A systematic review of interventions to reduce anticholinergic burden in older people with dementia in primary care

Abstract

Objective: This systematic review aimed to assess the types and effectiveness of interventions that sought to reduce anticholinergic burden (ACB) in people with dementia (PwD) in primary care. Methods:One trial registry and eight electronic databases were systematically searched to identify eligible English language studies from inception until December 2021. To be eligible for inclusion, studies had to be randomised controlled trials (RCTs) or non-randomised studies (NRS), including controlled before-and-after studies and interrupted time-series studies, of interventions to reduce ACB in PwD aged ≥65 years (either community-dwelling or care home residents). All outcomes were to be considered. Quality was to be assessed using the Cochrane Risk of Bias tool for RCTs and ROBINS-I tool for NRS. If data could not be pooled for meta-analysis, a narrative synthesis was to be conducted. Results:In total, 1880 records were found, with 1594 records remaining after removal of duplicates. Following title/abstract screening, 13 full-text articles were assessed for eligibility. None of these studies met the inclusion criteria for this review. Reasons for exclusion were incorrect study design, ineligible study population, lack of focus on reducing ACB, and studies conducted outside the primary care setting. Conclusions: This 'empty' systematic review highlights the lack of interventions to reduce ACB in PwD within primary care, despite this being highlighted as a priority area for research in recent clinical guidance. Future research should focus on development and testing of interventions to reduce ACB in this patient population through high-quality clinical trials.

Managing drugs with anticholinergic activity

“…There is currently a lack of published studies looking at the development of interventions to reduce anticholinergic burden in older people, despite this being an area of high priority. Future research should focus on developing effective interventions to reduce anticholinergic burden and determining whether these interventions have an effect on the incident of dementia as well as dementia outcomes 38…”

“…Future research should focus on developing effective interventions to reduce anticholinergic burden and determining whether these interventions have an effect on the incident of dementia as well as dementia outcomes. 38 Before prescribing anticholinergic agents, the potential risks involved should be discussed with patients and carers. There are, of course, other considerations when balancing benefits and risks when considering prescribing of anticholinergic medications.…”

Carers' experiences and perspectives of the use of anticholinergic medications in people living with dementia: Analysis of an online discussion forum

“…10 A systematic review found no eligible studies that aimed to reduce ACB among PLWD in primary care. 11 This was an unexpected finding as it is recognised that interventions are needed to reduce ACB and the use of medicines with anticholinergic activity in this population without affecting the management of other conditions for which these medicines are prescribed. 12 There is very limited literature describing the experiences and perspectives of PLWD and their carers about the use of anticholinergic medications in PLWD; a greater appreciation of these perspectives may help researchers and clinicians to better understand PLWD and carers' concerns about the use of these medications and facilitate their more judicious use by clinicians and prescribers.…”

“… 10 A systematic review found no eligible studies that aimed to reduce ACB among PLWD in primary care. 11 This was an unexpected finding as it is recognised that interventions are needed to reduce ACB and the use of medicines with anticholinergic activity in this population without affecting the management of other conditions for which these medicines are prescribed. 12…”

“…A recently published observational study highlighted that higher anticholinergic burden (ACB—the cumulative effect of using multiple medications with anticholinergic properties concomitantly) was associated with significantly higher mortality rates in PLWD in comparison to PLWD who had no ACB 10 . A systematic review found no eligible studies that aimed to reduce ACB among PLWD in primary care 11 . This was an unexpected finding as it is recognised that interventions are needed to reduce ACB and the use of medicines with anticholinergic activity in this population without affecting the management of other conditions for which these medicines are prescribed 12…”