Medications are Additive (Anticholinergic) Diane W. Healey, M.D. Center for Healthy Aging March 10, 2017

Transcription

1 Medications are Additive (Anticholinergic) Diane W. Healey, M.D. Center for Healthy Aging March 10, 2017

2 Disclosures This speaker has indicated there are no relevant financial relationships to be disclosed. 2

3 Dr. Diane Healey is a geriatrician with a certificate of added qualification, a certified medical director, and a boardcertified internist. She has her undergraduate degree from Purdue University and her medical degree from Indiana University. She completed her internal medicine residency at St. Vincent Hospital and her geriatric fellowship in Nottingham, England at the Queen s Medical Centre. She is co-medical director of the St. Vincent Hospital Center for Healthy Aging with direct patient care, nursing home care, medical directorships, program development, and education. She is a on the full time teaching faculty at St. Vincent Hospital. She has an amazing husband and three wonderful children.

4 Objectives 1. Quick overview of acetylcholine (ACh) and anticholinergic 2. Understand there are different anticholinergic burden scales 3. Realize there are many medications that have anticholinergic activity 4. Describe consequences of the chronic use of medications that have anticholinergic activity

5 Definitions Acetylcholine: A human molecule that acts as a neurotransmitter that transfers signals between cells to affect how your body functions Has effects on brain, gastrointestinal system, bladder, lungs, muscles Anticholinergic: anything that inhibits the action of acetylcholine

6 Uses for anticholinergic (ACh) drugs Treat dizziness and motion sickness Anti-Parkinson s- decrease involuntary movement Treat diarrhea Treat overactive bladder Bronchodilators for COPD Pre-anesthetics-decrease mucous secretions, keep heartbeat normal, relax the patient

7 How many of you would take a medication that could easily cause Memory impairment Confusion Hallucinations Dry mouth Blurred vision Constipation Nausea Urinary retention Impaired sweating Tachycardia Sedation

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9 Increased risks in older adults Age related changes in the brain -decreased acetylcholine Changes in pharmacodynamics and pharmacokinetics Increased permeability of the blood brain barrier?does pharmacogenomics play a role? 9

10 Adverse effects of acute use anticholinergic medications Known Accentuated in older adults Confusion Dry mouth Blurred vision Constipation Urinary hesitancy Delirium Ability to communicate, predispose to malnutrition, mucosa damage (dentures), Saliva change (risk for infection) Acute angle glaucoma Falls Fecal impaction Urinary retention Impaired sweating Hyperthermia Tachycardia Sedation Angina Decreased function

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12 Definition of anticholinergic (ACh) burden Additive effect of medications that contain some degree of anticholinergic activity, whether being used intentionally for that purpose, or as an unwanted side effect. Drugs can have low, medium, or high potency ACh effects

13 Measuring anticholinergic burden At least 7 different scales available and they are not all in concordance -use expert opinion -use serum levels -use published literature and data reviews They do ALL show varying concerns with long term cumulative use of these medications 13

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15 Anticholinergic burden possible risks Risk of community acquired pneumonia 9 Cognitive decline 1, 4 Decreased executive function 4 Dementia 7 Increased brain atrophy 10 Increased health care utilization 2 Higher in someone with dementia 8 Higher in nursing home residents with coronary artery disease 11 Functional decline 6 Fractures in depressed nursing home patients 3 Increased mortality 4

16 Beers criteria Recommendations on drugs to avoid and drugs to use with caution Most medications with significant anticholinergic activity show up on Beers list List of alternatives also available Information available at : 16

17 Geriatric prescribing What symptom or disease are you treating? Do the risks outweigh the burdens? Are there nonpharmacologic ways to treat the problem? Discontinue medications that are no longer needed, or whose risks outweigh the benefits (deprescribe)

18 Non- pharmacologic treatments when appropriate Garfinkel D, Mangin D. Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older AdultsAddressing Polypharmacy. Arch Intern Med. 2010;170(18): doi: /archinternmed

19 Summary Anticholinergic burden can be a subtle but dangerous situation for our patients Consider educating your patients about the potential adverse effects of anticholinergic medications Minimize medication usage when possible 19

20 Bibliography 1. Cai, Xueya et al.long-term anticholinergic use and the aging brain Alzheimer's & Dementia: The Journal of the Alzheimer's Association, Volume 9, Issue 4, Campbell, N. L., Perkins, A. et. Al. (2016),Association of Anticholinergic Burden with Cognitive Impairment and Health Care Utilization Among a Diverse Ambulatory Older Adult Population. Pharmacotherapy, 36: Chatterjee S, Bali V, et al. Anticholinergic Medication Use and Risk of Fracture in Elderly Adults with Depression. Journal of the American Geriatrics Society, 64: , Fox, C., Richardson, K.,et al. (2011), Anticholinergic Medication Use and Cognitive Impairment in the Older Population: The Medical Research Council Cognitive Function and Ageing Study. Journal of the American Geriatrics Society, 59: Fox C, Smith T, et al. Effect of medications with anti-cholinergic properties on cognitive function, delirium, physical function and mortality: A systematic review. Age Ageing 43: , ;

21 Bibliography 6. Garfinkel D, Mangin D. Feasibility Study of a Systematic Approach for Discontinuation of Multiple Medications in Older Adults Addressing Polypharmacy. Arch Intern Med. 2010;170(18): Gray SL, Anderson ML, Dublin S, et al Cumulative use of strong anticholinergics and incident dementia SOJAMA Intern Med. 2015; 8. Kalisch Ellett LM, Pratt NL, Et al. Multiple anticholinergic medication use and risk of hospital admission for confusion or dementia. J Am Geriatr Soc 62: , Paul, KJ, et al. Anticholinergic Medications and Risk of Community-Acquired Pneumonia in Elderly Adults: A Population-Based Case-Control Study. JAGS 63: ,

22 Bibliography 10. Risacher SL, McDonald BC, et al, for the Alzheimer s Disease Neuroimaging Initiative. Association Between Anticholinergic Medication Use and Cognition, Brain Metabolism, and Brain Atrophy in Cognitively Normal Older Adults. JAMA Neurol. 2016;73(6): Vetrano DL, La Carpia D, et al. Anticholinergic Medication Burden and 5-Year risk of Hospitalization and Death in Nursing Home Elderly Residents with Coronary Artery Disease. JAMDA 17: ,