Differences of anticholinergic drug burden between older hospitalized patients with and without delirium: a systematic review and meta-analysis based on prospective cohort studies
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SUBMITTER: Ieong C
PROVIDER: S-EPMC11241997 | biostudies-literature | 2024 Jan
REPOSITORIES: biostudies-literature
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Project description:AimsA recent review identified 19 anticholinergic burden scales (ABSs) but no study has yet compared the impact of all 19 ABSs on delirium. We evaluated whether a high anticholinergic burden as classified by each ABS is associated with incident delirium.MethodWe performed a retrospective cohort study in a Swiss tertiary teaching hospital using data from 2015-2018. Included were patients aged ≥65, hospitalised ≥48 hours with no stay >24 hours in intensive care. Delirium was defined twofold: (i) ICD-10 or CAM and (ii) ICD-10 or CAM or DOSS. Patients' cumulative anticholinergic burden score, calculated within 24 hours after admission, was classified using a binary (<3: low, ≥3: high burden) and a categorical approach (0: no, 0.5-3: low, ≥3: high burden). Association was analysed using multivariable logistic regression.ResultsOver 25 000 patients (mean age 77.9 ± 7.6 years) were included. Of these, (i) 864 (3.3%) and (ii) 2770 (11.0%) developed delirium. Depending on the evaluated ABS, 4-63% of the patients were exposed to at least one anticholinergic drug. Out of 19 ABSs, (i) 14 and (ii) 16 showed a significant association with the outcomes. A patient with a high anticholinergic burden score had odds ratios (ORs) of 1.21 (95% confidence interval [CI]: 1.03-1.42) to 2.63 (95% CI: 2.28-3.03) for incident delirium compared to those with low or no burden.ConclusionA high anticholinergic burden within 24 hours after admission was significantly associated with incident delirium. Although prospective studies need to confirm these results, discontinuing or substituting drugs with a score of ≥3 at admission might be a targeted intervention to reduce incident delirium.
| S-EPMC9796852 | biostudies-literature
Project description:BackgroundPostoperative delirium (POD) is a frequent and serious complication after surgery. Evidence of a relationship between anticholinergic medication and the development of delirium is inconclusive, but studies on POD are rare.ObjectivesThe objective of this study was to evaluate the anticholinergic load of preoperative medication in older adult patients and its association with the development of POD.MethodsThis investigation was part of the European BioCog project ( http://www.biocog.eu ), a prospective multicenter observational study in older adult surgical patients (ClinicalTrials.gov identifier: NCT02265263, 15 October 2014). Patients with a Mini-Mental State Examination score ≤ 23 points were excluded. POD was assessed up to 7 days after surgery using the Nursing Delirium Screening Scale, Confusion Assessment Method and a patient chart review. The preoperative anticholinergic load was calculated using the Anticholinergic Drug Scale (ADS), the Anticholinergic Risk Scale (ARS) and the Anticholinergic Cognitive Burden Scale (ACBS), and associations with POD were analyzed using logistic regression analysis adjusting for age, comorbidities, duration of anesthesia and number of drugs used.ResultsIn total, 837 participants were included for analysis, and 165 patients (19.7%) fulfilled the criteria of POD. After adjusting for confounders, we found no association between preoperative anticholinergic load and the development of POD (ADS [points] odds ratio [OR] 0.928; 95% confidence interval [CI] 0.749-1.150; ARS [points] OR 0.832; 95% CI 0.564-1.227; ACBS [points] OR 1.045; 95% CI 0.842-1.296).ConclusionThis study found no association between the anticholinergic load of drugs used preoperatively and the development of POD in older adult patients without severe preexisting cognitive impairment. Future analyses should examine the influence of intra- and postoperative administration of anticholinergic drugs as well as dosages of and interactions between medications.
| S-EPMC8007502 | biostudies-literature
Project description:PurposePostoperative delirium (POD) is a common complication in older adult patients after surgery. A patient's preoperative anticholinergic (AC) burden is a potentially modifiable risk factor for POD. As the influence of the drug dose remains unknown, we aimed to compare three AC burden scores in relation to POD, two of which were dose-related.MethodsThis retrospective cohort study (03/22-10/22) included orthopaedic and trauma surgery patients > 65 years. POD was assessed using the four A's test (4AT), delirium diagnosis, and chart review. The AC burden was determined using the non-dose-related German Anticholinergic Burden score (GerACB), an extension of the dose-related Muscarinic Acetylcholinergic Receptor ANTagonist Exposure scale (extMARANTE), and the dose-related German Drug Burden Index (GerDBI). Multivariable logistic regression analysis determined the association between the preoperative AC burden and POD. Scores were compared using kappa statistics, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).ResultsPOD was observed in 71 of 385 patients (18.4%). For all three scores, a high AC burden was significantly associated with POD after adjusting for age, sex, dementia, preoperative physical status, and number of prescribed drugs (p < 0.001). The overall agreement among the burden classifications was substantial (no POD: κ = 0.645, POD: κ = 0.632). The GerACB had the lowest sensitivity with 23.9% (extMARANTE: 42.3%, GerDBI: 40.8%), but the highest PPV with 48.6% (extMARANTE: 38.5%, GerDBI: 43.3%).ConclusionBoth dose-related and non-dose-related AC burden scores have limited sensitivity and modest PPV for screening a patient's medication for POD. However, given the additional effort required for dose consideration, the non-dose-related GerACB remains sufficient in clinical practice, with the lowest sensitivity but highest PPV.
| S-EPMC11634912 | biostudies-literature
Project description: Not available
| S-EPMC5706782 | biostudies-literature
Project description:ObjectivesThe Drug Burden Index (DBI) tool quantifies individual exposure to anticholinergic and sedative medications. The DBI has been internationally validated against adverse health outcomes in older people. DBI exposure has not been reported in the Irish older population. This study aimed to: (1) develop a list of drugs with clinically significant anticholinergic and/or sedative effects (DBI medications) relevant to Ireland; (2) examine, using the DBI formula, the prevalence of exposure to DBI medications in Irish older people and (3) explore patient factors associated DBI exposure.DesignA cross-sectional national pharmacy claims database study.SettingCommunity setting using the General Medical Services (GMS) scheme pharmacy claims database maintained by the Health Service Executive Primary Care Reimbursement Services.ParticipantsIrish older individuals (aged ≥65 years) enrolled in the GMS scheme and dispensed at least one prescription item in 2016 (n=428 516).Main outcome measuresPrevalence of exposure to DBI medications and patient factors associated with DBI exposure.Results282 874 (66%) of the GMS population aged ≥65 years were exposed to at least one DBI medication in 2016. Prevalence of exposure to DBI medications was significantly higher in females than males (females 71.6% vs males 58.7%, adjusted OR 1.65, 95% CI 1.63 to 1.68). Prevalence of DBI exposure increased progressively with the number of chronic drugs used, rising from 42.7% of those prescribed 0-4 chronic drugs to 95.4% of those on ≥12 chronic drugs (adjusted OR 27.8, 95% CI 26.7 to 29.0). The most frequently used DBI medications were codeine/paracetamol combination products (20.1% of patients), tramadol (11.5%), zopiclone (9.5%), zolpidem (8.5%), pregabalin (7.9%) and alprazolam (7.8%).ConclusionsThe majority of older people in Ireland are exposed to medications with anticholinergic and/or sedative effects, particularly females and those with multiple comorbidities. The high use of low-dose codeine/paracetamol combination products, Z-drugs and benzodiazepines, suggests there are opportunities for deprescribing.
| S-EPMC6045724 | biostudies-literature
Project description:BackgroundDelirium in older hospitalized patients (> 65) is a common clinical syndrome, which is frequently unrecognized.AimsWe aimed to describe the detailed clinical course of delirium and related cognitive functioning in geriatric patients in a mainly non-postoperative setting in association with demographic and clinical parameters and additionally to identify risk factors for delirium in this common setting.MethodsInpatients of a geriatric ward were screened for delirium and in the case of presence of delirium included into the study. Patients received three assessments including Mini-Mental-Status-Examination (MMSE) and the Delirium Rating Scale Revised 98 (DRS-R-98). We conducted correlation and linear mixed-effects model analyses to detect associations.ResultsOverall 31 patients (82 years (mean)) met the criteria for delirium and were included in the prospective observational study. Within one week of treatment, mean delirium symptom severity fell below the predefined cut-off. While overall cognitive functioning improved over time, short- and long-term memory deficits remained. Neuroradiological conspicuities were associated with cognitive deficits, but not with delirium severity.DiscussionThe temporal stability of some delirium symptoms (short-/long-term memory, language) on the one hand and on the other hand decrease in others (hallucinations, orientation) shown in our study visualizes the heterogeneity of symptoms attributed to delirium and their different courses, which complicates the differentiation between delirium and a preexisting cognitive decline. The recovery from delirium seems to be independent of preclinical cognitive status.ConclusionTreatment of the acute medical condition is associated with a fast decrease in delirium severity. Given the high incidence and prevalence of delirium in hospitalized older patients and its detrimental impact on cognition, abilities and personal independence further research needs to be done.
| S-EPMC10019648 | biostudies-literature
Project description:Background:It is unknown whether the association between delirium and mortality is consistent for individuals across the whole range of health states. A bimodal relationship has been proposed, where delirium is particularly adverse for those with underlying frailty, but may have a smaller effect (perhaps even protective) if it is an early indicator of acute illness in fitter people. We investigated the impact of delirium on mortality in a cohort simultaneously evaluated for frailty. Methods:We undertook an exploratory analysis of a cohort of consecutive acute medical admissions aged ?70. Delirium on admission was ascertained by psychiatrists. A frailty index (FI) was derived according to a standard approach. Deaths were notified from linked national mortality statistics. Cox regression was used to estimate associations between delirium, frailty, and their interactions on mortality. Results:The sample consisted of 710 individuals. Both delirium and frailty were independently associated with increased mortality rates (delirium: HR 2.4, 95% CI 1.8-3.3, p < .01; frailty (per SD): HR 3.5, 95% CI 1.2-9.9, p = .02). Estimating the effect of delirium in tertiles of FI, mortality was greatest in the lowest tertile: tertile 1 HR 3.4 (95% CI 2.1-5.6); tertile 2 HR 2.7 (95% CI 1.5-4.6); tertile 3 HR 1.9 (95% CI 1.2-3.0). Conclusion:Although delirium and frailty contribute to mortality, the overall impact of delirium on admission appears to be greater at lower levels of frailty. In contrast to the hypothesis that there is a bimodal distribution for mortality, delirium appears to be particularly adverse when precipitated in fitter individuals.
| S-EPMC5861945 | biostudies-literature
Project description:ObjectivesTo investigate the association between delirium motor subtypes and hospital mortality and 12-month mortality in hospitalized older adults.DesignProspective cohort study conducted from 2009 to 2015.SettingGeriatric ward of a university hospital in Sao Paulo, Brazil.ParticipantsWe included 1,409 consecutive admissions of acutely ill patients aged 60 years and over. We excluded admissions for end-of-life care, with missing data on the main variables, length of stay shorter than 48 hours, or when consent to participate was not given.Main outcomes and measuresDelirium was detected using the Confusion Assessment Method and categorized in hypoactive, hyperactive, or mixed delirium. Primary outcomes were time to death in the hospital, and time to death in 12 months (for the discharged sample). Comprehensive geriatric assessment was performed at admission and included socio-demographic, clinical, functional, cognitive, and laboratory variables. Further clinical data were documented upon death or discharge. Multivariate analyses used Cox proportional hazards models adjusted for possible confounders.ResultsWe included 1,409 admissions, with a mean age of 80 years. The proportion of in-hospital deaths was 19%, with a cumulative mortality of 38% in 12 months. Delirium occurred in 47% of the admissions. Hypoactive delirium was the predominant motor subtype (53%), followed by mixed delirium (30%) and hyperactive delirium (17%). Hospital mortality rates were respectively 33%, 34% and 15%. We verified that hypoactive and mixed delirium were independently associated with hospital mortality, with respective hazard ratios of 2.43 (95%CI = 1.64-3.59) and 2.31 (95%CI = 1.53-3.50). Delirium motor subtypes were not independently predictive of 12-month mortality.ConclusionsOne in three acutely ill hospitalized older adults who suffered hypoactive or mixed delirium died in the hospital. Clinicians should be aware that hypoactive symptoms of delirium, whether shown exclusively or in alternation with hyperactive symptoms, are indicative of a worse prognosis in this population.
| S-EPMC5790217 | biostudies-literature
Project description:ObjectivesThe aims of our study were to examine the anticholinergic drug use and to assess the association between anticholinergic burden and cognitive function in the multimorbid elderly patients of the MultiCare cohort.SettingMultiCare was conducted as a longitudinal cohort study in primary care, located in eight different study centres in Germany.Participants3189 patients (59.3% female).Primary and secondary outcome measuresBaseline data were used for the following analyses. Drugs were classified according to the well-established anticholinergic drug scale (ADS) and the recently published German anticholinergic burden (German ACB). Cognitive function was measured using a letter digit substitution test (LDST) and a mixed-effect multivariate linear regression was performed to calculate the influence of anticholinergic burden on the cognitive function.ResultsPatients used 1764 anticholinergic drugs according to ADS and 2750 anticholinergics according to the German ACB score (prevalence 38.4% and 53.7%, respectively). The mean ADS score was 0.8 (±1.3), and the mean German ACB score was 1.2 (±1.6) per patient. The most common ADS anticholinergic was furosemide (5.8%) and the most common ACB anticholinergic was metformin (13.7%). The majority of the identified anticholinergics were drugs with low anticholinergic potential: 80.2% (ADS) and 73.4% (ACB), respectively. An increasing ADS and German ACB score was associated with reduced cognitive function according to the LDST (-0.26; p=0.008 and -0.24; p=0.003, respectively).ConclusionMultimorbid elderly patients are in a high risk for using anticholinergic drugs according to ADS and German ACB score. We especially need to gain greater awareness for the contribution of drugs with low anticholinergic potential from the cardiovascular system. As anticholinergic drug use is associated with reduced cognitive function in multimorbid elderly patients, the importance of rational prescribing and also deprescribing needs to be further evaluated.Trial registration numberISRCTN89818205.
| S-EPMC7993236 | biostudies-literature
Project description:Although no gold standard exists to assess a patient's anticholinergic burden, a review identified 19 anticholinergic burden scales (ABSs). No study has yet evaluated whether a high anticholinergic burden measured with all 19 ABSs is associated with in-hospital mortality and length of stay (LOS). We conducted a cohort study at a Swiss tertiary teaching hospital using patients' electronic health record data from 2015-2018. Included were patients aged ≥65 years, hospitalised ≥48 h without stays and >24 h in intensive care. Patients' cumulative anticholinergic burden score was classified using a binary (<3: low, ≥3: high) and categorical approach (0: no, 0.5-3: low, ≥3: high). In-hospital mortality and LOS were analysed using multivariable logistic and linear regression, respectively. We included 27,092 patients (mean age 78.0 ± 7.5 years, median LOS 6 days). Of them, 913 died. Depending on the evaluated ABS, 1370 to 17,035 patients were exposed to anticholinergics. Patients with a high burden measured by all 19 ABSs were associated with a 1.32- to 3.03-fold increase in in-hospital mortality compared with those with no/low burden. We obtained similar results for LOS. To conclude, discontinuing drugs with anticholinergic properties (score ≥3) at admission might be a targeted intervention to decrease in-hospital mortality and LOS.
| S-EPMC9299782 | biostudies-literature