Association of Anticholinergic Burden with Cognitive and Functional Status in a Cohort of Hospitalized Elderly: Comparison of the Anticholinergic Cognitive Burden Scale and Anticholinergic Risk Scale

Abstract Background Drugs with anticholinergic effects are associated with adverse events such as delirium and falls as well as cognitive decline and loss of independence. Objective The aim of the study was to evaluate the association between anticholinergic burden and both cognitive and functional status, according to the hypothesis that the cumulative anticholinergic burden, as measured by the Anticholinergic Cognitive Burden (ACB) Scale and Anticholinergic Risk Scale (ARS), increases the risk of cognitive decline and impairs activities of daily living. Methods This cross-sectional, prospective study (3-month telephone follow-up) was conducted in 66 Italian internal medicine and geriatric wards participating in the Registry of Polytherapies SIMI (Societa` Italiana di Medicina Interna) (REPOSI) study during 2010. The sample included 1,380 inpatients aged 65 years or older. Cognitive status was rated with the Short Blessed Test (SBT) and physical function with the Barthel Index. Each patient’s anticholinergic burden was evaluated using the ACB and ARS scores. Results The mean SBT score for patients treated with anticholinergic drugs was higher than that for patients receiving no anticholinergic medications as also indicated by the ACB scale, even after adjustment for age, sex, education, stroke and transient ischaemic attack [9.2 (95 % CI 8.6–9.9) vs. 8.5 (95 % CI 7.8–9.2); p = 0.05]. There was a dose–response relationship between total ACB score and cognitive impairment. Patients identified by the ARS had more severe cognitive and physical impairment than patients identified by the ACB scale, and the dose–response relationship between this score and ability to perform activities of daily living was clear. No correlation was found with length of hospital stay. Conclusions Drugs with anticholinergic properties identified by the ACB scale and ARS are associated with worse cognitive and functional performance in elderly patients. The ACB scale might permit a rapid identification of drugs potentially associated with cognitive impairment in a dose–response pattern, but the ARS is better at rating activities of daily living

Gout, allopurinol intake and clinical outcomes in the hospitalized multimorbid elderly

Background: Increased serum uric acid has been considered a cardiovascular risk factor but no study has assessed its relation with hospital mortality or length of stay. On the basis of data obtained from a prospective registry, the prevalence of gout/hyperuricemia and its association with these and other clinical parameters was evaluated in an Italian cohort of elderly patients acutely admitted to internal medicine or geriatric wards. Methods: While the prevalence of gout was calculated by counting patients with this diagnosis hyperuricemia was inferred in patients taking allopurinol at hospital admission or discharge, on the assumption that this drug was only prescribed owing to the \ufb01nding of high serum levels of uric acid. A series of clinical and demographic variables were evaluated for their association with gout/hyperuricemia. Results: Of 1380 patients, 139 (10%) had a diagnosis of gout or were prescribed allopurinol. They had more co-morbidities (7.0 vs 5.6; P b 0.0001) and consumed more drugs (6.8 vs 5.0; P b 0.0001). The CIRS (co-morbidity index) was worse in these patients (OR 1.28 95% CI 1.15\u20131.41). Multivariable regression analysis showed that only renal and heart failures were independently associated with gout/allopurinol intake. Moreover, this combined event was associated with an increased risk of adverse events during hospitalization (OR 1.66, 95% CI 1.16\u20132.36), but not with the risk of re-hospitalization, length of hospital stay or death. Conclusions: Gout/allopurinol intake has a high prevalence in elderly patients acutely admitted to hospital and are associated with renal and cardiovascular diseases, an increased rate of adverse events and a high degree of drug consumption. In contrast, this \ufb01nding did not affect the length of hospitalization nor hospital mortality

Adherence to antibiotic treatment guidelines and outcomes in the hospitalized elderly with different types of pneumonia

Background: Few studies evaluated the clinical outcomes of Community Acquired Pneumonia (CAP), Hospital-Acquired Pneumonia (HAP) and Health Care-Associated Pneumonia (HCAP) in relation to the adherence of antibiotic treatment to the guidelines of the Infectious Diseases Society of America (IDSA) and the American Thoracic Society (ATS) in hospitalized elderly people (65 years or older). Methods: Data were obtained from REPOSI, a prospective registry held in 87 Italian internal medicine and geriatric wards. Patients with a diagnosis of pneumonia (ICD-9 480-487) or prescribed with an antibiotic for pneumonia as indication were selected. The empirical antibiotic regimen was defined to be adherent to guidelines if concordant with the treatment regimens recommended by IDSA/ATS for CAP, HAP, and HCAP. Outcomes were assessed by logistic regression models. Results: A diagnosis of pneumonia was made in 317 patients. Only 38.8% of them received an empirical antibiotic regimen that was adherent to guidelines. However, no significant association was found between adherence to guidelines and outcomes. Having HAP, older age, and higher CIRS severity index were the main factors associated with in-hospital mortality. Conclusions: The adherence to antibiotic treatment guidelines was poor, particularly for HAP and HCAP, suggesting the need for more adherence to the optimal management of antibiotics in the elderly with pneumonia

Caregivers' perceptions of the therapeutic benefits of drug treatments for dementia

Background and aims: To collect opinions, perceptions, and expectations on the therapeutic benefits of drug treatment for dementia and the impact on the care of the patient in a large sample of caregivers. Only few studies deal with this topic in a small number of participants. Methods: This used an ad-hoc online questionnaire to collect the opinions of caregivers of patients with dementia and assess their expectations and perceptions of the therapeutic benefits of drug treatments. The questionnaire was accessible for nearly 4 months on the Federazione Alzheimer Italia website and had three sections: (1) information on the patient with dementia; (2) information on the caregiver's perception of the therapeutic benefits of drug treatments; (3) information on caregivers. To evaluate the relationship between the caregiver's expectations of the therapeutic benefits of dementia treatments and some characteristics of the patients and the caregivers, we used the Chi-square test. Results: During the access time, 439 questionnaires were filled, and 369 were validated for inclusion in the analysis; of these, 329 also had information on caregivers. The expectations of drug treatment effects were not statistically significantly influenced by any variables considered about the patients or the caregivers. Caregivers' beliefs about the effectiveness of dementia treatment, their expectations and changes in their lives were clear. Conclusions: This study addresses a gap in knowledge about caregivers' experiences and their views of drug treatments, and highlights the need for a pharmaceutical treatment that helps to resolve the symptoms and outcomes of dementia

Electrocardiographic monitoring for new prescriptions of quetiapine co-prescribed with acetylcholinesterase inhibitors or memantine from 2005 to 2009 : a population study on community-dwelling older people in Italy

Purpose: The aims of this study are to analyse, in community-dwelling people aged 65+ living in Italy's Lombardy Region, electrocardiographic (ECG) monitoring for new users of the atypical antipsychotic quetiapine co-prescribed with acetylcholinesterase inhibitors (AChEIs) or memantine and to find independent predictors of ECG monitoring before and after the starting of this prescription. Methods: The Lombardy Region's administrative health database was used to retrieve prescriptions of ECG exams as well as prevalence rates of subjects aged 65+ who were prescribed such psychotropic drugs from 2005 to 2009. Multivariable analyses were adjusted for age, sex, number of drugs, treatment with beta-blockers, digoxin, verapamil or diltiazem, any antiarrhythmic drug and antidepressants. Results: Overall 2,623 community-dwelling older people started therapy with quetiapine, co-prescribed with AChEIs or memantine, during these 5 years. At least one ECG was performed in 714 cases (27.2 %) in the 6 months before - and in 398 cases (15.2 %) within 3 months after - the starting of this prescription. ECG monitoring was performed both before and after starting quetiapine in only 160 cases (6.1 %). At multivariable analyses, number of drugs taken, beta-blocker and antiarrhythmic drug use were found to be independent correlates of ECG monitoring whereas female sex was associated with a lower probability of receiving an ECG within 3 months after the initiation of quetiapine (odds ratio 0.78, 95 % CI 0.62-0.98). Conclusions: ECG monitoring for new prescriptions of quetiapine in older people suffering from behavioural and psychological symptoms in dementia was actually performed infrequently, independently of the age of drug users, especially in women. Our results support the need for greater awareness within the medical community of the importance of such ECG monitoring

New prescriptions of spironolactone associated with angiotensin-converting- enzyme inhibitors and/or angiotensin receptor blockers and their laboratory monitoring from 2001 to 2008 : a population study on older people living in the community in Italy

Purpose: To analyse, in older community-dwelling people living in Italy's Lombardy region, 8-year trends in new users of spironolactone co-prescribed with angiotensin-converting-enzyme inhibitors (ACE-Is) and/or angiotensin receptor blockers (ARBs); blood test monitoring; and independent predictors of appropriate blood test monitoring. Methods: The region's administrative health database from 2001 to 2008 was used to retrieve yearly frequencies of subjects aged 65+ who started this co-prescription. Multivariate analyses were adjusted for age, sex, local health unit, treatment with beta-blockers, drugs for diabetes, and polypharmacy (i.e., exposure to five or more different drugs). Results: Only new users of spironolactone co-prescribed with ARBs increased from 2001 to 2008 (P < 0.001). In the 6 months before starting the co-prescriptions 96 to 100% of patients measured serum creatinine (mean 99.3%), sodium (97.3%) and potassium (98.6%). Within 3 months of starting the co-prescriptions 96 to 99% of patients measured serum sodium (mean 97.3%) and potassium (98.6%), but on average only 48% of them (range 43 to 53%) measured serum creatinine, with an increase over time (odds ratio [change in regression per year] = 1.03, 95% CI 1.02-1.05, P < 0.001). At multivariate analysis polypharmacy was found to be the only independent predictor of such creatinine monitoring (P < 0.001). Conclusions: Our results support the need for greater awareness within the medical community of the potential renal toxicity of the association of spironolactone with ACE-Is and/or ARBs. Adequate short-term monitoring of serum creatinine in all older community-dwelling people who receive such co-prescription is necessary in order to ensure safe usage of these medications

Gender difference in drug use in hospitalized elderly patients

PURPOSE: The aims of this study were to evaluate whether or not there are gender differences in drug use at hospital admission and prescription at discharge and to evaluate the effect of hospitalization on medication patterns in the elderly. METHOD: In-patients aged &gt;65years included in the REPOSI registry during a recruitment period of 3years (2008-2010-2012) were analyzed in order to evaluate drug use at hospital admission and prescription at discharge according to gender. RESULTS: A total of 3473 patients, 52% women and 48% men, were considered. Polypharmacy (&gt;5 drugs) is more frequent in men both at hospital admission and discharge. At hospital discharge, the number of prescriptions increased in both sexes at all age groups. Neuropsychiatric drugs were significantly more prescribed in women (p&lt;0.0001). At admission men were more likely to be on antiplatelets (41.7% vs 36.7%; p=0.0029), ACE-inhibitors (28.7% vs 24.7%; p=0.0072) and statins (22.9% vs 18.3%; p=0.0008). At discharge, antiplatelets (43.7% vs 37.3%; p=0.0003) and statins (25,2% vs 19.6%; p&lt;0.0001) continued to be prescribed more often in men, while women were given beta-blockers more often than men (21.8% vs 18.9%; p=0.0340). Proton pump inhibitors were the most prescribed drugs regardless of gender. At discharge, the medication pattern did not change according to gender. CONCLUSION: Our study showed a gender difference in overall medications pattern in the hospitalized elderly. Hospitalization, while increasing the number of prescriptions, did not change drug distribution by sex

Antipsychotics prescription and cerebrovascular events in Italian older persons

Meta-analyses have found conflicting evidence on the link between antipsychotics and cerebrovascular events (CVEs). The primary aim of this study was to evaluate the association between any antipsychotic prescription and CVEs in Italian elderly; second, to compare the effect of typical and atypical antipsychotics on CVEs; and, third, to investigate the effect of antipsychotics on CVEs in the subgroup of persons co-prescribed with acetilcholinesterase inhibitors (AChEI). Administrative claims from community-dwelling people aged 65 to 94 years living in Northern Italy were analysed using a retrospective case-control design, from 2003 to 2005. The primary outcome measure was a hospital discharge diagnosis of CVEs during 2005. Four age-, gender-, and local health unit-matched controls were identified for each case. Antihypertensive drugs, anticoagulants, platelet inhibitors, antidiabetics, lowering lipid drugs and AChEI were used as covariates in conditional logistic regression models testing the odds ratio for CVEs due to antipsychotics use. 3855 cases of CVEs were identified and matched with 15420 controls. In multi-adjusted models, the association of any antipsychotics, typical or atypical with CVEs was not significant. When antipsychotics were categorized according to number of boxes prescribed during the observational period, being prescribed with at least 19 boxes of typical antipsychotics was significantly associated with CVEs (OR=2.4;95%CI=1.08-5.5). An interaction was found between any antipsychotic and AChEI co-prescription on CVEs (OR=0.46;95%CI=0.23-0.92). In conclusions, only typical antipsychotics were associated with an increased odd of CVEs but the association was duration-dependent. Persons prescribed simultaneously with AChEI and antipsychotics may be at a lower risk of CVEs