11/07/2019

Aims of Session

Anticholinergic Burden Project  Explore what Anticholinergic (AC) Burden is

Anna Mould RMN  Look at how AC Burden is measured OPMH Practitioner, MHLT

Non-Medical Prescriber July 2019  Discuss drugs to consider in terms of AC Burden

 Project findings… and what next

Pre-Conference Survey Results: Pre-Conference Survey Results: Have you heard of Anticholinergic How confident are you in your Burden? knowledge?

No Extremely confident (2.7%) (23.5%) Not at all Very confident (2.7%) confident (39.7%) Yes (76.5%) Somewhat confident (23.7%)

Not so confident (31.6%)

Pre-Conference Survey Results: List 5 medications in Anticholinergic What is “Anticholinergic Burden”? category

1 11/07/2019

What is “Anticholinergic Burden”? What is “Anticholinergic Burden”?

 Anticholinergic (AC) drugs are used in many different conditions, such as Parkinson’s disease, depression,  In the brain, nausea and vomiting, COPD and pain is one of the key  “Anticholinergic Burden” is the consequence of neurotransmitters taking multiple medications with anticholinergic involved in learning and potential: memory  It is the cumulative effect of using multiple drugs with  It is the main anticholinergic effects neurotransmitter  The adverse AC effects increase with increasing drug implicated in Alzheimer’s dose. Disease  Multiple low-level AC drugs can add up to the same burden as (or more than) a single high-level AC drug.

What is “Anticholinergic Burden”? Two year longitudinal study by Fox et al (2011) looked at 13000 adults over 65yrs. At baseline, 47% of participants were taking medication with possible anticholinergic properties; 4%, definite properties.  Individuals with cognitive impairment / early dementia are especially vulnerable to the effects of Key findings: AC drugs, with research showing a high AC Burden  20% those taking drugs with total AC Burden score of 4+ had died can lead to an increase in confusion, falls and by end of 2 year study, compared with 7% of those taking no AC mortality. drugs  For every additional AC Burden point, odds of dying increased by 26%  Those taking drugs with combined AC Burden of 5+ scored 4% lower in cognitive function test than those taking no AC drugs  Increased risks of AC drugs shown to be cumulative – based on number of drugs and strength of each drug’s effect.  Those who were older, lower social class, and greater number of health conditions tended to take the most AC drugs.

Measuring AC Burden – Measuring AC Burden Anticholinergic Risk Scale

 There is no single standard AC Burden scale  (ARS; Rudolph et al, 2008) to aid measurement of  500 most prescribed drugs reviewed anticholinergic burden.  Geriatrician and pharmacists

 “..estimating the extent to which an individual patient  http://www.acbcalc.com/ may be at risk of anticholinergic adverse events”  an online tool which  49 drugs rated according to anticholinergic potential calculates AC Burden quickly  Scale 0 (nil potential) to 3 (very strong potential)  Uses drop-down lists for  High ARS scores = adverse anticholinergic effects drugs – CAUTION!

2 11/07/2019

Measuring AC Burden – Measuring AC Burden Anticholinergic Cognitive Burden scale

 ARS modified – mARS (Sumukadas et al, 2014)  (ACB; Boustani et al, 2008)  Inc. newer drugs available in UK  Identifying severity of adverse reactions of AC drugs,  Exc. drugs not available in UK particularly on cognition  Systematic review of medical literature looking at drugs  Medications rated as “moderate-severe risk” on other with known AC effects scales included; those listed in BNF as having  significant anticholinergic properties included 88 drugs, ranked 0-3 based on severity of effect

Measuring AC Burden: Measuring AC Burden Modified Anticholinergic Risk Scale (mARS)

 Gives AC rating for a range of drugs in the following  ARS was found to be more specific than ACB in classes: “capturing medication associated with a higher  degree of cognitive and functional impairment”  Antipsychotics (Pasina et al, 2013)  Nausea &  Urinary antispasmodics  Both scales supported the hypothesis that cumulative  Sedative effects of AC drugs have a negative impact on the  functioning of older adults. Anti-allergics  H2 blockers  Anti-parkinson  “Other”

Drugs to consider… Drugs to consider… Antidepressants Antipsychotics

Drug mARS score Drug mARS score ; 3 ; 3 Sertraline; , Trifluperazine; other 2 TCAs ; 2 Trazadone; ; ; ; 1 Paroxetine; 1 Venlafaxine; Duloxetine; Little or nil AC activity Least anticholinergic Trazadone

3 11/07/2019

Drugs to consider… Drugs to consider… Nausea Urinary anti-spasmodics

Drug mARS score Drug mARS score - 3 Oxybutinin 3 2 Darifenacin; Dosulepine; 2 Metoclopramide 1 Solifenacin; Tolteridone Domperidone Alternative - 1 Mirabegron Alternative (different drug class); assess ongoing need for tx

Drugs to consider… Drugs to consider… Anti-allergics H2 blockers

Drug mARS score Drug mARS score 3 - 3 ; 2 2 Loratidine 1 - 1 PPIs Alternative may be an alternative.

Drugs to consider… Drugs to consider… Parkinson’s medication Others

Drug mARS score Drug mARS score Procyclidine 3 Atropine; Dicyclomine; 3 Amantadine 2 ; Tizanidine Levodopa; Carbidopa; 1 Loperamide; Tiotropium 2 Selegiline; Entacapone; Pseudoephedrine; Pramipexole Baclofen; Propiverine No alternative suggested Methocarbamol; 1 Reboxetine

4 11/07/2019

The Project – The Project – findings so far: Expectations retrospective referral review “Patients with a high mARS score (3+) will have evidence of (increased) cognitive impairment 65 referrals for “cognitive impairment” in 3month and/or increased risk of falls” period (Jan-Mar 2018); 27 referrals did not lead to assessment. A two-part scoping exercise:  45 F; 20 M  A retrospective review of referrals to OPMH, where reason for referral was “cognitive impairment”  Average age = 83yrs  A review of 30 random drug charts from MOPRS Of the 38 pts assessed:  66% had cognitive impairment/dementia noted  Both exercises were to explore whether there was  73% had hx of falls correlation between mARS score, falls and cognitive  Average no. medications prescribed = 7 impairment.  Nearly half scored against mARS

The Project – findings so far: drug chart review

 30 drugs charts reviewed; 15 F, 15 M  Average age = 87yrs  43% had a diagnosis of cognitive impairment/dementia noted  56% had hx falls  Average no. medications prescribed = 7  50% scored against mARS

“Patients with a high mARS score (3+) will have evidence of (increased) cognitive impairment and/or increased risk of falls” Referral review Pt.68 No. patientAge historiesGender reviewed:Cognitive impairment?Falls? No. drugs No. psychotropicmARS score drugs 11 individuals2 76-85 had:F Y Y 2 1 2 - cognitive3 65-75 impairmentF Y identifiedY plus high12 falls risk2 2 13 65-75 F Y Y 15 2 3 - mARS40 86-95 scoreF 2+ Y Y 9 1 2 - no.58 medications76-85 F rangingY fromY 2-15 7 1 3 - from63 76-85 MH persepctiveF Y , all wereY px at least11 one 3 2 psychotropic65 86-95 M drug Y Y 7 2 2

Drug chart review Pt.3 No. of theAge 11 individualsGender Cognitive had: impairment?Falls? No. drugs No. psychotropicmARS score drugs - mARS12 76-85 scoreM 3+ Y 3+ in 12months 8 2 2 - no.17 medications86-95 F rangingY 7-<315 in 12months 5 1 2 23 86-95 F Y 3+ in 12months 12 2 6 26 86-95 F Y <3 in 12months 10 1 2

5 11/07/2019

Case Review Case Review  78yr old lady  Current medication:  History of “recurrent  ATORVASTATIN 10mg nocte  PRIADEL (LITHIUM) MR 400mg “Offending” drugs (mARS OPMH Management plan: depression” nocte  Admitted with reduced  AMITRIPTYLINE 30mg nocte score):  Reduce and stop mobility, “?drug-induced  VENLAFAXINE MR 112.5mg od Parkinsonism” & polypharmacy  AMITRIPTYLINE CHLORPROMAZINE  500mcg tds (mARS=3)  Physical health:  LEVOTHYROXINE 150mcg mane  Reduce and stop  Type 2 diabetes  LANSOPRAZOLE 30mg mane  Tricyclic AMITRIPTYLINE  Peripheral vascular disease  CHLORPROMAZINE 50mg nocte  CHLORPROMAZINE (3)  CKD 3a  BETAHISTINE 8mg tds  Alternative to  MOVICOL 2sachets bd  Antipsychotic  Hypothyroidism SOLIFENACIN can be used  Ureteric stent  INSULIN as directed  VENLAFAXINE (1)  SENNA 15mg nocte from different class of  Overactive bladder  LINAGLIPTIN 5mg od  Antidepressant  Constipation drug, e.g. MIRABEGRON  ASPIRIN 75mg mane  SOLIFENECIN (3)  Recurrent UTIs  SOLIFENECIN 10mg mane  Gastro-Oesophageal Reflux  GAVISCON ADVANCE 5-10mls tds  Antimuscurinic for Disease  COLECALCIFEROL 3200units od unstable bladder  LOPERAMIDE 2mg prn, max bd

Recommendations (PrescQIPP, 2016) Recommendations (PrescQIPP, 2016)

 Identify those taking anticholinergic drugs  Minimise their use where possible  If on medication with mARS score of 2 or 3, or on a range of drugs that add up to a score of 3 or more, should be discontinued or switched to alternative  Review regularly for efficacy/tolerance  Review in older people who have had a fall/at high risk of falls (multifactorial risk assessment)

Recommendations cont. What next?

 In patients with dementia/cognitive impairment:  Teaching session completed with junior pharmacists  Medication review – identify and minimise drugs which may exacerbate cognitive impairment  To raise awareness with junior doctors  If AC induced cognitive impairment suspected, conduct cognitive assessment (MMSE/MOCA) and consider  Trial project to embed measurement of ACB in the patient switching/stopping treatment if confirmed/clinically assessment pathway in PHT, and to assess it’s impact appropriate

 Avoid prescribing anticholinergics with  To publish… Acetylcholinesterase Inhibitors

6 11/07/2019

Shameless plug…

Prescribing for Mental Health (Closed Facebook group)

https://www.facebook.com/group s/283868562285867/ A forum for Non-Medical Prescribers to discuss practice in the diverse field of mental health. We have much experience and skill in our chosen specialties, and this is a great platform to share with fellow NMPs. We have members from across the country, and this is an invitation for you to join us! Engagement and discussion in the forum can be used toward CPD.

References

 Boustani, M. et al, 2008, Impact of anticholinergic drugs on the ageing brain: a review and practical application. Ageing Health; 4(3):11-20  Fox, C., Livingstone, G., Maidment, I.D. et al, 2011, The impact of anticholinergic burden in Alzheimer’s Dementia –the Laser-AD study. Age Ageing; 40; 730-5  Pasina, L. et al, 2013, Association of anticholinergic burden with cognitive and functional status in a cohort of hospitalised elderly: comparison of the Anticholinergic Cognitive Burden Scale and Anticholinergic Risk Scale. Drugs Ageing; 30: 103-112  PrescQIPP, July 2016, “Anticholinergic Drugs”, B140; 2.1 https://www.prescqipp.info/media/1017/b140-anticholinergics-drugs-21.pdf  Rudolph, J. et al, 2008, The Anticholinergic Risk Scale and anticholinergic adverse effects in older persons. Archive Intern Medicine; 168 (5): 508-513  SIGN, (2015), Polypharmacy Guidance http://www.sign.ac.uk/pdf/polypharmacy_guidance.pdf  Sumukadas, D. et al, 2014, Temporal trends in anticholiergic medication prescription in older people: repeated cross-sectional analysis of population prescribing data. Age & Ageing; 42: 515-521

7