Medication Use & Risk of Cognitive Decline

Transcription

1 Medication Use & Risk of Cognitive Decline Malaz Boustani, MD, MPH Richard M Fairbanks Professor of Aging Research Indiana University School of Medicine 1

2 Disclosure No conflict of Interest. Funding provided by NIA CMMI AHRQ 2

3 Objectives Discuss adverse cognitive effects of medications as a modifiable risk factor for cognitive decline. Suggest a surveillance system to disclose the adverse cognitive effects of medications for the lay public. Develop cost-effective and scalable interventions to reduce adverse cognitive effects of medications Sources of Data: 2012 SER conducted by AGS to support the BEERS criteria 2014 SER investigated the adverse cognitive effects of Anticholinergics that included studies conducted by IU-EAU (USA-UK) collaboration 3

4 Background Up to 75% of older Americans suffer from multiple chronic conditions & are prescribed at least five medications. Up to 50% of older Americans use medications with adverse cognitive effects. Many of the adverse cognitive effects of medications are not recognized and might be reversible. There is no standardized approach to recognize the adverse cognitive effects of medications. There is no cost-effective scalable services to reduce the adverse cognitive burden of medications. Ernst FR, J Am Pharm Assoc 2001; White TJ, Pharmacoeconomics 1999; Moore TJ, JAMA 1998; Campbell N, Clin Interv Aging 2008; Anderson G, RWJF 2010; Cai X, AD&Dem

5 High Risk Medications AGS based Guideline recommends avoiding the following class of Medication among older adults due to their adverse cognitive effects (Quality of Evidence: High. Strength of Recommendation: Strong) Medications with definite Anticholinergic activities Benzodiazepines H2-Receptors Antagonists AGS Panel, JAGS

6 Adverse Cognitive Effects of Benzodiazepine A recent review of adverse cognitive effects of medications reported that 38 of 39 studies found an association between cognitive impairment and benzodiazepines. The class of histamine-2 receptor antagonists (cimetidine, ranitidine, famotidine, nizatidine) are also associated with adverse cognitive effects with two observational studies showing that histamine-2 receptor antagonists increase the risk of incident cognitive impairment. Tannenbaum et al, Drug and Aging 2012; Boustani et al, JAGS 2007; Hanlon et al, Pharmacoepidemiol Drug Saf

7 Adverse Cognitive Effects of Anticholinergics 14 prospective cohorts studies with moderate to high internal and external validity. Community or primary care setting No dementia at baseline Follow-up: 1 to 12 years Self report, research assistant inspection of home medications, or drug dispensing. N: 281 to Anticholinergics were identified by validated scales such as the ACB scale, the ADS, ARS. Smith T, et al. Age and Aging 2014 (In press). 7

8 Adverse Cognitive Effects of Anticholinergics All of the 14 (100%) longitudinal observational studies conducted in community or primary care setting among patients with no dementia at baseline showed an association between Exposure to definite anticholinergics and the development of incident cognitive impairment. Effect size: OR from 1.25 to 2.5 Smith T, et al. Age and Aging 2014 (In press). 8

9 Adverse Cognitive Effects of Anticholinergics There is some evidence for accumulative adverse cognitive effects of medications with mild anticholinergics activities. APO E4 Non-carriers were at higher risk. 90 days of exposure to at least three medications with mild anticholinergics activities 60 days of exposure to at least one medication with moderate to severe anticholinergics activities. The effects of anticholinergics may be reversible. No effect on dementia May be more impact on executive function than memory Fox et al, JAGS 2011; Smith et al, Age&Aging in press; Campbell et al Neurology 2010; Cai et al, AD&Dementia

10 Conclusion Develop a national medication surveillance and consumer advisory systematic process to the identification, monitoring, and public reporting of the adverse cognitive effects of medications used by older adults in general and those with multiple chronic conditions. (Similar to the current system available for detecting adverse cardiac, hepatic, or renal effects of medications) Develop cost-effective and scalable interventions to reduce adverse cognitive effects of medications 10

11 References: Anderson G. Chronic Care: Making the Case for Ongoing Care. Princton, NJ: Robert Wood Johnson Foudnation, Available at Panel Experts. American Geriatrics Society Updated Beers Criteria for Potnetially Inappropriate Medication Use in Older Adults. JAGS 2012; (DOI: /j x) Smith T, et al. Effect of medications with anti-cholinergic properties on cognitive function, delirium, physical function and mortality: a systematic review. Age and Aging 2014 (In press). Cai X, Campbell N, Khan B, Callahan C, Boustani M. Long-term anticholinergic use and the aging brain. Alzheimer s & Dementia Nov 22 (Online DOI: /j.jalz ) Fox C, Richardson K, Maidment ID, Savva GL, Matthews FE, Smithard D, Coulton S, Katona C, Boustani MA, Brayne C. Anticholinergic medication use and cognitive impairment in the older population: the medical research council cognitive function and ageing study. J Am Geriatr Soc Aug;59(8): Campbell NL, Boustani MA, Lane KA, Gao S, Hendrie H, Khan BA, Murrell JR, Unverzagt FW, Hake A, Smith-Gamble V, Hall K. Use of anticholinergics and the risk of cognitive impairment in an African American population. Neurology Jul 13;75(2): Campbell N, Boustani M, Limbil T, Ott C, Fox C, Maidment I, Schubert CC, Munger S, Fick D, Miller D, Gulati R. The cognitive impact of anticholinergics: a clinical review. Clin Interv Aging. 2009;4: Review. Boustani M, Hall K, Lane K, Aljadhey H, Gao S, Unverzagt F, Murray M, Hendrie H. The association between cognition and histamine-2 receptor antagonists among African Americans. J Am Geriatr Soc Aug;55(8): 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 and opioid drugs. Drugs Aging. 2012;29(8): Hanlon JT, Landerman LR, Artz MB, Gray SL, Fillenbaum GG, Schmader KE. Histamine2 receptor antagonist use and decline in cognitive function among community dwelling elderly. Pharmacoepidemiol Drug Saf. 2004;13(11):