Prevalence of anticholinergic burden and risk factors amongst the older population: analysis of insurance claims data of Korean patients

Background Despite growing interest in the negative clinical outcomes of multiple anticholinergic use, limited studies have evaluated anticholinergic burden in the geriatric population nationally. Objective To evaluate the prevalence of high anticholinergic burden using the newly developed Korean Anticholinergic Burden Scale in comparison with previous tools and to identify associated factors. Setting National insurance data from a cross section (20%) of older Koreans (2016). Methods Anticholinergic burden was measured using the Korean scale in comparison to the Anticholinergic Drug Scale, Anticholinergic Cognitive Burden, and Anticholinergic Risk Scale. High anticholinergic burden was defined as a summed score of ≥?3 for concurrent medications or a dose-standardized average daily score of ≥?3, using each anticholinergic scale. Main outcomes measured Prevalence and predictors of high anticholinergic burden. Results Data of 1,292,323 patients were analyzed. According to the Korean scale, the prevalence of high anticholinergic burden was 25.5%. This result was similar to that from the Anticholinergic Drug Scale (24.9%) and Anticholinergic Cognitive Burden (22.2%). Factors associated with an increased likelihood of anticholinergic burden include: age, gender (female), high Charlson comorbidity index score, polypharmacy, medical aid beneficiary, co-morbidities (such as schizophrenia, depression, urinary incontinence, and Parkinson’s disease), frequent healthcare visits, various healthcare facilities utilized, and predominantly visiting hospital-level facilities. According to the Korean Anticholinergic Burden Scale, the major drugs contributing to the anticholinergic burden were ranitidine, chlorpheniramine, tramadol, and dimenhydrinate. Conclusion This study showed that 1 in 4 older Koreans are exposed to high anticholinergic burden. The predictors identified in this research might assist pharmacists in early interventions for their patients.

     

Drugs with anticholinergic properties: a current perspective on use and safety

Introduction: Many commonly used drugs have primary or secondary anticholinergic effects contributing to adverse outcomes ranging from mild-to-severe to potentially lethal. Anticholinergic adverse effects frequently occur with medications prescribed with other intended mechanisms of action, including antihistamines, antidepressants, and antipsychotics. Anticholinergic drugs are also the principal treatments of clinical conditions, such as urinary incontinence, that tend to occur in the elderly. Older patients and those with mental illness are particularly vulnerable to the adverse neuropsychiatric effects of anticholinergics as they may already have cognitive impairment.

Areas covered: Medline and Pubmed literature searches (1966 – the present) were performed using ‘anticholinergic’ and ‘drug safety’. Abstracts were assessed and references scanned for appropriate articles. Here, the authors i) describe the neural pathways of the cholinergic system; ii) outline the main clinical uses and adverse effects of anticholinergic agents with a focus on cognitive impairment; and iii) discuss anticholinergic safety monitoring.

Expert opinion: Prescribers need to be vigilant for adverse anticholinergic effects, particularly in older patients. The symptoms may range from subtle cognitive impairment to delirium and may be due to the cumulative effect of multiple medications of modest antimuscarinic activity. The Anticholinergic Drug Scale and tables listing drugs with known anticholinergic properties may help in guiding clinical decision-making to reduce anticholinergic burden.     

Anticholinergics: theoretical and clinical overview

ABSTRACT

Introduction: Anticholinergics are a class of medicines that block the neurotransmitter, acetylcholine, in the brain and peripheral tissues. Medicines with anticholinergic activity are widely prescribed for and used by older people for various medical conditions. One-third to one-half of the medicines commonly prescribed for older people have anticholinergic activity. Several studies have reported anticholinergic burden to be a predictor of cognitive and functional impairments in older people.

Areas covered: This article exemplifies the theoretical and clinical aspects of medicines with anticholinergic activity, including pharmacology (definition of medicines that possess anticholinergic activity, antimuscarinic receptors, therapeutic and adverse effects), epidemiology, measures and effects of cumulative anticholinergic burden in older adults, and clinical recommendations. In addition, the gaps in the literature have been identified for future research.

Expert opinion: Many medicines that are commonly prescribed to older people have a degree of anticholinergic activity that can contribute to anticholinergic burden. Anticholinergic burden, measured in several ways that consider number, dose and/or degree of anticholinergic activity of medicines, has shown to be a predictor of adverse health and functional outcomes. The anticholinergic burden on older people should be minimised by avoiding, reducing dose and deprescribing medicines with anticholinergic activity where clinically possible.     

Anticholinergic Drug Burden in Older People's Brain – How well is it Measured?

Concurrent use of several drugs with potential anticholinergic properties is highly prevalent in the elderly. Methods to determine the overall anticholinergic drug burden have been developed to estimate the risk of central anticholinergic adverse effects. The objective of this MiniReview was to critically appraise the clinical utility of the methods used to assess the anticholinergic drug burden in older people's brain. We evaluated the in vitro method used to measure the anticholinergic activity in a patient's serum and the four anticholinergic drug scales: Anticholinergic Risk Scale, Anticholinergic Cognitive Burden, Drug Burden Index and Anticholinergic Drug Scale. Medline searches of the literature from January 1988 to January 2013 were performed. Studies that related anticholinergic drug burden to central adverse outcomes in elderly people were included, while case reports and studies of single substances were excluded. Despite the consistently reported association between a high anticholinergic drug burden and negative cognitive and psychomotor outcomes in older patients, there are discrepancies in the literature. Furthermore, no significant cognitive improvements after the anticholinergic drug burden was reduced have been shown in randomized controlled trials. It is reasonable to question whether the estimated anticholinergic drug burden can predict the overall brain effects of multiple anticholinergic agents in older people.     

Systematic review of anticholinergic risk scales in older adults

Background

Anticholinergic drugs are often involved in explicit criteria for inappropriate prescribing in older adults. Several scales were developed for screening of anticholinergic drugs and estimation of the anticholinergic burden. However, variation exists in scale development, in the selection of anticholinergic drugs, and the evaluation of their anticholinergic load. This study aims to systematically review existing anticholinergic risk scales, and to develop a uniform list of anticholinergic drugs differentiating for anticholinergic potency.

Methods

We performed a systematic search in MEDLINE. Studies were included if provided (1) a finite list of anticholinergic drugs; (2) a grading score of anticholinergic potency and, (3) a validation in a clinical or experimental setting. We listed anticholinergic drugs for which there was agreement in the different scales. In case of discrepancies between scores we used a reputed reference source (Martindale: The Complete Drug Reference®) to take a final decision about the anticholinergic activity of the drug.

Results

We included seven risk scales, and evaluated 225 different drugs. Hundred drugs were listed as having clinically relevant anticholinergic properties (47 high potency and 53 low potency), to be included in screening software for anticholinergic burden.

Conclusion

Considerable variation exists among anticholinergic risk scales, in terms of selection of specific drugs, as well as of grading of anticholinergic potency. Our selection of 100 drugs with clinically relevant anticholinergic properties needs to be supplemented with validated information on dosing and route of administration for a full estimation of the anticholinergic burden in poly-medicated older adults.     

A survey of care pathway and health-related quality of life impact for children with central precocious puberty

Abstract

Objective: To describe the timeline to diagnosis for children with central precocious puberty (CPP) and evaluate their psychosocial and health-related quality of life (HRQoL).

Methods: A cross-sectional survey was used to prospectively collect data from caregivers, recruited via the MAGIC Foundation, of children with CPP. The control (non-CPP) group was recruited from a national panel of parents/caregivers. After completing a screening survey, respondents completed a burden of illness survey. Respondents in both groups completed the Pediatric Quality of Life Inventory (PedsQL) and Patient-Reported Outcomes Measurement Information System (PROMIS) peer relationship instruments.

Results: Responses from 142 caregivers of children with and 300 without CPP were assessed. Mean time to treatment after a child’s visit to the pediatric endocrinologist was 220?days and time from onset of symptoms to initiating treatment was approximately 2?years. Responses to HRQoL inventories were all lower in children with CPP versus non-CPP. Adjusted mean (± standard error) PedsQL total (65.3?±?1.8 versus 75.7?±?1.2), Psychosocial Health Summary (62.4?±?1.8 versus 73.4?±?1.2), and Physical Health Summary (70.7?±?2.2 versus 79.9?±?1.5) scores were significantly lower (p?<?.01) in CPP versus non-CPP group. PROMIS peer relationship T score (± standard error) was numerically lower for the CPP versus non-CPP group (45.4?±?1.0 versus 47.4?±?0.7, p = .11).

Conclusions: In clinical practice, there is a longer than expected delay between CPP symptom onset and referral to an endocrinologist and ultimate treatment. Children with CPP experience a substantial disease burden with a significant impact on emotional, social, and physical functioning compared with children without CPP.     

Comparing the economic burden of ischemic stroke patients with and without atrial fibrillation: a retrospective study in Beijing,China

Background: Little is known about the economic burden for ischemic stroke (IS) patients with atrial fibrillation (AF) in China.

Aim: We aimed to compare the economic burden of treatment-related costs in IS patients with AF vs. without AF in China.

Methods: This retrospective analysis used economic burden data from the Beijing urban health insurance database. Using a random sampling method, 10% of the patients diagnosed with IS from 1 January through 31 December 2012 were enrolled. First hospitalization was considered as the index event and hospital utilization after the index event was followed up until September 2013. Overall healthcare cost during the study period was analyzed.

Results: In 4061 patients with IS (mean?±?SD age, 68.45?±?13.95 years; AF: 992; without AF: 3069), the AF group had a higher percentage of patients with co-morbidities at baseline. Compared with the non-AF group, the AF group had significantly greater hospitalization at the index event (p?p?Conclusions: AF increased the use of healthcare resources, treatment cost, and economic burden in patients with IS. Therefore, prevention of cardio-embolic events in patients with AF by anticoagulants may decrease the economic burden in patients with IS.     

Using telehealth to enable collaboration of pharmacists and geriatricians in residential medication management reviews

Background Practical issues impede optimum collaboration between pharmacists and other clinical specialists in the current Australian residential medication review services which potentially affect efficiency, timeliness and quality of outcomes. Objective This mixed methods study aimed to explore the potential value of an existing telehealth platform to enable collaboration of pharmacists and geriatricians in residential medication reviews. Setting Long term care facilities in Australia. Method Twenty vignettes of aged care residents were prepared and independently reviewed by five pharmacists and five geriatricians using a telehealth platform to record their recommendations for medications. The geriatricians were subsequently asked to re-consider their recommendations after being provided with a pharmacist’s report. Main outcome measure The level of agreement between pharmacists and between geriatricians, changes in the mean number of medications after pharmacists’ and geriatricians’ reviews, number of changes in geriatricians’ recommendations after viewing a pharmacist’s report, and pharmacists’ and geriatricians’ feedback. Results Both pharmacists and geriatricians had fair agreement about their recommendations for medications (kappa of 0.30 and 0.31 respectively). The mean number of medications over 20 cases was significantly reduced from a baseline of 14.9 to 13.4 by pharmacists, and to 12.3 by geriatricians after their reviews. There was disagreement between geriatricians and pharmacists on 430/1485 (29%) recommendations on medications; after viewing a pharmacist’s report, geriatricians changed their mind in 51 occasions. Geriatricians found the pharmacist report useful in 72% of the cases. The majority of the pharmacists (4/5) were prepared to use the online system routinely. Conclusion The tested telehealth platform has the potential of being used as a part of routine practice to improve accessibility of the service and to enable synchronous collaboration among healthcare professionals.

     

Effects of triptolide on pharmacokinetics of amlodipine in rats by using LC–MS/MS

Context: Triptolide and amlodipine are often simultaneously used for reducing urine protein excretion after renal transplantation in China clinics.

Objective: This study investigated the effects of triptolide on the pharmacokinetics of amlodipine in male Sprague–Dawley rats.

Materials and methods: The pharmacokinetics of amlodipine (1?mg/kg) with or without triptolide pre-treatment (2?mg/kg/day for seven?days) were investigated using a sensitive and reliable LC–MS/MS method. Additionally, the inhibitory effects of triptolide on the metabolic stability of amlodipine were investigated using rat liver microsome incubation systems.

Results: The results indicated that when the rats were pre-treated with triptolide, the C_max of amlodipine increased from 13.78?±?3.57 to 19.96?±?4.56?ng/mL (p?T_max increased from 4.04?±?1.15 to 5.89?±?1.64?h (p?AUC_0–t increased by approximately 104% (p?p?Conclusions: In conclusion, these results indicated that triptolide could affect the pharmacokinetics of amlodipine, possibly by inhibiting the metabolism of amlodipine in rat liver when they are co-administered.     

Anticholinergic Activity of Psychotropic Drugs and Cognitive Impairment Among Participants Aged 45 and Over: The CONSTANCES Study

Introduction

Psychotropic drugs such as anxiolytics, antidepressants and antipsychotics may have anticholinergic properties that could directly affect patients’ cognition.

Objectives

Our objective was to assess the relationship between exposure to anticholinergic-positive (AC+) psychotropic drugs and cognitive impairment compared with psychotropic drugs without anticholinergic activity (AC−).

Methods

This analysis included participants (aged 45–70 years) enrolled between January 2012 and October 2017 in the CONSTANCES cohort treated with psychotropic drugs (antidepressants n = 2602, anxiolytics n = 1195, antipsychotics n = 197) in the 3 years preceding cognitive assessment. Within each drug class, the Anticholinergic Cognitive Burden scale was used to classify drugs as either AC+ or AC−. Cognitive impairment was defined as a score below − 1 standard deviation from the standardized mean of the neuropsychological score. We used multiple logistic regression models and matching on propensity score to estimate the relationship between anticholinergic activity and cognitive impairment.

Results

Our analyses did not show any increased risk of cognitive impairment for AC+ antidepressants and anxiolytics, with the exception of a slight increase for AC+ antidepressants in episodic memory (odds ratio [OR] 1.19; 95% confidence interval [CI] 1.05–1.36). Conversely, we found a more marked increase in risk with AC+ antipsychotics on executive function (Trail Making Test-A [TMT-A], OR 4.49 [95% CI 2.59–7.97] and TMT-B, OR 3.62 [95% CI 2.25–5.89]).

Conclusion

Our results suggest there is no clinically relevant association between the anticholinergic activity of antidepressant and anxiolytic drugs and cognitive impairment in middle-aged adults. An association could exist between AC+ antipsychotics and executive function.

     

Delirium assessed by Memorial Delirium Assessment Scale in advanced cancer patients admitted to an acute palliative/supportive care unit

Background: Delirium is often unrecognized in cancer patients. The aim of this study was to investigate the prevalence of delirium assessed by the Memorial Delirium Assessment Scale (MDAS) and possible associated factors on admission to an acute palliative/supportive care unit (APSCU). The secondary outcome was to assess changes in MDAS and symptom burden at time of discharge.

Methods: A consecutive sample of advanced cancer patients who were admitted to an APSCU was prospectively assessed for a period of 10 months. Patient demographics, including age, gender, primary diagnosis, Karnofsky status, stage of disease, and educational level were collected. The Edmonton Symptom Assessment Scale (ESAS) and the MDAS were measured at hospital admission and discharge.

Results: A total of 314 patients were surveyed. Of 292 patients with MDAS available at T0, 74 (25.3%) and 24 (8.2%) had a MDAS of 7–12 and ≥13, respectively. At discharge, there was a significant decrease in the number of patients with a MDAS ≥7/30. Higher values of MDAS were associated with age (p?=?.028), a lower Karnofsky status (p?p?=?.04), low level of education (p?=?.002), less awareness of disease (p?p?p?=?.026), hospital stay (p?=?.038) and death (p?p?Conclusion: Delirium is highly prevalent in patients admitted to APSCU, characterized by a low mortality due to early referral. Comprehensive assessment and treatment may allow a decrease in the level of cognitive disorders and symptom burden.     

Side effects from acute myeloid leukemia treatment: results from a national survey

Objective: Acute myeloid leukemia (AML) is experiencing a therapeutic renaissance due to the heightened biomedical understanding of AML and patient-focused drug development (PFDD). Many AML patients now live long-term with the side effects of treatment. This study documents the prevalence and severity of AML treatment-related side effects.

Methods: A national cross-sectional survey designed with the Leukemia & Lymphoma Society assessed patients’ experiences with short-term (nausea/vomiting, diarrhea, hair loss, mouth sores, infection, rash) and long-term (organ dysfunction, chemobrain, fatigue, neuropathy) treatment side effects. Patient and caregiver participants rated side effect severity (none–severe).

Results: Survey participants (n?=?1182) were mostly female (65%), AML patients (76%), and had undergone chemotherapy (94%). Eighty-seven per cent of participants reported severe short-term effects, and 33% reported severe long-term effects of treatment. Only 11% of respondents did not have any severe effects. Hair loss and fatigue were the most common severe short- and long-term side effects (78%, 33%). There was a moderate correlation between having short- and long-term adverse effects (r?=?0.41, p?<?0.001). Caregivers were more likely than patients to report severe organ dysfunction, fatigue, and neuropathy (p-values <?0.05).

Conclusions: Survivors experience a high burden of side effects from AML treatments highlighting the need for the development of less toxic therapies. Differences in patients’ and caregivers’ experiences illustrate the importance of sampling from diverse sources to understand the full burden of AML treatment, and the need for less toxic drugs. This study informs patients, patient-advocacy groups, clinicians, and regulators about AML treatment burdens and provides the community with information to inform PFDD.     

Inter-rater reliability of scales and tests used to measure mild cognitive impairment by general practitioners and psychologists

SUMMARY

Background: This study was conducted to assess whether general practitioners (GPs) can be trained to use a simple battery of functional scales and neuropsychological tests to detect people likely to develop dementia as reliably as neuropsychologists in clinical practice.

Methods: Fifty GPs with medium-sized practices in the Bordeaux area of France were recruited by monitors and trained to use a battery of tests (Mini-Mental State Examination (MMSE), Isaacs Set Test (IST), Benton Visual Retention Test (BVRT) and Zazzo's Cancellation Test (ZCT)). Each GP was required to recruit one patient. The tests were administered first by the GP, and then by a trained psychologist.

Results: Overall, the GPs showed interest in participating in the study. They had no difficulty

in recruiting patients according to the inclusion and exclusion criteria and none reported any difficulty in using the scales and tests battery. In total, 35 subjects were interviewed by both a trained GP and a psychologist. The scores obtained by the GPs and psychologists did not differ statistically for two of the four tests (IST, p?=?0.6; BVRT, p?=?0.7), but were statistically different for the other two tests (MMSE, p?=?0.04; ZCT; p?<?0.002).

Conclusions: The results confirm the feasibility of conducting a study for detecting cognitive deficit in general practice. The GPs were interested and participated well, patient adherence was good, and the concordance correlation coefficients between the GPs' and psychologists' scores were satisfactory.     

The partnership between renalase and ejection fraction as a risk factor for increased cardiac remodeling biomarkers in chronic heart failure patients

Abstract

Objective: Heart failure (HF) represents a huge socio-economic burden. It has been demonstrated, experimentally, that renalase, a newly discovered protein, prevents cardiac hypertrophy and adverse remodeling, which is seen in HF. We postulated the following aims: to investigate associations of renalase with biomarkers of cardiac remodeling: galectin-3, soluble suppression of tumorigenicity, (sST2), growth differentiation factor 15 (GDF-15) and syndecan-1, myocardial stretch (BNP) and cardio-renal axis (cystatin C) in HF patients with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF) to determine whether renalase, in combination with left ventricular ejection fraction (LVEF), represents a risk factor for plasma elevation in biomarkers.

Methods: We classified HF patients (n?=?76) according to LVEF (preserved/reduced), applied a median plasma renalase (113?ng/mL) as a cut-off value (low/high) and created four subgroups of HF patients: HFpEF/low renalase (n?=?19), HFrEF/low renalase (n?=?19), HFrEF/high renalase (n?=?32) and HFpEF/high renalase (n?=?6). A control group (n?=?35) consisted of healthy volunteers.

Results: Plasma concentrations of evaluated biomarkers were determined using an ELISA technique and were highest in HF patients with reduced EF (p?<?.001, respectively), and renalase’s positive correlations were obtained relating to all biomarkers: galectin-3 (r?=?0.913; p?<?.001), sST2 (r?=?0.965; p?<?.001), GDF-15 (r?=?0.887; p?<?.001), syndecan-1 (r?=?0.922; p?<?.001), BNP (r?=?0.527; p?<?.001) and cystatin C (r?=?0.844; p?<?.001) and strong and negative correlation with LVEF (r?=??0.456, p?<?.001). Increased renalase, regardless of the EF (preserved/reduced), was shown to be an independent risk factor for an increase in all evaluated cardiac remodeling biomarkers, p?<?.001, respectively. However, increased renalase and reduced EF was the only independent risk factor for BNP and cystatin C elevation, p?<?.001, respectively. Results after multivariable adjustments (age/gender) were identical.

Conclusion: When elevated plasma renalase and HF are present, regardless of EF being reduced or preserved, that represents a significant risk factor for increase in cardiac remodeling biomarker plasma concentrations. However, only elevated renalase and reduced EF demonstrated significance as a risk factor for BNP and cystatin C plasma elevation. Renalase may be considered a promising molecule for the improved predictive abilities of conventional biomarkers and is worthy of further investigation.     

Efficacy and safety of ultrasound-guided percutaneous polidocanol sclerotherapy in benign predominantly cystic thyroid nodules: a prospective study

Objective: To evaluate the efficacy and safety of percutaneous polidocanol injection (PPI) in treatment of predominantly cystic thyroid nodules.

Materials and methods: This prospective study included 111 patients with 122 benign predominantly cystic thyroid nodules inducing pressure symptoms or cosmetic problems. The nodules were randomized to a single aspiration with (n?=?61) or without (n?=?61) subsequent PPI and followed up after 1, 3, 6, and 12 months. Ten patients (12 nodules) declined to follow up after aspiration in group 2. Nodule volumes, symptoms scores, and cosmetic scores were evaluated before and after treatment. The therapeutic success rate and safety of PPI for treatment of predominantly cystic thyroid nodules were also evaluated.

Results: In the PPI group, the nodule volumes were reduced from 13.67?±?9.90 to 2.60?±?2.66 (p?50%) was obtained in 57 of 61 (93.44%) nodules in the PPI group, compared to seven of 49 (14.29%) in the aspiration group (p?p?p?p?Conclusions: US-guided PPI of benign recurrent predominantly cystic thyroid nodules is effective and safe. PPI is an important alternative to benign recurrent predominantly cystic thyroid nodules.     

Antinociceptive and anticonvulsant effects of the monoterpene linalool oxide

Context: Linalool oxide (OXL) (a monoterpene) is found in the essential oils of certain aromatic plants, or it is derived from linalool. The motivation for this work is the lack of psychopharmacological studies on this substance.

Objective: To evaluate OXL’s acute toxicity, along with its anticonvulsant and antinociceptive activities in male Swiss mice.

Material and methods: OXL (50, 100 and 150?mg/kg, i.p.) was investigated for acute toxicity and in the Rota-rod test. Antinociceptive activity was evaluated by the acetic acid-induced writhing test, and by formalin testing. Anticonvulsant effects were demonstrated by testing for pentylenetetrazol (PTZ)-induced seizures and by Maximum Electroshock headset (MES) test. OXL was administered to the animals intraperitoneally 30?min before for pharmacological tests.

Results: OXL showed an LD₅₀ of ～721 (681–765) mg/kg. In the Rota-rod test, it was observed that OXL caused no damage to the animal’s motor coordination. OXL significantly reduced (p?p?p?p?p?p?p?Conclusion: The tested doses of OXL were safe, with no motor impairment, and show clear antinociceptive and anticonvulsant potential. Future investigations with this monoterpene may lead to the development of a new molecule with even higher potency and selectivity.     

Anticholinergic burden and risk of cognitive impairment in elderly nursing home residents with depression

BackgroundAlthough the adverse cognitive effects of anticholinergic medications in the elderly are well-documented, little is known regarding the cognitive impact of anticholinergics among nursing home residents with depression.ObjectiveThis study examined the risk of mild-to-moderate cognitive impairment due to anticholinergic burden among elderly nursing home residents with depression.MethodsA population-based nested case-control study was conducted using Minimum Data Set (MDS)-linked Medicare data where the base cohort included patients ≥ 65 years with depression who had intact cognition (MDS Cognition score of 0 or 1) and no dementia. Cases were identified as those who had mild-to-moderate cognition (MDS Cognition score of 2–4). Each case was matched on age and sex to one control using incidence density sampling. The study evaluated cumulative anticholinergic burden (defined as score of 3 or more) within 30, 60 and 90 days preceding the event date based on the Anticholinergic Drug Scale (ADS). Conditional logistic regression model stratified on matched case-control sets was performed to evalaute cognitive impairment due to cumulative anticholinergic burden after controlling for other risk factors.ResultsThe study sample included 3707 cases with mild-to-moderate cognition and 3707 matched controls with intact cognition. Bivariate analysis showed significant association between cumulative anticholinergic exposure and cognitive impairment (Odds Ratio [OR], 1.15; 95% Confidence Interval [CI],1.04–1.30); after controlling for potential risk factors, cumulative anticholinergic exposure 30 days preceding the event was no longer associated with cognitive impairment, (aOR, 1.07; 95% CI, 0.95–1.21). However, the odds of cognitive impairment increased with cumulative anticholinergic exposure 60 days (aOR 1.16; 1.04–1.30) and 90 days (aOR 1.28; 1.14–1.44) before the event date.ConclusionCumulative anticholinergic use for prolonged exposure periods was associated with modestly increased risk of cognitive impairment in elderly residents with depression who had intact cognition. The findings suggest the need to be cautious when prescribing multiple anticholinergic drugs in residents, including those with intact cognition.     

The feasibility of alcohol screening and interventions in emergency care: a comparison of primary and specialised health care settings

Background: Implementation of alcohol screening and brief intervention in emergency departments is inadequate and the evidence base more mixed than in primary health care (PHC). This comparison study investigates the feasibility of alcohol screening and interventions by nurses in emergency departments, seven based in PHC and two in specialised health care clinics. The aim is to analyse barriers to implementation in these two contexts.

Methods: A questionnaire was used among emergency nurses in the Kymenlaakso hospital district in Finland. The response rate was 71% (N?=?112; PHC clinics n?=?42; specialised clinics n?=?38). The statistical differences in responses were analysed using the χ² test. Open-ended questions were analysed qualitatively.

Results: The nurses in specialised clinics treated patients with alcohol-attributable conditions/traumas more often than the nurses in PHC did (p?p?p?Conclusions: The results indicate an intervention paradox in the emergency care setting: compared to nurses in PHC clinics, nurses in specialised health care clinics work more often with intoxicated patients but they are less willing to implement alcohol screening and interventions. The findings highlight the need for institutional-level support in addition to capacity building among nurses.