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Anticholinergic and Sedative Medication Use in Older University of Groningen Anticholinergic and sedative medication use in older community-dwelling people van der Meer, Helene G; Taxis, Katja; Teichert, Martina; Griens, Fabiënne; Pont, Lisa G; Wouters, Hans Published in: Pharmacoepidemiology and Drug Safety DOI: 10.1002/pds.4698 IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it. Please check the document version below. Document Version Publisher's PDF, also known as Version of record Publication date: 2019 Link to publication in University of Groningen/UMCG research database Citation for published version (APA): van der Meer, H. G., Taxis, K., Teichert, M., Griens, F., Pont, L. G., & Wouters, H. (2019). Anticholinergic and sedative medication use in older community-dwelling people: A national population study in the Netherlands. Pharmacoepidemiology and Drug Safety, 28(3), 315-321. https://doi.org/10.1002/pds.4698 Copyright Other than for strictly personal use, it is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), unless the work is under an open content license (like Creative Commons). Take-down policy If you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediately and investigate your claim. Downloaded from the University of Groningen/UMCG research database (Pure): http://www.rug.nl/research/portal. For technical reasons the number of authors shown on this cover page is limited to 10 maximum. Download date: 29-04-2019 Received: 16 July 2018 Revised: 18 September 2018 Accepted: 16 October 2018 DOI: 10.1002/pds.4698 ORIGINAL REPORT Anticholinergic and sedative medication use in older community‐dwelling people: A national population study in the Netherlands Helene G. van der Meer1 | Katja Taxis1 | Martina Teichert2 | Fabiënne Griens3 | Lisa G. Pont4 | Hans Wouters1,5 1 PharmacoTherapy, Epidemiology and Economics, Groningen Research Institute of Abstract Pharmacy, University of Groningen, Purpose: To identify the proportion of older adults with a high anticholinergic/sed- Groningen, the Netherlands ative load and to identify patient subgroups based on type of central nervous system 2 Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, (CNS)‐active medication used. Leiden, the Netherlands Methods: A cross‐sectional study of a nationwide sample of patients with anticho- 3 Foundation for Pharmaceutical Statistics, The Hague, the Netherlands linergic/sedative medications dispensed by 1779 community pharmacies in the Neth- 4 Discipline of Pharmacy, Graduate School of erlands (90% of all community pharmacies) in November 2016 was conducted. Health, University of Technology Sydney, Patients aged older than 65 years with a high anticholinergic/sedative load defined Ultimo, Australia 5 Department General Practice and Elderly as having a drug burden index (DBI) greater than 1 were included. Proportion of Care Medicine, University Medical Centre patients with a high anticholinergic/sedative load was calculated by dividing the Groningen, University of Groningen, Groningen, the Netherlands number of individuals in our study population by the 2.4 million older patients using Correspondence medications dispensed from study pharmacies. Patient subgroups based on type of H. G. van der Meer, University of Groningen, CNS‐active medications used were identified with latent class analysis. Groningen Research Institute of Pharmacy, PharmacoTherapy, Epidemiology and Results: Overall, 8.7% (209 472 individuals) of older adults using medications had a Economics, HPC: XB45, Antonius Deusinglaan 1, 9713 AV Groningen, the Netherlands. DBI greater than 1. Latent class analysis identified four patient subgroups (classes) Email: [email protected] based on the following types of CNS‐active medications used: “combined Funding information psycholeptic/psychoanaleptic medication” (class 1, 57.9%), “analgesics” (class 2, Foundation for Pharmaceutical Statistics; Royal Dutch Pharmacists Association 17.9%), “antiepileptic medication” (class 3, 17.8%), and “anti‐Parkinson medication” (class 4, 6.3%). Conclusions: A large proportion of older adults in the Netherlands had a high anti- cholinergic/sedative load. Four distinct subgroups using specific CNS‐active medica- tion were identified. Interventions aiming at reducing the overall anticholinergic/ sedative load should be tailored to these subgroups. KEYWORDS aged, drug burden index, drug utilisation research, hypnotics and sedatives, latent class analysis, muscarinic antagonists, pharmacoepidemiology Prior postings and presentations: Oral presentation at the 34th International Conference on Pharmacoepidemiology & Therapeutic Risk Management, August 22 to 26 2018, in Prague, Czech Republic. -------------------------------------------------------------------------------------------------------------------------------- This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. © 2019 The Authors Pharmacoepidemiology & Drug Safety Published by John Wiley & Sons Ltd Pharmacoepidemiol Drug Saf. 2019;28:315–321. wileyonlinelibrary.com/journal/pds 315 316 VAN DER MEER ET AL. 1 | INTRODUCTION KEY POINTS Despite their adverse effects on physical and cognitive function,1,2 • A large proportion of older community‐dwelling patients anticholinergic and sedative medications are frequently prescribed to in the Netherlands had a high load of anticholinergic/ older patients.3,4 Some medications are deliberately prescribed for sedative medication. their anticholinergic or sedative effect, for example, inhaled anticholin- • According to the type of CNS‐active medications used, ergics for chronic airway diseases or benzodiazepines for insomnia. four distinct patient subgroups with high However, for most medications, the anticholinergic/sedative effect is anticholinergic/sedative loads were identified using a side effect.5 Anticholinergic/sedative medications mostly act on latent class analysis. the central nervous system (CNS) and include psycholeptics, psychoanaleptics, and analgesics.6 So far, most research has focused • Interventions aiming at reducing the cumulative on quantifying the cumulative exposure of multiple anticholinergic/sedative load can be targeted to these anticholinergic/sedative medications in older patients with patient subgroups. polypharmacy.7 Little is known about the prevalence of combinations of multiple anticholinergic/sedative medications resulting in a high DBI was associated with an increased risk of medication harm among load or whether subgroups of these patients based on types of older populations.12 The DBI was calculated using the following for- anticholinergic/sedative medications used can be identified. mula: Latent class analysis (LCA) is a person‐centred approach, which identifies underlying patterns within populations that cannot be D directly measured or observed.8 In a population of older adults having DBI ¼ ∑ ; D þ δ a high anticholinergic/sedative load, LCA has the potential to identify subgroups of patients based on specific medication patterns or types where D = prescribed daily dose and δ = the minimum recommended of anticholinergic/sedative medications used. This is a novel approach daily dose according to Dutch pharmacotherapeutic reference to investigate medication use. In this study, we will firstly determine sources.13,14 the proportion of older adults having a high cumulative All prescription medications dispensed by the pharmacy with mild anticholinergic/sedative load, and secondly, we will perform an LCA or strong anticholinergic and/or sedative (side) effects with a usage to identify subgroups of patients based on the most likely type of date in the study period (1 month) were included in the DBI calcula- CNS‐active medications used. tion. Medications without known prescribed daily dose and prepara- tions for which daily dose could not be determined were excluded from the DBI calculation. These comprised dermatological, gastro 2 | METHODS enteral, nasal, rectal, and vaginal preparations, oral fluids, oral and sublingual sprays, oral drops, parenteral medications and “as needed” | 2.1 Study design and setting medications. Our database did not include data of medications dis- pensed “over the counter”. A cross‐sectional study on a nationwide sample of patients with pre- We included all medications classified as anticholinergic by scriptions for anticholinergic/sedative medications dispensed by com- Duran et al.6 Then, we systematically reviewed all other medications munity pharmacies in the Netherlands in November 2016 was used in the Netherlands and included those with anticholinergic or conducted. Data were provided by the Foundation for Pharmaceutical sedative properties and those with frequently reported sedative side Statistics (Stichting Farmaceutische Kengetallen [SFK]),9 which identi- effects reported in Dutch pharmacotherapeutic reference fied 783 540 older patients aged 65 years and over from 1779 com- sources.13,14 munity pharmacies (90% of total Dutch community pharmacies) Following the formula above, the DBI per medication ranged using at least one anticholinergic/sedative medication in the study between 0 and 1, depending on the prescribed daily dose. If the
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