Polypharmacy and cumulative anticholinergic burden in older adults hospitalized with fall

Ho Lun Wong, Claire Weaver, Lauren Marsh, Khine Oo Mon, John M Dapito, Fouad R Amin, Rahul Chauhan, Amit K J Mandal, Constantinos G Missouris, Ho Lun Wong, Claire Weaver, Lauren Marsh, Khine Oo Mon, John M Dapito, Fouad R Amin, Rahul Chauhan, Amit K J Mandal, Constantinos G Missouris

Abstract

Introduction: Polypharmacy is a growing phenomenon associated with adverse effects in older adults. We assessed the potential confounding effects of cumulative anticholinergic burden (ACB) in patients who were hospitalized with falls.

Methods: A noninterventional, prospective cohort study of unselected, acute admissions aged ≥ 65 years. Data were derived from electronic patient health records. Results were analyzed to determine the frequency of polypharmacy and degree of ACB and their relationship to falls risk. Primary outcomes were polypharmacy, defined as prescription of 5 or more regular oral medications, and ACB score.

Key results: Four hundred eleven (411) consecutive subjects were included, mean age 83.8 ± 8.0 years: 40.6% men. There were 38.4% patients who were admitted with falls. Incidence of polypharmacy was 80.8%, (88.0% and 76.3% among those admitted with and without fall, respectively). Incidence of ACB score of 0, 1, 2, ≥ 3 was 38.7%, 20.9%, 14.6%, and 25.8%, respectively. On multivariate analysis, age [odds ratio (OR) = 1.030, 95% CI:1.000 ~ 1.050, P = 0.049], ACB score (OR = 1.150, 95% CI:1.020 ~ 1.290, P = 0.025), polypharmacy (OR = 2.140, 95% CI:1.190 ~ 3.870, P = 0.012), but not Charlson Comorbidity Index (OR = 0.920, 95% CI:0.810 ~ 1.040, P = 0.172) were significantly associated with higher falls rate. Of patients admitted with falls, 29.8% had drug-related orthostatic hypotension, 24.7% had drug-related bradycardia, 37.3% were prescribed centrally acting drugs, and 12.0% were taking inappropriate hypoglycemic agents.

Conclusion: Polypharmacy results in cumulative ACB and both are significantly associated with falls risk in older adults. The presence of polypharmacy and each unit rise in ACB score have a stronger effect of increasing falls risk compared to age and comorbidities.

Keywords: anticholinergic burden; fall; older; outcomes; polypharmacy.

Conflict of interest statement

All authors understand the policy of declaration of interests. H.L.W., C.W., L.M., K.O.M., J.D., F.R.A., R.C., A.K.J.M., and C.G.M. all declare that that they have no competing interests.

© 2023 The Authors. Aging Medicine published by Beijing Hospital and John Wiley & Sons Australia, Ltd.

Figures

FIGURE 1
FIGURE 1
Patient inclusion flowchart
FIGURE 2
FIGURE 2
Mean ACB score against age. ACB, anticholinergic burden.

References

    1. Masnoon N, Shakib S, Kalisch‐Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017;17(1):230. doi:10.1186/s12877-017-0621-2
    1. Medication safety in polypharmacy. World Health Organization; 2019. Accessed January 07, 2022.
    1. Rawle MJ, Richards M, Davis D, Kuh D. The prevalence and determinants of polypharmacy at age 69: a British birth cohort study. BMC Geriatr. 2018;18(1):118. doi:10.1186/s12877-018-0795-2
    1. Nguyen JK, Fouts MM, Kotabe SE, Lo E. Polypharmacy as a risk factor for adverse drug reactions in geriatric nursing home residents. Am J Geriatr Pharmacother. 2006;4(1):36‐41. doi:10.1016/j.amjopharm.2006.03.002
    1. Rawle MJ, Cooper R, Kuh D, Richards M. Associations between polypharmacy and cognitive and physical capability: a British birth cohort study. J Am Geriatr Soc. 2018;66(5):916‐923. doi:10.1111/jgs.15317
    1. Spaniolas K, Cheng JD, Gestring ML, Sangosanya A, Stassen NA, Bankey PE. Ground level falls are associated with significant mortality in elderly patients. J Trauma. 2010;69(4):821‐825. doi:10.1097/TA.0b013e3181efc6c6
    1. Cartagena LJ, Kang A, Munnangi S, et al. Risk factors associated with in‐hospital mortality in elderly patients admitted to a regional trauma center after sustaining a fall. Aging Clin Exp Res. 2017;29(3):427‐433. doi:10.1007/s40520-016-0579-5
    1. Fadare JO, Obimakinde AM, Aina FO, et al. Anti‐cholinergic drug burden among ambulatory elderly patients in a Nigerian tertiary healthcare facility. Front Pharmacol. 2021;12:580152. doi:10.3389/fphar.2021.580152
    1. Tan MP, Tan GJ, Mat S, et al. Use of medications with anticholinergic properties and the long‐term risk of hospitalization for falls and fractures in the EPIC‐Norfolk longitudinal cohort study. Drugs Aging. 2020;37(2):105‐114. doi:10.1007/s40266-019-00731-3
    1. Cai X, Campbell N, Khan B, Callahan C, Boustani M. Long‐term anticholinergic use and the aging brain. Alzheimers Dement. 2013;9(4):377‐385. doi:10.1016/j.jalz.2012.02.005
    1. Tannenbaum C, Paquette A, Hilmer S, Holroyd‐Leduc J, Carnahan R. A systematic review of amnestic and non‐amnestic mild cognitive impairment induced by anticholinergic, antihistamine. GABAergic Opioid Drugs Drugs Aging. 2012;29(8):639‐658. doi:10.1007/BF03262280
    1. Richardson K, Fox C, Maidment I, et al. Anticholinergic drugs and risk of dementia: case‐control study. BMJ. 2018;361:k1315. doi:10.1136/bmj.k1315 Erratum in: BMJ 2019 Oct 31;367:l6213.
    1. Onder G, Liperoti R, Fialova D, et al. Polypharmacy in nursing home in Europe: results from the SHELTER study. J Gerontol A Biol Sci Med Sci. 2012;67(6):698‐704. doi:10.1093/gerona/glr233
    1. Leelakanok N, Holcombe AL, Lund BC, Gu X, Schweizer ML. Association between polypharmacy and death: a systematic review and meta‐analysis. J Am Pharm Assoc. 2003;57(6):729‐738.e10. doi:10.1016/j.japh.2017.06.002
    1. Fox C, Richardson K, Maidment ID, 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(8):1477‐1483. doi:10.1111/j.1532-5415.2011.03491.x
    1. Sweeney MD, Zhao Z, Montagne A, Nelson AR, Zlokovic BV. Blood‐brain barrier: from physiology to disease and Back. Physiol Rev. 2019;99(1):21‐78. doi:10.1152/physrev.00050.2017
    1. Hopewell S, Copsey B, Nicolson P, Adedire B, Boniface G, Lamb S. Multifactorial interventions for preventing falls in older people living in the community: a systematic review and meta‐analysis of 41 trials and almost 20 000 participants. Br J Sports Med. 2020;54(22):1340‐1350. doi:10.1136/bjsports-2019-100732
    1. Soundararajan K, Balchandra P. Staff awareness of anti‐cholinergic burden (ACB) – a qualitative cross‐sectional study in a tertiary care hospital. Cureus. 2021;13(3):e14141. doi:10.7759/cureus.14141
    1. 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(2):147‐162. doi:10.1007/s00228-020-02994-x
    1. NICE . Falls: Assessment and Prevention of Falls in Older People (CG161). NICE; 2013. Accessed January 01, 2023.
    1. Stewart C, Taylor‐Rowan M, Soiza RL, Quinn TJ, Loke YK, Myint PK. Anticholinergic burden measures and older people's falls risk: a systematic prognostic review. Therap Adv Drug Safety. 2021;12:1‐10. doi:10.1177/20420986211016645

Source: PubMed

스폰서 및 공동 작업자

건강 상태

약물 개입

3
구독하다