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Anticholinergic Burden and Cognitive Impairment in Nursing Homes: A Comparison of Four Anticholinergic Scales

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Abstract

Background

Medications with anticholinergic effects are commonly used in nursing homes, and their cumulative effect is of particular concern for the risk of adverse effects on cognition.

Objective

The relation between cognitive function and anticholinergic burden measured with four scales, the Anticholinergic Cognitive Burden (ACB) Scale, the Anticholinergic Risk Scale, the German Anticholinergic Burden Scale, and the CRIDECO Anticholinergic Load Scale, is assessed according to the hypothesis that a higher anticholinergic burden is associated with reduced cognitive performance.

Methods

This retrospective cross-sectional multicenter study was conducted in a sample of Italian long-term-care nursing homes (NH). Sociodemographic details, diagnosis, and drug treatments of each NH resident were collected using medical records four times during 2018 and 2019. Cognitive status was rated with the Mini-Mental State Examination (MMSE). The prevalence of anticholinergic use and its burden were calculated referring to the last time point for each patient. A longitudinal analysis was done on NH residents with at least two MMSE between 2018 and 2019 to assess the relation between the anticholinergic load and decline in MMSE.

The relationship between drug-related anticholinergic burden and cognitive performance was analyzed using Poisson regression model theory. Multivariate analyses were adjusted according to the known risk factors of reduced cognitive performance available [age, sex, history of stroke or transient ischemic attack (TIA), and number of non-anticholinergic drugs] and for cholinesterase inhibitors. In view of the high number of subjects with an MMSE score = 0 among residents with dementia, for this group a zero-inflated Poisson regression model was used to give more consistent results. The association of anticholinergic burden with mortality was examined from each patient’s last visit using a multivariate logistic model adjusted for age, sex, and Charlson Comorbidity Index (CCI).

Results

Among 1412 residents recruited, a clear direct relationship was found between higher anticholinergic burden and cognitive impairment only for the Anticholinergic Cognitive Burden Scale. Residents taking an anticholinergic who scored 5 or more had 2.5 points more decline than those not taking them (p < 0.001). Among residents without dementia there was a trend toward direct relationship for the Anticholinergic Cognitive Burden Scale and the Anticholinergic Risk Scale. Residents with higher scores had about 2 points more decline than residents not taking anticholinergic drugs. No relation was found between anticholinergic burden and cognitive decline or mortality.

Conclusions

The cumulative effect of medications with modest antimuscarinic activity may influence the cognitive performance of NH residents. The anticholinergic burden measured with the ACB scale should help identify NH residents who may benefit from reducing the anticholinergic burden.

A clear direct relationship between anticholinergic burden and cognitive impairment was found only for the ACB Scale.

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References

  1. Kersten H, Wyller TB. Anticholinergic drug burden in older people’s brain—how well is it measured? Basic Clin Pharmacol Toxicol. 2014;114:151–9.

    Article  CAS  PubMed  Google Scholar 

  2. Salahudeen MS, Duffull SB, Nishtala PS. Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review. BMC Geriatr. 2015;15:31.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Cardwell K, Hughes CM, Ryan C. The association between anticholinergic medication burden and health related outcomes in the “oldest old”: a systematic review of the literature. Drugs Aging. 2015;32:835–48.

    Article  CAS  PubMed  Google Scholar 

  4. Welsh TJ, van der Wardt V, Ojo G, Gordon AL, Gladman JRF. Anticholinergic drug burden tools/scales and adverse outcomes in different clinical settings: a systematic review of reviews. Drugs Aging. 2018;35:523–38.

    Article  CAS  PubMed  Google Scholar 

  5. Fox C, Smith T, Maidment I, Chan W-Y, Bua N, Myint PK, et al. Effect of medications with anti-cholinergic properties on cognitive function, delirium, physical function and mortality: a systematic review. Age Ageing. 2014;43:604–15.

    Article  PubMed  Google Scholar 

  6. Egberts A, Moreno-Gonzalez R, Alan H, Ziere G, Mattace-Raso FUS. Anticholinergic drug burden and delirium: a systematic review. J Am Med Dir Assoc. 2021;22:65-73.e4.

    Article  PubMed  Google Scholar 

  7. Abrams P, Andersson K-E, Buccafusco JJ, Chapple C, de Groat WC, Fryer AD, et al. Muscarinic receptors: their distribution and function in body systems, and the implications for treating overactive bladder. Br J Pharmacol. 2006;148:565–78.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Salahudeen MS, Chyou T-Y, Nishtala PS. Serum anticholinergic activity and cognitive and functional adverse outcomes in older people: a systematic review and meta-analysis of the literature. PLoS ONE. 2016;11: e0151084.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Lisibach A, Benelli V, Ceppi MG, Waldner-Knogler K, Csajka C, Lutters M. Quality of anticholinergic burden scales and their impact on clinical outcomes: a systematic review. Eur J Clin Pharmacol. 2021;77:147–62.

    Article  PubMed  Google Scholar 

  10. Brombo G, Bianchi L, Maietti E, Malacarne F, Corsonello A, Cherubini A, et al. Association of anticholinergic drug burden with cognitive and functional decline over time in older inpatients: results from the CRIME Project. Drugs Aging. 2018;35:917–24.

    Article  CAS  PubMed  Google Scholar 

  11. Durán CE, Azermai M, Vander Stichele RH. Systematic review of anticholinergic risk scales in older adults. Eur J Clin Pharmacol. 2013;69:1485–96.

    Article  PubMed  Google Scholar 

  12. Avorn J, Gurwitz JH. Drug use in the nursing home. Ann Intern Med. 1995;123:195–204.

    Article  CAS  PubMed  Google Scholar 

  13. Pasina L, Novella A, Cortesi L, Nobili A, Tettamanti M, Ianes A. Drug prescriptions in nursing home residents: an Italian multicenter observational study. Eur J Clin Pharmacol. 2020;76:1011–9.

    Article  PubMed  Google Scholar 

  14. Landi F, Dell’Aquila G, Collamati A, Martone AM, Zuliani G, Gasperini B, et al. Anticholinergic drug use and negative outcomes among the frail elderly population living in a nursing home. J Am Med Dir Assoc. 2014;15:825–9.

    Article  PubMed  Google Scholar 

  15. Boustani M, Campbell N, Munger S, Maidment I, Fox C. Impact of anticholinergics on the aging brain: a review and practical application. Aging Health. 2008;4:311–20.

    Article  CAS  Google Scholar 

  16. Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med. 2008;168:508–13.

    Article  PubMed  Google Scholar 

  17. Kiesel EK, Hopf YM, Drey M. An anticholinergic burden score for German prescribers: score development. BMC Geriatr. 2018;18:239.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Ramos H, Moreno L, Pérez-Tur J, Cháfer-Pericás C, García-Lluch G, Pardo J. CRIDECO Anticholinergic load scale: an updated anticholinergic burden scale. Comparison with the ACB scale in spanish individuals with subjective memory complaints. J Pers Med. 2022;12:207.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. Tools for assessment of the appropriateness of prescribing and association with patient-related outcomes: a systematic review. Drugs Aging. 2018;35:43–60.

    Article  PubMed  Google Scholar 

  20. Ghibelli S, Marengoni A, Djade CD, Nobili A, Tettamanti M, Franchi C, et al. Prevention of inappropriate prescribing in hospitalized older patients using a computerized prescription support system (INTERcheck®). Drugs Aging. 2013;30:821–8.

    Article  PubMed  Google Scholar 

  21. Pasina L, Marengoni A, Ghibelli S, Suardi F, Djade CD, Nobili A, et al. A multicomponent intervention to optimize psychotropic drug prescription in elderly nursing home residents: an Italian multicenter, prospective, pilot study. Drugs Aging. 2016;33:143–9.

    Article  PubMed  Google Scholar 

  22. Morris JC, Edland S, Clark C, Galasko D, Koss E, Mohs R, et al. The consortium to establish a registry for Alzheimer’s disease (CERAD). Part IV. Rates of cognitive change in the longitudinal assessment of probable Alzheimer’s disease. Neurology. 1993;43:2457–65.

    Article  CAS  PubMed  Google Scholar 

  23. Teramura-Grönblad M, Raivio M, Savikko N, Muurinen S, Soini H, Suominen M, et al. Potentially severe drug-drug interactions among older people and associations in assisted living facilities in Finland: a cross-sectional study. Scand J Prim Health Care. 2016;34:250–7.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Hsu W-H, Wen Y-W, Chen L-K, Hsiao F-Y. Comparative associations between measures of anti-cholinergic burden and adverse clinical outcomes. Ann Fam Med. 2017;15:561–9.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Ali S, Peterson GM, Bereznicki LR, Salahudeen MS. Association between anticholinergic drug burden and mortality in older people: a systematic review. Eur J Clin Pharmacol. 2020;76:319–35.

    Article  PubMed  Google Scholar 

  26. Patnode CD, Perdue LA, Rossom RC, Rushkin MC, Redmond N, Thomas RG, et al. Screening for cognitive impairment in older adults: an evidence update for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 [cited 2023 Jun 7]. http://www.ncbi.nlm.nih.gov/books/NBK554654/. Accessed 23 Aug 2023.

  27. Fox C, Richardson K, Maidment ID, Savva GM, Matthews FE, Smithard D, et al. Anticholinergic medication use and cognitive impairment in the older population: the medical research council cognitive function and ageing study. J Am Geriatr Soc. 2011;59:1477–83.

    Article  PubMed  Google Scholar 

  28. Pasina L, Lucca U, Tettamanti M. Relation between anticholinergic burden and cognitive impairment: results from the Monzino 80-plus population-based study. Pharmacoepidemiol Drug Saf. 2020;29:1696–702.

    Article  CAS  PubMed  Google Scholar 

  29. Pasina L, Colzani L, Cortesi L, Tettamanti M, Zambon A, Nobili A, et al. Relation between delirium and anticholinergic drug burden in a cohort of hospitalized older patients: an observational study. Drugs Aging. 2019;36:85–91.

    Article  CAS  PubMed  Google Scholar 

  30. Pasina L, Djade CD, Lucca U, Nobili A, Tettamanti M, Franchi C, et al. Association of anticholinergic burden with cognitive and functional status in a cohort of hospitalized elderly: comparison of the anticholinergic cognitive burden scale and anticholinergic risk scale: results from the REPOSI study. Drugs Aging. 2013;30:103–12.

    Article  CAS  PubMed  Google Scholar 

  31. Pasina L, Rizzi B, Nobili A, Recchia A. Anticholinergic load and delirium in end-of-life patients. Eur J Clin Pharmacol. 2021;77:1419–24.

    Article  CAS  PubMed  Google Scholar 

  32. Kua C-H, Mak VSL, Huey Lee SW. Health outcomes of deprescribing interventions among older residents in nursing homes: a systematic review and meta-analysis. J Am Med Dir Assoc. 2019;20:362-372.e11.

    Article  PubMed  Google Scholar 

  33. Ailabouni N, Mangin D, Nishtala PS. DEFEAT-polypharmacy: deprescribing anticholinergic and sedative medicines feasibility trial in residential aged care facilities. Int J Clin Pharm. 2019;41:167–78.

    Article  PubMed  Google Scholar 

  34. Hilmer SN, Mager DE, Simonsick EM, Cao Y, Ling SM, Windham BG, et al. A drug burden index to define the functional burden of medications in older people. Arch Intern Med. 2007;167:781–7.

    Article  PubMed  Google Scholar 

  35. Hilmer SN. Calculating and using the drug burden index score in research and practice. Expert Rev Clin Pharmacol. 2018;11:1053–5.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgments

The authors are very grateful to Korian Italy for the possibility of analyzing data of their NH residents. Korian Italy had no role in the conception and design of the study, data analysis and interpretation, the preparation and writing of the report, or the decision to submit the manuscript for publication. We are grateful to J.D. Baggott for language editing.

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Authors and Affiliations

  1. Laboratory of Clinical Pharmacology and Appropriateness of Drug Prescription, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri, 2, 20156, Milan, Italy

    Alessio Novella, Chiara Elli & Luca Pasina

  2. Over, Milan, Italy

    Aladar Ianes

Authors
  1. Alessio Novella
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  2. Chiara Elli
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  3. Aladar Ianes
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  4. Luca Pasina
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Corresponding author

Correspondence to Luca Pasina.

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Funding

No sources of funding were used in the conducting of this study or the preparation of this article.

Conflicts of Interest

The authors have no conflicts of interest that are directly relevant to the content of this manuscript.

Ethics Approval

Data collection complied fully with Italian law on personal data protection, and the study was approved by the ethics committee of the IRCCS Carlo Besta Foundation.

Consent to Participate

All data were anonymous, and informed consent was not required for the purpose of this study.

Consent for Publication

Not applicable.

Data Availability Statement

The data are not publicly available due to privacy or ethical restrictions. Data will be made available on request.

Code Availability

The code that supports the findings of this study is available on request from the corresponding author.

Authors’ Individual Contributions

All authors participated in drafting the manuscript or critical revision of the manuscript for important intellectual content and provided approval of the final submitted version. Individual contributions are as follows: LP and AN designed the study, interpreted data, and wrote the manuscript; CE carried out and interpreted statistical analyses; AI made the final critical revision for important intellectual content.

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Novella, A., Elli, C., Ianes, A. et al. Anticholinergic Burden and Cognitive Impairment in Nursing Homes: A Comparison of Four Anticholinergic Scales. Drugs Aging 40, 1017–1026 (2023). https://doi.org/10.1007/s40266-023-01058-w

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