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The current anticholinergic risk scales tend to simplify the complexity of pharmacological mechanisms, which is quite challenging in geriatric risk assessment in older populations due to increased biological variation. However, there is no standardised consensus on how to quantify the anticholinergic burden and it is difficult to compare the study results from different methods and studies that have used the same method because different cut-off values for anticholinergic burden have been reported [ 3]. The majority of scales have not considered the multiple actions of medicines on the muscarinic receptor subtypes, the possible synergistic or antagonistic effects of medicines, or possible development of tolerance for anticholinergic medicine effects over time. Moreover, anticholinergic adverse effects are dose-dependent and the relative anticholinergic activities of various medicines are unlikely to be proportional to a 0:1:2:3 ratio. Also, there was no consensus on the definition of an anticholinergic medicine, and both the number and ranking of the anticholinergic drugs listed vary considerably between the scales [ 3, 37]. Some scales considered the impact of different routes of administration when ranking the anticholinergic activity of medicines, while others excluded topical, ophthalmic, otologic and inhaled preparations. Pasina L, Djade CD, Lucca U, Nobili A, Tettamanti M, Franchi C, et al. 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(2):103–12. To our knowledge, this is the first systematic review that compare anticholinergic burden quantified by the anticholinergic risk scales and evaluated associations with adverse outcomes in older people. The cumulative effect of taking multiple medicines with anticholinergic properties termed as anticholinergic burden can adversely impact cognition, physical function and increase the risk of mortality. Expert opinion derived risk scales are routinely used in research and clinical practice to quantify anticholinergic burden. These scales rank the anticholinergic activity of medicines into four categories, ranging from no anticholinergic activity (= 0) to definite/high anticholinergic activity (= 3). The aim of this systematic review was to compare anticholinergic burden quantified by the anticholinergic risk scales and evaluate associations with adverse outcomes in older people. Methods
of adults aged 16 to 24 years had taken a Class A drug in the last year (approximately 274,000); a fall of 37% compared with 7.4% in year ending March 2020 Koyama A, Steinman M, Ensrud K, Hillier TA, Yaffe K. Ten-year trajectory of potentially inappropriate medications in very old women: importance of cognitive status. J Am Geriatr Soc. 2013;61(2):258–63. Huang K-H, Chan Y-F, Shih H-C, Lee C-Y. Relationship between Potentially Inappropriate Anticholinergic Drugs (PIADs) and Adverse Outcomes among Elderly Patients in Taiwan. J Food Drug Anal. 2012;20(4):930–7. Anticholinergic Cognitive Burden Scale (ACB) developed by Boustani et al. [ 24] is based on a systematic literature review of medicines with known anticholinergic activity. The ACB scale included medicines that were likely to have a negative impact on cognition [ 27, 28]. A multi-disciplinary panel assessed individual drugs to have none, possible, or definite anticholinergic properties with a score ranging from 0 to 3. ACB scale reported 88 medicines with known anticholinergic activity. Studies that employed the ACB scale have shown that higher anticholinergic burden predicts cognitive impairment in older people. In addition, the study conducted by Pasina L et al. showed that anticholinergic burden quantified by the ACB scale predicted impairment in physical functioning [ 27]. ADS=Anticholinergic Drug Scale; ABC=Anticholinergic Burden Classification; CrAS=Clinician-rated Anticholinergic Score; ARS=Anticholinergic Risk Scale; ACB=Anticholinergic Cognitive Burden Scale; AAS=Anticholinergic Activity Scale; ACL=Anticholinergic Loading Scale; SAA=Serum Anticholinergic Activity.
Author Contributions
It is important to note that personal characteristics are not necessarily independently related to drug use. For example, the relationship between drug use and marital status may be related to age. Lifestyle characteristics Mintzer J, Burns A. Anticholinergic side-effects of drugs in elderly people. J R Soc Med. 2000;93(9):457–62. Mobility, defined as the ability to move independently in one’s environment, is crucial for independent living and good quality of life [ 3]. Declining mobility in older adults increases their dependence on other people to carry out basic activities of daily living. For example, the older adult or their family might require hiring a home carer or paying for care homes, which would have economic impacts. In countries with a free healthcare system, mobility status is a key determinant for accessing publicly funded healthcare support. Mobility decline in older adults thus has an economic impact on public finance and healthcare needs [ 4]. Mobility is multidimensional, and several tools may be utilised to obtain information about the mobility status of individuals. The methods assess gait, transfer skills, and activities of daily living (ADL) [ 5, 6, 7], among others.
The CSEW covers the population living in households in England and Wales; it does not cover the population living in group residences (for example, care homes or student halls of residence) or other institutions, for example, prisons. for Interdisciplinary Addiction Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany This study provides an updated German addiction medicine expert ranking of the average overall harms as well as harms in specific health and social dimensions of various psychoactive substances, including analgesics. Alcohol was estimated to be among the most harmful addictive substances, along with heroin, cocaine, methamphetamine, GHB, and NPS (i.e., synthetic cannabinoids, cathinones). The elevated risks of alcohol are somewhat discordant with the German narcotic law, similar to most countries. Cannabis and ketamine were ranked in midrange on par with benzodiazepines. Therapeutically used drugs such as non-opioid analgesics, methylphenidate, and opioids were estimated to be on the whole to be the least harmful at present. Such relative safety perception however is certainly subject to change should misuse and abuse patterns change over time ( 45). Data Availability Statement Fox C, Livingston G, Maidment ID, Coulton S, Smithard DG, Boustani M, et al. The impact of anticholinergic burden in Alzheimer's dementia-the LASER-AD study. Age Ageing. 2011;40(6):730–5. Increasing occurrence of new psychoactive substances (NPS), in particular a plethora of synthetic cannabinoids and stimulants (mostly cathinones) ( 12– 14).
Conflict of Interest
UB: conception and design. MSp: analysis of the data. UB and MSp: collection and interpretation of data. UB: drafting the article. All authors: revising it critically for important intellectual content. Conflict of Interest The number of deaths in Scotland where benzodiazepines were implicated in or potentially contributed to the cause of death has increased markedly over the past 3 years, from 191 deaths registered in 2015 to 792 deaths in 2018. Most of this increase is due to ‘street’ benzodiazepines, mainly etizolam. Benzodiazepines were mentioned on the death certificate in 60% of DRDs registered in Northern Ireland in 2018. A systematic literature search was conducted across five electronic databases, EMBASE, CINAHL, PSYCHINFO, Cochrane CENTRAL and MEDLINE, from inception to December 2021, to identify studies on the association of anticholinergic burden with mobility. The search was performed following a strategy that converted concepts in the PECO elements into search terms, focusing on terms most likely to be found in the title and abstracts of the studies. For observational studies, the risk of bias was assessed using the Newcastle Ottawa Scale, and the Cochrane risk of bias tool was used for randomised trials. The GRADE criteria was used to rate confidence in evidence and conclusions. For the meta-analyses, we explored the heterogeneity using the Q test and I 2 test and the publication bias using the funnel plot and Egger’s regression test. The meta-analyses were performed using Jeffreys’s Amazing Statistics Program (JASP). Results Psychotherapy and Psychosomatics, Landschaftsverband Westfalen-Lippe-Hospital Marsberg, Marsberg, Germany
Rudolph JL, Salow MJ, Angelini MC, ET AL (2008). The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med. doi: 10.1001/archinternmed.2007.106. Consequently, the study concluded that there is no standardized tool available for measuring anticholinergic burden accurately. Additionally, cohort studies have consistently shown that a higher anticholinergic burden is associated with adverse effects on the brain, including poorer functional and cognitive outcomes. The results revealed a total of 1,250 records across the three databases. The review identified seven expert-based anticholinergic rating scales that met the inclusion criteria. Among these, one scale rated certain anticholinergic medications as having high anticholinergic activity, one as moderate, and two as low.Subjects in 3 groups; healthy controls (N=211), MCI (N=768) and AD (N = 133) of mean age 70.0±7.0, 75.7±7.6, and 78.0±8.6 years Medicines with anticholinergic properties are frequently prescribed in the older population for various medical conditions [ 1]. The cumulative effect of taking one or more medicines with anticholinergic properties is referred to as anticholinergic burden [ 2]. The majority of medicines commonly prescribed to older people are not routinely recognised as having anticholinergic activity and empirically physicians prescribe these medicines based on their anticipated therapeutic benefits overlooking the risk of cumulative anticholinergic burden [ 3].
The specialist physicians had worked for a median of 15 years (cohort 1) and 16.5 years (cohort 2) in the tertiary care of patients with SUD. Approximately three out of four participants worked in acute care hospitals, with the remainder working in rehabilitation clinics ( Table 1). Average Overall HarmIncreasing availability of highly potent cannabis products with increased risk for psychosis and addiction ( 11, 13, 16, 17). Points in rating scale represents, 0=no anticholinergic activity, 1=mild anticholinergic activity, 2=moderate anticholinergic activity, and 3=severe anticholinergic activity. The definition of any drug has changed over time. For more detailed descriptions on what drugs are included in each year, see Section 1 of the accompanying dataset. New psychoactive substances Methadone was assessed as less harmful than standard opioid analgesics, which viewpoint might be biased by addiction medicine physicians' conception of methadone primarily as a standard opioid dependence maintenance treatment, which in this context has been repeatedly shown to reduce morbidity and mortality ( 15). In the context of illicit use and abuse, methadone's harms (e.g., apneic and torsades-de-pointe deaths, addiction, and diversion) are obviously considerably higher than those of several other drugs ranked above it. This exposes a major limitation of drug harm-ranking studies based upon subjective assessments as they may not allow for clear differentiation between the harms of a drug with therapeutic indication in a medical context vs. illicit use/misuse outside of that context. These discrepancies in ranking of analgesics among other agents suggest that perhaps raters' experience in pain medicine should have been surveyed as well. Kersten H, Molden E, Tolo IK, Skovlund E, Engedal K, Wyller TB. Cognitive effects of reducing anticholinergic drug burden in a frail elderly population: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2013;68(3):271–8.
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