cognitive Burden Scale; (3) translated and implemented the collaborative dementia care model into two local health care systems; (4) created web-based tracking software, the Enhanced Medical Record for Aging Brain Care (eMR-ABC), to support care coordination for patients with dementia; (5) received more than USD

Indianapolis discovery network for dementia: Four years and going

24 million in funding for members for dementia-related research studies; and (6) adopted a new group-based problem-solving process called the “IDND consultancy round.” Conclusion A local interdisciplinary “think-tank” network focused on dementia that promotes collaboration in research projects, educational initiatives, and quality improvement efforts that meet the local research, clinical, and community needs relevant to dementia care has been built.

P2-283: Indianapolis discovery network for dementia: Where we are after two years

Background: Despite numerous quality improvement efforts, best practice guidelines, and clinical and basic research activities over the past three decades, dementia is still underdiagnosed and undertreated, especially among minorities. Furthermore, even among those receiving optimal care, only a small proportion participate in clinical trials. The Institute of Medicine has recommended the need for system thinking and integrated, locally sensitive collaboration among the various members of the local community, health care systems and research organizations. It is hypothesized that an effective collaboration would improve diagnosis and treatment of the dementia patient, as well as increase participation in research. Methods: A local and diverse network of dementia researchers, clinical providers, patient advocates and policy makers who are interested in improving the care for dementia patients in Indianapolis were invited to participate in bimonthly face-to-face meetings and regular email interactions. The Network uses the Complex Adaptive System theoretical framework and the Reflective Adaptive Process to facilitate and sustain effective interactions among its members. Results: The Network was established in February 2006 and includes more than 150 members from more than 20 local organizations, representing over 20 disciplines. To date, the network has built a web-based resource center, created a social networking forum through Facebook, has delivered numerous educational seminars, developed and disseminated educational materials and quick reference cards; and developed numerous clinical tools. Currently, the Network is deploying research projects into community practices, looking at a new screening and management tool (the Healthy Aging Brain Care Monitor), has developed an electronic medical record specifically designed to address the concerns of the cognitively impaired population (eMR-ABC), and has taken a NIH funded study into primary care practices outside of academic practice setting (PRISM-PC). Conclusions: Building and sustaining a local interdisciplinary ‘‘think-tank’’ network in dementia facilitates conducting various collaborative research, educational and quality improvement programs that meet the local research, clinical, and community needs relevant to dementia.

Pharmacological Management of Delirium in Hospitalized Adults - A Systematic Evidence Review

Background: Despite numerous quality improvement efforts, best practice guidelines, and clinical and basic research activities over the past three decades, dementia is still underdiagnosed and undertreated, especially among minorities. Furthermore, even among those receiving optimal care, only a small proportion participate in clinical trials. The Institute of Medicine has recommended the need for system thinking and integrated, locally sensitive collaboration among the various members of the local community, health care systems and research organizations. It is hypothesized that an effective collaboration would improve diagnosis and treatment of the dementia patient, as well as increase participation in research. Methods: A local and diverse network of dementia researchers, clinical providers, and policy makers who are interested in improving the care for dementia patients in Indianapolis was invited to participate in bimonthly meetings. The Network uses the Complex Adaptive System theoretical framework and the Reflective Adaptive Process to facilitate and sustain effective interactions among its members. Results: The Network was established in February 2006 and includes more than 60 members from more than 20 local organizations representing geriatrics, neurology, psychiatry, pathology, neuropsychology, psychology, nursing, social work, primary care, geriatric pharmacy, health services research, epidemiology, pharmaceutical industry, Alzheimer advocacy, state policy makers, health administration, medical education, and biostatistics. The network uses two types of communication among its members. The first is a 3-hour face-to-face bimonthly meeting that includes all members. The second is a project-based workgroup meeting that focuses on a specific task and includes a segment of the network members. To date, the network has built a web-based resource center, completed 4 full-day educational seminars, received funding to test a research enrollment process utilizing the local Alzheimer’s Association help line, enabled clinicians to refer patients directly to a research registry, facilitated the submission of two NIH applications, tested a new group interaction method called “consultancy”, and has established a new dementia care clinic at the county hospital. Conclusions: Building a local interdisciplinary “think-tank” network in dementia facilitates conducting various collaborative research, educational and quality improvement programs that meet the local research, clinical, and community needs relevant to dementia.