Background: Medications with anticholinergic properties are frequently used in the elderly population. However, evidence suggests that these medications are associated with significant adverse effects and may lead to worsening of cognitive impairment, particularly in elderly patients with dementia.
Objective: To examine the utilization of anticholinergic medications and factors associated with anticholinergic medication use in elderly nursing home patients with dementia.
Methods: The study examined anticholinergic medication utilization for patients aged ≥65 years with dementia, using the 2004 US National Nursing Home Survey (NNHS) data. Anticholinergic drugs were identified using the Anticholinergic Drug Scale (ADS), which classifies anticholinergic drugs into four levels in increasing order of their anticholinergic activity. Descriptive analysis was conducted using sampling weights to determine the prevalence of anticholinergic medication use. Multiple logistic regression within the conceptual framework of the Andersen Behavioral Model was used to examine the factors associated with anticholinergic medication use in the study population. Use of medications with marked anticholinergic activities (ADS level 2 or 3) was the dependent variable, and independent variables were the various predisposing, enabling and need factors.
Results: According to the 2004 NNHS, 509 931 (95% CI 490 160, 529 702) or 73.62% (95% CI 72.23, 75.00) of elderly patients with dementia used anticholinergic medications. The highest prevalence of anticholinergic medication use among elderly patients with dementia was seen for level-1 medications (67.96%;95% CI 66.51, 69.41), and 21.27% (95% CI 19.93, 22.60) used ADS level-2 or level-3 medications. Multivariate regression analysis showed that the predisposing factor of age was negatively associated with the use of medications with marked anticholinergic activities (ADS level 2 or 3) and the enabling factor of Medicaid as the source of payment increased the likelihood of receiving these higher-level anticholinergics. Among the need factors, dependence in decision-making ability and behavioural symptoms decreased the likelihood of receiving higher-level anticholinergics, whereas factors such as total number of medications, depressed mood indicators and diagnoses of schizophrenia, anxiety and Parkinson’s disease increased the likelihood of use of such medications.
Conclusions: Over one in five elderly nursing home residents with dementia used medications with marked anticholinergic activities. The study findings suggest the need to optimize the use of anticholinergic medications in vulnerable patients with dementia given the potentially severe adverse cognitive effects of these agents.
No sources of funding were used to conduct this study. The authors have no conflicts of interest that are directly relevant to the content of this study. Part of the study findings were presented at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) conference 17–19 May 2010 in Atlanta, GA, USA.
Carnahan RM, Lund BC, Perry PJ, et al. The concurrent use of anticholinergics and cholinesterase inhibitors: rare event or common practice? J Am Geriatr Soc 2004 Dec; 52(12): 2082–7PubMedCrossRefGoogle Scholar
Doraiswamy PM, Husain MM. Anticholinergic drugs and elderly people: a no brainer? Lancet Neurol 2006 May; 5(5): 379–80PubMedCrossRefGoogle Scholar
Mintzer J, Burns A. Anticholinergic side-effects of drugs in elderly people. J R Soc Med 2000 Sep; 93(9): 457–62PubMedGoogle Scholar
Feinberg M. The problems of anticholinergic adverse effects in older patients. Drugs Aging 1993 Jul-Aug; 3(4): 335–48PubMedCrossRefGoogle Scholar
Tune LE. Anticholinergic effects of medication in elderly patients. J Clin Psychiatry 2001; 62Suppl. 21: 11–4PubMedGoogle Scholar
Ness J, Hoth A, Barnett MJ, et al. Anticholinergic medications in community-dwelling older veterans: prevalence of anticholinergic symptoms, symptom burden, and adverse drug events. Am J Geriatr Pharmacother 2006 Mar; 4(1): 42–51PubMedCrossRefGoogle Scholar
Rémillard AJ. A pharmacoepidemiological evaluation of anticholinergic prescribing patterns in the elderly. Pharmacoepidemiol Drug Saf 1996 May; 5(3): 155–64PubMedCrossRefGoogle Scholar
Kemper RF, Steiner V, Hicks B, et al. Anticholinergic medications: use among older adults with memory problems. J Gerontol Nurs 2007 Jan; 33(1): 21–9; quiz 30–1PubMedGoogle Scholar
Rudolph JL, Salow MJ, Angelini MC, et al. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med 2008 Mar 10; 168(5): 508–13PubMedCrossRefGoogle Scholar
Lechevallier-Michel N, Molimard M, Dartigues JF, et al. Drugs with anticholinergic properties and cognitive performance in the elderly: results from the PAQUID Study. Br J Clin Pharmacol 2005 Feb; 59(2): 143–51PubMedCrossRefGoogle Scholar
Chan WY, Setter SM, Sclar DA, et al. The use of anticholinergic medications in homebound elderly patients with dementia. Consult Pharm 2006 May; 21(5): 391–9PubMedCrossRefGoogle Scholar
Roe CM, Anderson MJ, Spivack B. Use of anticholinergic medications by older adults with dementia. J Am Geriatr Soc 2002 May; 50(5): 836–42PubMedCrossRefGoogle Scholar
Low LF, Anstey KJ, Sachdev P. Use of medications with anticholinergic properties and cognitive function in a young-old community sample. Int J Geriatr Psychiatry 2009 Jun; 24(6): 578–84PubMedCrossRefGoogle Scholar
Campbell N, Boustani M, Limbil T, et al. The cognitive impact of anticholinergics: a clinical review. Clin Interv Aging 2009; 4: 225–33PubMedGoogle Scholar
Kamble P, Chen H, Sherer JT, et al. Use of antipsychotics among elderly nursing home residents with dementia in the US: an analysis of National Survey Data. Drugs Aging 2009; 26(6): 483–92PubMedCrossRefGoogle Scholar
Cancelli I, Gigli GL, Piani A, et al. Drugs with anticholinergic properties as a risk factor for cognitive impairment in elderly people: a population-based study. J Clin Psychopharmacol 2008 Dec; 28(6): 654–9PubMedCrossRefGoogle Scholar
Blazer II DG, Federspiel CF, Ray WA, et al. The risk of anticholinergic toxicity in the elderly: a study of prescribing practices in two populations. J Gerontol 1983 Jan; 38(1): 31–5PubMedCrossRefGoogle Scholar
Seifert R, Jamieson J, Gardner Jr R. Use of anticholinergics in the nursing home: an empirical study and review. Drug Intell Clin Pharm 1983 Jun; 17(6): 470–3PubMedGoogle Scholar
Kolanowski A, Fick DM, Campbell J, et al. A preliminary study of anticholinergic burden and relationship to a quality of life indicator, engagement in activities, in nursing home residents with dementia. J Am Med Dir Assoc 2009 May; 10(4): 252–7PubMedCrossRefGoogle Scholar
National Nursing Home Survey: questionnaires, datasets, and related documentation from the National Nursing Home Survey. Centers for Disease Control and Protection (CDC) [online]. Available from URL: http://www.cdc.gov/nchs/nnhs/nnhs_questionnaires.htm [Accessed 2010 Sep 15]
Agashivala N, Wu WK. Effects of potentially inappropriate psychoactive medications on falls in US nursing home residents: analysis of the 2004 National Nursing Home Survey database. Drugs Aging 2009; 26(10): 853–60PubMedCrossRefGoogle Scholar
Carnahan RM, Lund BC, Perry PJ, et al. The Anticholinergic Drug Scale as a measure of drug-related anticholinergic burden: associations with serum anticholinergic activity. J Clin Pharmacol 2006 Dec; 46(12): 1481–6PubMedCrossRefGoogle Scholar
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 Dec; 56(12): 2203–10PubMedCrossRefGoogle Scholar
Modi A, Weiner M, Craig BA, et al. Concomitant use of anticholinergics with acetylcholinesterase inhibitors in Medicaid recipients with dementia and residing in nursing homes. J Am Geriatr Soc 2009 Jul; 57(7): 1238–44PubMedCrossRefGoogle Scholar
Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. Mil-bank Mem Fund Q Health Soc 1973; 51(1): 95–124CrossRefGoogle Scholar
Katz IR, Sands LP, Bilker W, et al. Identification of medications that cause cognitive impairment in older people: the case of oxybutynin chloride. J Am Geriatr Soc 1998 Jan; 46(1): 8–13PubMedGoogle Scholar
Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Arch Intern Med 1997 Jul 28; 157(14): 1531–6PubMedCrossRefGoogle Scholar
Beers MH, Ouslander JG, Rollingher I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. UCLA Division of Geriatric Medicine. Arch Intern Med 1991 Sep; 151(9): 1825–32PubMedCrossRefGoogle Scholar
Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 2003 Dec 8–22; 163(22): 2716–24PubMedCrossRefGoogle Scholar
Jano E, Aparasu RR. Healthcare outcomes associated with Beers’ criteria: a systematic review. Ann Pharmacother 2007 Mar; 41(3): 438–47PubMedCrossRefGoogle Scholar
Lau DT, Kasper JD, Potter DE, et al. Potentially inappropriate medication prescriptions among elderly nursing home residents: their scope and associated resident and facility characteristics. Health Serv Res 2004 Oct; 39(5): 1257–76PubMedCrossRefGoogle Scholar
Hägglund D. A systematic literature review of incontinence care for persons with dementia: the research evidence. J Clin Nurs 2010 Feb; 19(3–4): 303–12PubMedCrossRefGoogle Scholar
Bartels SJ, Horn SD, Smout RJ, et al. Agitation and depression in frail nursing home elderly patients with dementia: treatment characteristics and service use. Am J Geriatr Psychiatry 2003 Mar-Apr; 11(2): 231–8PubMedGoogle Scholar
Rabins PV, Blacker D, Rovner BW, et al. American Psychiatric Association practice guideline for the treatment of patients with Alzheimer’s disease and other dementias, 2nd edition. Am J Psychiatry 2007 Dec; 164(12 Suppl.): 5–56PubMedGoogle Scholar
Katzenschlager R, Sampaio C, Costa J, et al. Anticholinergics for symptomatic management of Parkinson’s disease. Cochrane Database Syst Rev 2003; (2): CD003735Google Scholar
Miyasaki JM, Martin W, Suchowersky O, et al. Practice parameter: initiation of treatment for Parkinson’s disease: an evidence-based review. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2002 Jan 8; 58(1): 11–7PubMedCrossRefGoogle Scholar
Gill SS, Mamdani M, Naglie G, et al. A prescribing cascade involving cholinesterase inhibitors and anticholinergic drugs. Arch Intern Med 2005 Apr 11; 165(7): 808–13PubMedCrossRefGoogle Scholar
Mann JL, Evans TS, Taylor RD, et al. The use of medications with known or potential anticholinergic activity in patients with dementia receiving cholinesterase inhibitors. Consult Pharm 2003 Dec; 18(12): 1042–9PubMedGoogle Scholar