To determine whether anticholinergic burden may predict differently 1-year mortality in older patients discharged from acute care hospitals with or without dependency in basic activities of daily living (BADL).
Prospective observational study.
Setting and participants
Our series consisted of 807 patients aged 65 years or older consecutively discharged from 7 acute care geriatric wards throughout Italy between June 2010 and May 2011.
Overall anticholinergic burden was assessed by the anticholinergic cognitive burden (ACB) score. Dependency was rated by BADL, and dependency in at least 1 BADL was considered as a potential mediator in the analysis. The study outcome was all-cause mortality during 12-months of follow-up.
Patients included in the study were aged 81.0 ± 7.4 years, and 438 (54.3%) were female. During the follow-up period, 177 out of 807 participants (21.9%) died. After adjusting for potential confounders, discharge ACB score = 2 or more was significantly associated with the outcome among patients with dependency in at least 1 BADL [hazard ratio (HR) 2.25 95% confidence (CI) 1.22‒4.14], but not among independent ones (HR 1.06 95% CI 0.50‒2.34). The association was confirmed among dependent patients after adjusting for the number of lost BADL at discharge (HR 2.20 95% CI 1.18‒4.04) or ACB score at 3-month follow-up (HR 2.18 95% CI 1.20‒3.98), as well as when considering ACB score as a continuous variable (HR 1.28 95% CI 1.11‒1.49). The interaction between ACB score at discharge and BADL dependency was highly significant (P < .001).
ACB score at discharge may predict mortality among older patients discharged from an acute care hospital carrying at least 1 BADL dependency. Hospital physicians should be aware that prescribing anticholinergic medications in this population may have negative prognostic implications and they should try to reduce anticholinergic burden at discharge whenever possible.
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- Anticholinergic drug use and negative outcomes among the frail elderly population living in a nursing home.J Am Med Dir Assoc. 2014; 15: 825-829
- Drugs with anticholinergic effects and cognitive impairment, falls and all-cause mortality in older adults: A systematic review and meta-analysis.Br J Clin Pharmacol. 2015; 80: 209-220
- Associations between different measures of anticholinergic drug exposure and Barthel Index in older hospitalized patients.Ther Adv Drug Saf. 2013; 4: 235-245
- Anticholinergic medications in community-dwelling older veterans: Prevalence of anticholinergic symptoms, symptom burden, and adverse drug events.Am J Geriatr Pharmacother. 2006; 4: 42-51
- Total anticholinergic burden and risk of mortality and cardiovascular disease over 10 years in 21,636 middle-aged and older men and women of EPIC-Norfolk prospective population study.Age Ageing. 2015; 44: 219-225
- Measures of anticholinergic drug exposure, serum anticholinergic activity, and all-cause postdischarge mortality in older hospitalized patients with hip fractures.Am J Geriatr Psychiatry. 2013; 21: 785-793
- Anticholinergic medication use and cognitive impairment in the older population: The medical research council cognitive function and ageing study.J Am Geriatr Soc. 2011; 59: 1477-1483
- Anticholinergic medication burden and 5-year Risk of hospitalization and death in nursing home elderly residents with coronary artery disease.J Am Med Dir Assoc. 2016; 17: 1056-1059
- Exposure to anticholinergic and sedative drugs, risk of falls, and mortality: An elderly inpatient, multicenter cohort.J Clin Psychopharmacol. 2014; 34: 565-570
- Anticholinergic drugs and their effects on delirium and mortality in the elderly.Dement Geriatr Cogn Dis Extra. 2011; 1: 43-50
- Anticholinergic drug use and mortality among residents of long-term care facilities: A prospective cohort study.J Clin Pharmacol. 2011; 51: 256-263
- Anticholinergic burden and 1-year mortality among older patients discharged from acute care hospital.Geriatr Gerontol Int. 2018; 18: 705-713
- Geriatric conditions and adverse drug reactions in elderly hospitalized patients.J Am Med Dir Assoc. 2012; 13: 96-99
- Risk factors for adverse drug reactions in older subjects hospitalized in a dedicated dementia unit.Am J Geriatr Psychiatry. 2017; 25: 290-296
- Pattern of medication use among older inpatients in seven hospitals in Italy: Results from the CRiteria to assess Appropriate Medication use among Elderly complex patients (CRIME) project.Curr Drug Safety. 2013; 8: 98-103
- Drug data coding and analysis in epidemiologic studies.Eur J Epidemiol. 1994; 10: 405-411
- Impact of anticholinergics on the aging brain: A review and practical application.Aging Health. 2008; 4: 311-320
- Use of anticholinergics and the risk of cognitive impairment in an African American population.Neurology. 2010; 75: 152-159
- Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychosocial function.JAMA. 1963; 185: 914-919
- “Mini-Mental State.” A practical method for grading the cognitive state of patients for the clinician.J Psychiatr Res. 1975; 12: 189-198
- Validation of the geriatric depression scale–short Form among inpatients.J Clin Psychol. 1994; 50: 256-260
- Anticholinergic side-effects of drugs in elderly people.J R Soc Med. 2000; 93: 457-462
- Anticholinergic drugs and negative outcomes in the older population: From biological plausibility to clinical evidence.Aging Clin Exp Res. 2016; 28: 25-35
- Age-related pharmacokinetic and pharmacodynamic changes and related risk of adverse drug reactions.Curr Med Chem. 2010; 17: 571-584
- Sensitivity to antipsychotic drugs in older adults.Curr Psychiatry Rep. 2010; 12: 28-33
- The non-neuronal cholinergic system of human skin.Horm Metab Res. 2007; 39: 125-135
- Role of muscarinic receptors in the regulation of immune and inflammatory responses.J Neuroimmunol. 2008; 194: 83-88
- Anticholinergic drugs and physical function among frail elderly population.Clin Pharmacol Ther. 2007; 81: 235-241
- 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: Results from the REPOSI study.Drugs Aging. 2013; 30: 103-112
- All-cause 1-, 5-, and 10-year mortality in elderly people according to activities of daily living stage.J Am Geriatr Soc. 2012; 60: 485-492
- Multimorbidity, disability, and mortality in community-dwelling older adults.Can Fam Phys. 2014; 60: e272-e280
- Measuring prognosis and case mix in hospitalized elders. The importance of functional status.J Gen Intern Med. 1997; 12: 203-208
- Development and validation of a prognostic index for 1-year mortality in older adults after hospitalization.JAMA. 2001; 285: 2987-2994
- Sarcopenia is associated with incident disability, institutionalization, and mortality in community-dwelling older men: The Concord Health and Ageing in Men Project.J Am Med Dir Assoc. 2015; 16: 607-613
- Use of a frailty index to identify potentially inappropriate prescribing and adverse drug reaction risks in older patients.Age Ageing. 2016; 45: 115-120
- Anticholinergic burden is associated with recurrent and injurious falls in older individuals.Maturitas. 2016; 84: 32-37
- Usual gait speed independently predicts mortality in very old people: A population-based study.J Am Med Dir Assoc. 2013; 14: 529.e521-529.e526
- Dizziness and death: An imbalance in mortality.Laryngoscope. 2016; 126: 2134-2136
- Cognitive impairment and mortality among nonagenarians: The Danish 1905 cohort survey.Dement Geriatr Cogn Disord. 2002; 13: 156-163
- The effect of cognitive impairment on the predictive value of multimorbidity for the increase in disability in the oldest old: The Leiden 85-plus Study.Age Ageing. 2011; 40: 352-357
- Interleukin-6 and C-reactive protein, successful aging, and mortality: The PolSenior study.Immun Ageing. 2016; 13: 21
- Synergistic effects of cognitive impairment on physical disability in all-cause mortality among men aged 80 years and over: Results from longitudinal older veterans study.Plos One. 2017; 12: e0181741
- Optimizing medication appropriateness in older adults: A randomized clinical interventional trial to decrease anticholinergic burden.Alzheimers Res Ther. 2017; 9: 36
- Reduction of anticholinergic burden in older patients admitted to a multidisciplinary geriatric acute care unit.Eur Geriatr Med. 2017; 8: 492-495
- Health care practitioners' perspectives on deprescribing anticholinergic and sedative medications in older adults.Ann Pharmacother. 2016; 50: 625-636
- Deprescribing anticholinergic and sedative medicines: Protocol for a Feasibility Trial (DEFEAT-polypharmacy) in residential aged care facilities.BMJ Open. 2017; 7: e013800
- Can medication management review reduce anticholinergic burden (ACB) in the elderly? Encouraging results from a theoretical model.Int Psychogeriatr. 2013; 25: 1425-1431
- American geriatrics Society 2015 Updated Beers criteria for potentially inappropriate medication Use in older adults.J Am Geriatr Soc. 2015; 63: 2227-2246
Published online: July 23, 2018
The CRiteria to assess Inappropriate Medication use among Elderly complex patients (CRIME) project was partially supported by a grant from the Italian Ministry of Health (GR-2007-685638).
The authors declare no conflicts of interest.
© 2018 AMDA - The Society for Post-Acute and Long-Term Care Medicine.