Summary of Challenges of deprescribing and minimizing use of anticholinergic medications
Medications with anticholinergic properties are commonly prescribed to older adults and linked by observational studies to cognitive impairment and other harms. An editorial in Frontiers in Pharmacology by Regenstrief Institute and international colleagues highlights challenges in safely deprescribing these drugs, the need for randomized trials to establish causation, and growing clinician awareness. Ongoing large randomized deprescribing trials aim to clarify risks and guide reductions, and clinicians are urged to review all prescription and over-the-counter medications to assess anticholinergic exposure.
Parts used in theDeprescribing and Minimizing Use of Anticholinergic Medications:
- Anticholinergic medications (general class)
- Observerational studies and research data
- Randomized clinical trials
- Anticholinergic Burden Scale
- Editorial in Frontiers in Pharmacology
- Provider-patient medication review processes
- Deprescribing intervention protocols (multiyear trial)
- Clinical guidelines and deprescribing strategies
Medications with anticholinergic properties have been consistently associated with a wide range of adverse outcomes for older adults including cognitive impairment, yet these drugs continue to be commonly prescribed for depression, urinary incontinence, irritable bowel syndrome and Parkinson’s disease.
In an editorial published in the peer-reviewed journal Frontiers in Pharmacology, co-authors Noll Campbell, PharmD, M.S., and Malaz Boustani, M.D., MPH, of the Regenstrief Institute (U.S) and colleagues Roy Soiza, MBChB, of the University of Aberdeen (UK) and Arduino Mangoni, M.D., Ph.D., of Flinders University (Australia) highlight the complexity of gaining a better understanding of how to safely deprescribe anticholinergic medications given the risks they convey and the significant difficulty encountered across cultures in decreasing their use.
Anticholinergics affect the brain by blocking acetylcholine, a nervous system neurotransmitter that influences memory, alertness and planning skills. These medications are used by approximately one in four older adults each year in the United States.
The editorial authors observe that physician and pharmacist awareness of the dangers of anticholinergic therapy is growing, propelling research on these medications and on opportunities for deprescribing. However, there is currently no simple or reliable way for patients to know if the anticholinergics they use today will convey adverse effects in the future. Nor are there high-quality studies explaining how to identify which current users should stop these medications and what will happen if they do.
“While we at Regenstrief Institute and other researchers throughout the world have identified a strong and consistent link between anticholinergic drugs and cognitive impairment from observational studies, randomized clinical trials represent the only rigorous method to definitively establish a causal relationship between these frequently used drugs and various dementias,” said editorial co-author Dr. Campbell, an expert in deprescribing. “We are nearly mid-way through a large multiyear randomized, controlled anticholinergic deprescribing trial that will help us understand whether these medications have a causal link with cognitive impairment as well as other outcomes associated with deprescribing.”
He adds that “what we learn about how to make changes at both the provider and the patient level for anticholinergics may well be applicable to other high-risk drug classes like benzodiazepines and opioids.”
“Physicians should review with older patients all prescription as well as over-the-counter medications to determine anticholinergic exposure and discuss options that are less harmful to the aging brain,” said Dr. Boustani, a geriatrician and co-author of the editorial. Dr. Boustani is a pioneer in aging brain care research and clinical practice. He and Regenstrief Institute colleagues developed the Anticholinergic Burden Scale.
“Editorial: Deprescribing and Minimizing Use of Anticholinergic Medications” is published in the open access journal Frontiers in Pharmacology.
Source: Challenges of deprescribing and minimizing use of anticholinergic medications
- What are anticholinergic medications associated with in older adults?
They have been consistently associated with a wide range of adverse outcomes including cognitive impairment. - How common is anticholinergic use among older adults in the United States?
Approximately one in four older adults use anticholinergic medications each year in the United States. - Can current evidence definitively prove anticholinergics cause dementia?
No; randomized clinical trials are needed to definitively establish a causal relationship. - What is being done to determine causation between anticholinergics and cognitive decline?
A large multiyear randomized, controlled anticholinergic deprescribing trial is underway to help determine causation and outcomes. - What should physicians do regarding older patients and anticholinergic exposure?
Physicians should review all prescription and over-the-counter medications with older patients to determine anticholinergic exposure and discuss less harmful options. - Is clinician awareness about anticholinergic risks changing?
Yes; physician and pharmacist awareness of the dangers of anticholinergic therapy is growing, propelling research and deprescribing opportunities. - What tool did Regenstrief Institute colleagues develop related to anticholinergics?
They developed the Anticholinergic Burden Scale. - Could deprescribing approaches for anticholinergics apply to other drugs?
Yes; learnings about provider and patient level changes may apply to other high-risk drug classes like benzodiazepines and opioids.
