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Research ArticleOriginal Research

Assessing Risks of Polypharmacy Involving Medications With Anticholinergic Properties

Peter Hanlon, Terence J. Quinn, Katie I. Gallacher, Phyo K. Myint, Bhautesh Dinesh Jani, Barbara I. Nicholl, Richard Lowrie, Roy L. Soiza, Samuel R. Neal, Duncan Lee and Frances S. Mair
The Annals of Family Medicine March 2020, 18 (2) 148-155; DOI: https://doi.org/10.1370/afm.2501
Peter Hanlon
1General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
MSc
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Terence J. Quinn
2Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom
MD
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Katie I. Gallacher
1General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
PhD
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Phyo K. Myint
3Institute of Applied Health Sciences, University of Aberdeen, Foresterhill, Aberdeen, Scotland, United Kingdom
4Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, Scotland, United Kingdom
MD
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Bhautesh Dinesh Jani
1General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
PhD
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Barbara I. Nicholl
1General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
PhD
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Richard Lowrie
5Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, West Glasgow Ambulatory Care Unit, Glasgow, Scotland, United Kingdom
PhD
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Roy L. Soiza
3Institute of Applied Health Sciences, University of Aberdeen, Foresterhill, Aberdeen, Scotland, United Kingdom
4Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, Scotland, United Kingdom
MRCP
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Samuel R. Neal
3Institute of Applied Health Sciences, University of Aberdeen, Foresterhill, Aberdeen, Scotland, United Kingdom
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Duncan Lee
6School of Mathematics and Statistics, University of Glasgow, University Place, Glasgow, Scotland, United Kingdom
PhD
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Frances S. Mair
1General Practice and Primary Care, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
MD
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  • For correspondence: frances.mair@glasgow.ac.uk
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  • Figure 1
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    Figure 1

    Number of participants identified as taking anticholinergic medication, by each scale.

  • Figure 2
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    Figure 2

    Venn diagram of percent of participants scoring ≥1 on any of the 4 most validated scales.

    ACoB = Anticholinergic Cognitive Burden; ADS = Anticholinergic Drug Scale; ARS = Anticholinergic Risk Scale; CrAS = Clinician-rated Anticholinergic Scale.

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    Table 1

    Baseline Characteristics

    VariableScore = 0 on All Scales N = 367,319Score ≥1 on Any Scale N = 135,321
    Age, y, median (IQR)57 (49-62)60 (53-65)
    Missing00
    Sex, No. (%)
     Female198,346 (54)75,120 (55.5)
     Male168,973 (46)60,201 (44.5)
     Missing00
    Townsend score quintile (socioeconomic status), No. (%)
     1 (Least deprived)77,293 (21.1)23,394 (17.3)
     275,738 (20.6)24,381 (18.0)
     374,334 (20.3)26,078 (19.3)
     472,916 (19.9)27,479 (20.3)
     5 (Most deprived)66,602 (18.2)33,798 (25.0)
     Missing436191
    BMI category, No. (%)
     <18.51,975 (0.5)651 (0.5)
     18.5-24.9127,580 (35)29,887 (22.5)
     25.0-29.9159,715 (43.8)54,552 (41.1)
     ≥3074,969 (20.6)47,491 (35.8)
     Missing3,0802,740
    Smoking status, No. (%)
     Never208,977 (57.2)64,624 (48.1)
     Previous120,154 (32.9)52,944 (39.4)
     Current36,210 (9.9)16,779 (12.5)
     Missing1,978974
    Alcohol use, No. (%)
     Never/special occasions61,230 (16.7)37,460 (27.8)
     1-3 times per month39,987 (10.9)15,886 (11.0)
     1-4 times per week187,445 (51.2)57,339 (42.5)
     Daily/almost daily77,572 (21.2)24,218 (18.0)
     Missing1,085418
    Physical activity level, No. (%)
     High43,279 (11.9)6,798 (5.1)
     Medium290,383 (80.0)103,221 (77.9)
     Low11,330 (3.1)7,613 (5.7)
     None17,983 (5.0)14,875 (11.2)
     Missing4,3442,814
    Morbidity count, median (IQR)1 (0-1)2 (1-3)
    Missing1,173672
    Number of regular medications, median (IQR)1 (0-2)4 (3-7)
    Missing8620
    • BMI = body mass index; IQR = interquartile range.

    • Note: Percentages were calculated excluding missing values.

    • View popup
    Table 2

    Hazard Ratios (95% CI) for Anticholinergic Scales, by Outcome

    ScaleMACE/MortalityAll-Cause MortalityMACEFall or FractureDementia/Delirium
    CrAS1.05 (1.03-1.07)1.05 (1.04-1.07)1.03 (1-1.06)1.09 (1.06-1.11)1.23 (1.1-1.36)
    ARS1.05 (1.03-1.08)1.06 (1.04-1.08)1.01 (0.97-1.05)1.06 (1.03-1.1)1.23 (1.07-1.4)
    AAS-r1.06 (1.04-1.08)1.07 (1.05-1.08)1.07 (1.04-1.09)1.09 (1.06-1.12)1.14 (1.02-1.28)
    ALS1.06 (1.04-1.08)1.07 (1.05-1.08)1.04 (1.01-1.07)1.1 (1.07-1.13)1.26 (1.14-1.41)
    AAS1.06 (1.05-1.08)1.07 (1.05-1.09)1.07 (1.05-1.1)1.09 (1.06-1.12)1.24 (1.11-1.37)
    AEC1.07 (1.05-1.1)1.08 (1.06-1.1)1.04 (1-1.08)1.12 (1.09-1.16)1.45 (1.3-1.61)
    m-ARS1.07 (1.06-1.09)1.08 (1.06-1.1)1.02 (0.99-1.06)1.08 (1.05-1.12)1.27 (1.13-1.43)
    AIS1.08 (1.06-1.1)1.09 (1.07-1.11)1.04 (1.01-1.08)1.14 (1.1-1.17)1.38 (1.24-1.54)
    ACoB1.12 (1.1-1.14)1.13 (1.11-1.15)1.17 (1.14-1.2)1.11 (1.08-1.14)1.26 (1.14-1.4)
    ADS1.12 (1.11-1.14)1.13 (1.12-1.15)1.15 (1.12-1.17)1.13 (1.1-1.16)1.29 (1.16-1.42)
    • AAS = Anticholinergic Activity Scale; AAS-r = revised Anticholinergic Activity Scale; ACoB = Anticholinergic Cognitive Burden; ADS = Anticholinergic Drug Scale;

    • AEC = Anticholinergic Effect on Cognition; AIS = Anticholinergic Impregnation Scale; ALS = Anticholinergic Loading Scale; ARS = Anticholinergic Risk Scale; CrAS = Clinician-rated Anticholinergic Scale; MACE = major adverse cardiovascular event; m-ARS = Modified Anticholinergic Risk Scale.

    • Results from Model 3: Adjusted for age, sex, socioeconomic status, body mass index, smoking status, alcohol use, physical activity level, and morbidity count.

Additional Files

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    Supplemental Appendix

    Files in this Data Supplement:

    • Supplemental data: Appendix - PDF file
  • The Article in Brief

    Assessing Risks of Polypharmacy Involving Medications With Anticholinergic Properties

    Frances S. Mair , and colleagues

    Background Many common prescription medications for urinary problems and muscle spasms, as well over- the-counter medications for cold, cough and allergies, share an anticholinergic property. The use of multiple medications in this class can lead to negative cumulative effects referred to as anticholinergic burden. ACB is known to increase the risk for future adverse events like falls, dementia, heart attack, stroke, and death. Guidelines recommend against using anticholinergic medications for geriatric patients, but little is known about their effect on middle-aged patients. A variety of assessment scales are available for doctors and researchers to calculate a patient's risk of ACB. A study of more than 500,000 middle-aged adults, aged 37 to 73 years in the United Kingdom, compared 10 of those scales to assess their accuracy in predicting risk for future adverse events.

    What This Study Found Researchers found that all 10 ACB scales identified individuals at higher risk for heart attack, stroke and death, after adjusting for sociodemographic and baseline health factors. Each scale also had significant predictive accuracy for falls and dementia. While the study showed consistent association between ACB and adverse outcomes, regardless of which scale was used, the populations identified as being at risk varied considerably depending on which scale was used. Less than one in four people detected to be at risk by one scale were also detected by the other three most frequently used scales.

    Implications

    • This variation across scales has implications for clinical practice and research interventions to target anticholinergic burden.
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The Annals of Family Medicine: 18 (2)
The Annals of Family Medicine: 18 (2)
Vol. 18, Issue 2
March/April 2020
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Assessing Risks of Polypharmacy Involving Medications With Anticholinergic Properties
Peter Hanlon, Terence J. Quinn, Katie I. Gallacher, Phyo K. Myint, Bhautesh Dinesh Jani, Barbara I. Nicholl, Richard Lowrie, Roy L. Soiza, Samuel R. Neal, Duncan Lee, Frances S. Mair
The Annals of Family Medicine Mar 2020, 18 (2) 148-155; DOI: 10.1370/afm.2501

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Assessing Risks of Polypharmacy Involving Medications With Anticholinergic Properties
Peter Hanlon, Terence J. Quinn, Katie I. Gallacher, Phyo K. Myint, Bhautesh Dinesh Jani, Barbara I. Nicholl, Richard Lowrie, Roy L. Soiza, Samuel R. Neal, Duncan Lee, Frances S. Mair
The Annals of Family Medicine Mar 2020, 18 (2) 148-155; DOI: 10.1370/afm.2501
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