Anticholinergic drug use in long-term care facilities

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http://urn.fi/URN:ISBN:978-951-6809-2
Title: Anticholinergic drug use in long-term care facilities
Author: Aalto, Ulla
Contributor: University of Helsinki, Faculty of Medicine, Department of General Practice and Primary Health Care
Doctoral Program in Population Health
Publisher: Helsingin yliopisto
Date: 2020-12-11
URI: http://urn.fi/URN:ISBN:978-951-6809-2
http://hdl.handle.net/10138/321562
Thesis level: Doctoral dissertation (article-based)
Abstract: Drugs with anticholinergic properties (DAPs) are known to have a large spectrum of adverse effects affecting both the peripheral and central nervous system. Older multimorbid people in declining health as regards cognitive and physical performance are especially vulnerable to these adverse effects, such as dizziness, confusion and cognitive decline. Cumulative DAP use, reflecting a greater anticholinergic burden, increases the risks of adverse outcomes. There are several international criteria concerning DAPs and anticholinergic burden. However, there are relatively few studies comparing various criteria and their prognostic value. In addition, the relationship of DAPs with Quality of Life (QOL) among older people has received very little attention. The aim of this study was to explore the use of DAPs in long-term care facilities (LTCFs), and their associated factors, in particular psychological well-being (PWB), Health-related Quality of Life (HRQOL), and mortality. Furthermore, the relationships between anticholinergic burden and associated factors were also investigated by comparing three internationally well-established anticholinergic scales. In addition, temporal trends in DAP use were studied over a 14-year period. The study comprises four cross-sectional sub-studies conducted in 2003, 2007, 2011, and 2017 in LTCFs in Helsinki. All background data on demographic factors, medication use, and diagnoses of chronic and acute medical conditions were retrieved from medical records. Trained study nurses performed the assessments needed, using the same structured study protocol at each time point. The medications were classified according to WHO Anatomical Therapeutic Chemical (ATC) criteria. DAP use and anticholinergic burden were defined by using the Anticholinergic Risk Scale (ARS) (Studies I, III and IV), and by comparing three scales, the ARS, Chew’s list, and the Anticholinergic Drug Scale (ADS) (Study II). Of all residents living in nursing homes (NHs) and assisted living facilities (ALFs) in Helsinki, 2432 were included in Studies I and II. PWB was assessed by using a validated questionnaire. Mortality data was retrieved from central registers. In Study III, all residents living in NHs and ALFs in Helsinki in 2017 were invited to participate, and after exclusions, 2474 remained. DAP use was defined by the ARS score and HRQOL was assessed by use of the 15D instrument, separately among people with and without cognitive decline, according to their nutritional status, and functioning. In Study IV, temporal trends of DAP use defined by the ARS were investigated from 2003 to 2017 in three NH cohorts in 2003 (n=1979), in 2011 (n=1568), and in 2017 (n=750), and in three ALF cohorts in 2007 (n=1336), in 2011 (n=1556), and in 2017 (n=1673). In Studies I and II the residents in long-term care facilities were about 84 years of age and mostly female. DAP use was very common, since about half of the participants (51%) used at least one DAP according to the ARS (Study I). When defining DAP use by combination of the three scales, as many as 85% of participants were identified as DAP users (Study II). The three scales included partly the same, but mostly different drugs, and the scales only partly overlapped each other. DAP users were in general younger and had better cognition than non-users. A higher number of drugs used regularly was associated with DAP use (mean range 8.8–10.1) compared with non-users (mean 7.1, p for trend <0.001) (Study I). In NHs no significant trend in DAP use was observed over 14 years (52–46–52%, p for trend =0.19), whereas in ALFs an increasing trend in DAP use was observed over the years (41–51–54%, p for trend <0.001) (Study IV). In Study I an association between DAP use and poorer psychological well-being, measured by PWB score ranging from 0 to 1, was observed. Those not using DAPs had a significantly higher PWB score (mean 0.73) than those using them, and the PWB score had a decreasing trend along with increasing number of DAPs used (mean range 0.67-0.67-0.62, p for trend <0.001). The association remained in further analyses, irrespective of possible underlying depression or dependency in functioning. In Study II, when comparing how the three scales predicted PWB, Chew’s list alone, or combinations of two or three lists together showed an association with poorer PWB. Using a higher number of DAPs was also associated with poorer PWB. In 1-year follow-up no association between mortality and DAP use was seen, compared with not using any DAPs. However, an association between a higher number of DAPs used and an increased risk of mortality was observed. In Study III HRQOL measured by the 15D instrument showed an increasing trend along with higher ARS scores (mean 15D score 0.596–0.629, p linearity <0.001). However, after stratification according to cognitive and functional status, no significant differences in HRQOL between the ARS-score groups were any longer seen. Overall, residents with dementia, poor nutritional status, and dependency on another person’s assistance had lower HRQOL than those without dementia, those well-nourished or not dependent. Interactions between ARS score and dementia (p<0.001 for dementia and p=0.021 for interaction), and ARS score and dependency emerged (p<0.001 for dependency and p=0.017 for interaction). Despite clinical guidelines which advise against the use of DAPs, they have remained widely used in this frail population of older adults in long-term care, as roughly one in two residents in LTCFs use them. DAPs seem to be prescribed to younger individuals and those with better cognition, whereas the cognitively more impaired are spared them. Some favorable trends concerning DAP use in LTCFs during recent years, such as decrease of ARS scores in NHs, or disappearance of certain high potential DAPs, were observed. However, concerning results emerged as regards residents in ALFs, where an increasing trend in DAP use was observed. Although the three DAP scales investigated have certain similarities, they overlap only partly and seem to predict different outcomes. The results showing an association between anticholinergic burden and poorer PWB are worrisome, and further studies are warranted to investigate this topic.Monilla lääkkeillä on antikolinergisia vaikutuksia. Yksiselitteistä määritelmää antikolinergiselle lääkkeelle ei ole, vaan eriäviä kriteeristöjä ja listauksia on kansainvälisessä kirjallisuudessa lukuisia. Antikolinergien tunnettuja haittavaikutuksia ovat mm. suun kuivuminen, huimaus ja kognition heikkeneminen. Haittavaikutukset ilmenevät usein voimakkaampina käytettäessä lääkkeitä, joilla on vahva antikolinerginen potentiaali. Haitat myös lisääntyvät usean antikolinergin samanaikaisessa käytössä, jolloin puhutaan antikolinergisesta kuormasta. Iäkkäät, monisairaat ovat erityisen alttiita näille haittavaikutuksille, minkä vuoksi antikolinergeja suositellaan iäkkäillä välttämään. Psyykkisen hyvinvoinnin - elämänlaadun yhden osa-alueen - ja antikolinergien käytön välisestä yhteydestä on hyvin vähän aiempaa tutkimustietoa. Väitöstutkimuksen tavoitteena oli selvittää antikolinergisten lääkkeiden käyttöä ja niihin liittyviä tekijöitä, erityisesti psyykkistä hyvinvointia, terveyteen liittyvää elämänlaatua ja kuolleisuutta helsinkiläisillä ympärivuorokautisen hoidon asukkailla vuosina 2003-2017. Lisäksi selvitettiin kolmen eri antikolinergikriteeristön yhteneväisyyksiä ja eroavaisuuksia sekä niiden kykyä psyykkisen hyvinvoinnin ennustajana. Tutkittavat asuivat joko vanhainkodissa tai palveluasumisessa ja olivat keskimäärin yli 80-vuotiaita. Joka toisella oli säännöllisessä käytössä jokin antikolinerginen lääke. Tietyt psyykenlääkkeet olivat yleisimmin käytössä olevia antikolinergisia lääkkeitä. Antikolinergien käyttö painottui nuorempiin ikäryhmiin sekä niihin, joilla oli parempi kognitio. Näyttää siis siltä, että kaikista vanhimpia ja muistisairaimpia osataan suojella näiltä lääkkeiltä. Huolimatta suosituksista ja siitä, että nykyisin näiden lääkkeiden haitoista iäkkäillä tiedetään enemmän, ei antikolinergien käyttö ole vähentynyt lähivuosien aikana, vaan palveluasumisessa suuntaus on ollut jopa kasvava. Suotuisiakin muutoksia havaittiin, kuten se että tiettyjen vahvojen antikolinergien, kuten antihistamiini hydroksitsiinin käyttö loppui kokonaan seuranta-aikana. Toimintakyvyn, ravitsemuksen ja kognition mukaan ryhmiteltynä antikolinergisen kuorman ja terveyteen liittyvään elämänlaadun välillä ei havaittu yhteyttä. Sen sijaan antikolinergien käytön ja psyykkisen hyvinvoinnin välillä todettiin yhteys siten että antikolinergeja käyttävien psyykkinen hyvinvointi oli huonompi kuin heidän, joilla ei ollut näitä lääkkeitä käytössä. Niin ikään suuremman antikolinergisen kuorman ja heikomman psyykkisen hyvinvoinnin välillä näytti olevan yhteys, mikä on huolestuttava löydös. Iäkkäiden lääkityksen säännölliseen arviointiin ja sen myötä antikolinergisten lääkkeiden ja antikolinergisen kuorman tunnistamiseen tulisi kiinnittää entistä enemmän huomiota.
Subject: lääketiede
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