Anticholinergics
Clarissa Chan, PharmD
A new study published in the Journal of the American College of Clinical Pharmacy from July 2022 confirms that deprescribing anticholinergic medications in older adults—either by discontinuing or reducing the dosing—ultimately allows for a better chance of finding a difference in clinical outcomes. Past studies suggest that these drugs may potentially harm the aging brain.
“We wanted to describe the impact of the intervention using measures presented in epidemiologic studies that drew associations between anticholinergic use and dementia,” said Noll L. Campbell, PharmD, MS, who led the new study and is a faculty member at Purdue College of Pharmacy. “These measures may present an opportunity for clinical targets, barring results of ongoing clinical trials.”
Importance of deprescribing medications
“There’s an overmedication use issue,” said Donna Bartlett, PharmD, associate professor of pharmacy practice at Massachusetts College of Pharmacy and Health Services University in Worcester, MA, who was not involved in the study. “Medications have done their job for a lot of people, but [as] people are living longer into their 80s, 90s, and beyond, their list of medications can be[come] extreme and can eventually cause problems for them.”
Anticholinergic medications are important to monitor because they can cause many adverse effects, like dry eyes, dry mouth, constipation, confusion, weakness, and tachycardia.
“Dry mouth leads to a dry throat, which leads to difficulty swallowing, decreased appetite, and then weight loss and other cascading events that can be problematic for people,” said Bartlett.
Many older adults also may not have awareness of these symptoms because they’ve lost some cognition over time due to compounding effects of anticholinergic medications.
Campbell said anticholinergic medications are associated with several types of adverse effects that can impair quality-of-life in older adults. “One such adverse effect may be cognitive impairment or dementia,” he said. “This has been defined through studies of association, but not causation. Our particular interest is to determine—through deprescribing studies—whether anticholinergics cause cognitive impairment or dementia.”
With reduced kidney and liver function, changes—including absorption, distribution, metabolism, and excretion processes—affect people as they age and can also put them at increased risk of falls from medications they have been taking for decades.
Campbell said finding a mechanism to effectively deprescribe anticholinergics helps measure the impact of these medications.
Pharmacist-centric deprescribing makes a difference
With pharmacist-based deprescribing, Campbell and colleagues decreased the prescription rate of anticholinergics by 83% and overall use of anticholinergics by 70%. They created two models: a face-to-face clinic-based model and a telephone-based model. Although the telephone-based model of reaching out to patients to address concerns over the phone was less effective in reducing exposure of older patients to anticholinergic medications, it was more effective than automated computer or electronic-based alerts.
A number of factors could explain the differences between both models. “One could be the relationship between the ‘deprescribing coordinator’ pharmacist and the patient between the two settings,” said Campbell.
In the specialty clinic, patients interacted with the coordinator in person, he said, which could perhaps allow more direct communication and an opportunity to build trust. The telephone-based approach may not have allowed the same interaction to build trust.
Campbell also speculated that the participants in the clinic-based setting may have been more motivated to deprescribe as they were already invested in their brain health by pursuing care in a brain health specialty clinic.
Patient and prescriber deprescribing barriers
Many relevant barriers to deprescribing exist, including acute illness such as infections that distract from deprescribing opportunities, fears of symptom recurrence, lack of knowledge or prioritization of future harms, lack of awareness of alternatives, little time to discuss the opportunity to deprescribe, poor communication about the patient’s priorities, and cost of alternatives, said Campbell.
Prescribers also don’t have evidence-based guidance for deprescribing medications. While manufacturers provide guidance on prescribing medications and maximum daily dosing, very few include guidance on how to reduce, stop, or switch medications, said Bartlett.
“There’s not really the evidence out there for prescribers to necessarily say, ‘oh, it’s time to take you off of this medicine.’ And if people aren’t complaining, then [prescribers] are not going to proactively take off the medicine,” she said. “So people will say, ‘my doctor told me I’m doing great and to keep doing what I’m doing,’ rather than prescribers reviewing and reducing some of their medicines. This approach is not part of our culture, necessarily.”
Patients are more resistant to deprescribing or changing medications for acute conditions, like anxiety or sleep, in which they feel the effects when medications are not taken. There is less resistance to the deprescribing of medications for chronic asymptomatic conditions like hypertension and hyperlipidemia because patients may not feel a noticeable difference, said Bartlett.
“It really has to be an open communication dialogue centered on the patient’s own goals,” said Bartlett. “Some people want good-quality days and others want to live forever. That’s going to make a difference in how you’re going to work with the patient.”
How pharmacists can help
“Many people think about deprescribing for hospice or end-of-life situations, but we really need to push that back while patients are still ambulatory and vibrant in the community,” said Bartlett. “Do not wait for a fall, accident, injury, hospitalization, or traffic accident. Be proactive and preventive to avoid overmedicating our older adults.”
Pharmacists should look for medications that may not be providing a clinical benefit, medications that may be causing an adverse effect, or multiple medications attempting to treat the same diagnosis, said Campbell. Additionally, if a patient reports that they feel as though they’re using too many medications, they may be open to the dialogue supporting a deprescribing attempt, he said.
“We [at Purdue] teach pharmacists to identify prescribing cascades—when a medication may have been prescribed for a symptom or side effect introduced by another medication,” said Campbell. “Secondly, when multiple medications are used to treat the same symptom, it may be an indicator that one isn’t effective and could be stopped.”
Campbell noted that overactive bladder medications, anticholinergic antidepressants (e.g., tricyclic antidepressants), and skeletal muscle relaxants are the most common offending anticholinergics used in his study.
Educating patients about risks is important to begin with, but rarely sufficient by itself. Alignment with the patient’s goals and preferences as well as communication with prescribers are key elements of success when striving for the best patient outcomes, said Campbell.
Recurrence of symptoms can occur long after stopping a medication and may be more likely if abrupt withdrawal occurs. “To prevent recurrence of symptoms or withdrawal effects, we often take slow approaches to stopping medications,” said Campbell. “Offering patients and other members of the clinical team a positive experience through the deprescribing process goes a long way to support future changes and relationships.” Campbell noted that it’s also important to recognize that not all high-risk medications are harmful in everyone; some can be used safely if supervised and for a short-term period. ■
Helpful resources
■ STEADI, a CDC resource found at www.cdc.gov/steadi/index.html
■ American Geriatrics Society Beers Criteria
■ Frailty scale score calculators
■ Board Certified Geriatric Pharmacist certification
Although guidelines for deprescribing anticholinergics do not yet exist, guidelines for other important medications are available at deprescribing.org.