February 10, 2022

Challenges of deprescribing and minimizing use of anticholinergic medications

Noll Campbell quote: 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

Commonly prescribed drug class strongly associated with cognitive impairment in older adults

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., PhD, 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.

About Noll Campbell, PharmD, M.S.

In addition to his role as a research scientist at Regenstrief Institute, Noll Campbell, PharmD, M.S., is an assistant professor of pharmacy practice at the Purdue University College of Pharmacy and an adjunct assistant professor of medicine at IU School of Medicine.

About Malaz Boustani, M.D., MPH

In addition to his role as a research scientist at Regenstrief Institute, Malaz Boustani, M.D., MPH, is the founding director of the Center for Health Innovation and Implementation Science. He is a professor and the Richard M. Fairbanks Chair in Aging Research at Indiana University School of Medicine.

About Regenstrief Institute

Founded in 1969 in Indianapolis, Regenstrief Institute is a local, national and global leader dedicated to a world where better information empowers people to end disease and realize true health. A key research partner to Indiana University, Regenstrief and its research scientists are responsible for a growing number of major healthcare innovations and studies. Examples range from the development of global health information technology standards that enable the use and interoperability of electronic health records to improving patient-physician communications, to creating models of care that inform practice and improve the lives of patients around the globe.

Sam Regenstrief, a nationally successful entrepreneur from Connersville, Indiana, founded the institute with the goal of making healthcare more efficient and accessible for everyone. His vision continues to guide the institute’s research mission.

About Purdue University College of Pharmacy

The mission of the Purdue University College of Pharmacy is to advance scientific discovery and development, maximize global health outcomes through patient care and public service, and educate and train students to become leading pharmacists and scientists. The goal is to transform the practice and science of pharmacy to lead advances in human health.

About IU School of Medicine

IU School of Medicine is the largest medical school in the U.S. and is annually ranked among the top medical schools in the nation by U.S. News & World Report. The school offers high-quality medical education, access to leading medical research and rich campus life in nine Indiana cities, including rural and urban locations consistently recognized for livability.

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