Anticholinergic Prescribing in Medicare Part D Beneficiaries Residing in Nursing Homes: Results from a Retrospective Cross-Sectional Analysis of Medicare Data

Abstract

Background Prescribing of medications with anticholinergic properties in older nursing home residents is relatively common, despite an association with increased risk for falls, delirium and other outcomes. Few studies have investigated what factors influence different levels of prescribing of these agents. Objectives The primary objective was to identify factors associated with low- and high-level anticholinergic burden in nursing home residents. A secondary objective was to examine in detail the contribution of different medications to low versus high burden, to aid in determining drugs to target in interventions. Design Retrospective, cross-sectional analysis. Setting National sample of 2009–2010 Medicare Part A and B claims, Part D prescription drug events, and Minimum Data Set (MDS) v2.0 assessments. Participants The cohort included 4730 Medicare beneficiaries age ≥65 with continuous Medicare Parts A, B, and D enrollment, admitted for non-skilled stays ≥14 days between 01/01/2010–09/30/2010. Measurements Anticholinergic burden was defined using the Anticholinergic Cognitive Burden(ACB) scale. Medication scores were summed at the patient-level and categorized as high (score ≥3), low (score 1–2), or none. Baseline predisposing (age, sex, race/ethnicity), enabling (prior year hospital, emergency department, primary care, specialist visits; region; Medicaid/low-income subsidy), and medical need factors (dementia severity, anti-dementia medication, Charlson co-morbidity index [CCI], select comorbidities) were evaluated for association with anticholinergic burden using multinomial logistic regression. Results Overall, 29.6% had high-level anticholinergic burden, and 35.2% had low-level burden. High-level burden was most often (72%) due to one highly anticholinergic medication rather than cumulative effect. In adjusted analyses, factors associated with increased risk of both low and high anticholinergic burden included: comorbidity, antidementia medication, depression, hypertension, and prior year hospitalization. Older age was associated with decreased odds of high anticholinergic burden. Urinary incontinence and prior year specialist visit were associated with increased odds of high anticholinergic burden. Severe and non-severe dementia were associated with decreased odds of low-level burden, but increased odds of high-level burden. Conclusion Almost two-thirds of nursing home patients have some degree of anticholinergic burden. Several medical need variables are significantly associated with increased risk for low-level and high-level anticholinergic burden. Interventions should be developed to optimize prescribing for residents at increased risk of receiving medications with anticholinergic properties. Future study is needed to evaluate the difference in the risk of adverse outcomes associated with various levels of anticholinergic burden.

Temporal Trends in the Use of Anticholinergic Drugs Among Older People Living in Long-Term Care Facilities in Helsinki

“…The most prevalent DAP groups in our study were antipsychotics and antidepressants, which is consistent with previous studies [2,4,22]. Among ARS-defined antidepressants, mirtazapine was mostly responsible for the increase in antidepressant use.…”

“…The use of ARS-defined antipsychotics remained high compared with previous studies [4,18,[32][33][34]. However, some DAP scales do not consider, for example, antipsychotics, such as haloperidol, perphenazine, or risperidone, having anticholinergic properties [14].…”

“…However, there are also controversial results, depending on the study population and the DAP scale used [39]. In an American study in NHs, dementia was negatively associated with low-level anticholinergic burden, but, instead, dementia increased the risk of high-level anticholinergic burden [4].…”

“…According to recent literature, the use of drugs with anticholinergic properties (DAPs) among older people living in long-term care varies between 12 and 77%, depending on various populations and criteria for anticholinergic drugs [1][2][3][4][5]. The use of DAPs is common, despite adverse effects such as dryness of mouth and constipation [6], confusion, and even cognitive decline [7,8].…”

Older Patient and Caregiver Perspectives on Medication Value and Deprescribing: A Qualitative Study

“…P olypharmacy, generally defined as the use of five or more medications, affects up to 35% of communitydwelling older adults and as many as 85% of older nursing home residents, placing them at risk of receiving potentially inappropriate or unnecessary medications. [1][2][3][4][5][6] Polypharmacy and inappropriate medication use in older adults is associated with adverse drug events, increased risk of hospitalization and death, and unnecessary medical expenditures. 2,[7][8][9][10] To combat polypharmacy and reduce older patients' use of inappropriate medications, there is increasing interest in deprescribing at the prescriber, health system, and payer levels.…”