Medication Profiles of Patients with Cognitive Impairment and High Anticholinergic Burden
Drugs with anticholinergic properties are considered potentially inappropriate in patients with cognitive impairment because harms—including delirium, falls, and fractures—may outweigh benefits.
To highlight opportunities to improve clinical decision making and care for patients with cognitive impairment and multiple chronic conditions, we identified distinct subgroups of patients with mild cognitive impairment (MCI) and dementia who had high cumulative anticholinergic burden and specific patterns of anticholinergic use.
Patients and Methods
We conducted a retrospective cohort study in a not-for-profit, integrated delivery system. Participants included community-dwelling adults aged 65 years and older (n = 13,627) with MCI or dementia and at least two other chronic diseases. We calculated the Anticholinergic Cognitive Burden (ACB) score for each participant from pharmacy and electronic health record (EHR) data. Among individuals with a mean 12-month ACB score ≥ 2, we used agglomerative hierarchical clustering to identify groups or clusters of individuals with similar anticholinergic prescription patterns.
Twenty-four percent (3257 participants) had high anticholinergic burden, defined as an ACB score ≥ 2. Clinically meaningful clusters based upon anchoring medications or drug classes included a cluster of cardiovascular medications (n = 1497; 46%); two clusters of antidepressant medications (n = 633; 20%); and a cluster based on use of bladder antimuscarinics (n = 431; 13%). Several clusters comprised multiple central nervous system (CNS)-active drugs.
Cardiovascular and CNS-active medications comprise a substantial portion of anticholinergic burden in people with cognitive impairment and multiple chronic conditions. Antidepressants were highly prevalent. Clinical profiles elucidated by these clusters of anticholinergic medications can inform targeted approaches to care.
Compliance with Ethical Standards
This study was supported by R24AG045050-03S2 from the National Institute on Aging. Support was provided by Kaiser Permanente Colorado Pharmacy Department for Linda Weffald’s time. Ariel Green's time was partially supported by K23AG054742-01A1 from the National Institute on Aging.
Conflicts of interest
Dr. Boyd writes a chapter on multimorbidity for UpToDate, for which she receives a royalty. ARG, LMR, LAW, and EAB declare that they have no conflicts of interest relevant to the content of this study.
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