A comparison of anticholinergic burden in older patients with and without cancer.

Aim: To compare anticholinergic burden (ACB) in older patients with and without cancer and evaluate the effects of ACB on geriatric syndromes. Methods: A total of 291 patients from the geriatric clinic and 301 patients from the oncology clinic were evaluated. ACB <2 was categorized as low ACB and ACB ≥2 was categorized as high ACB. A comprehensive geriatric assessment was performed on patients from the geriatric clinic. Results: ACB scores were significantly higher in patients without cancer compared with those with cancer (p < 0.005). Number of falls and Geriatric Depression Scale 15 scores were higher and Mini-Nutritional Assessment and Barthel/Lawton activities of daily living scores were lower in geriatric patients with high ACB scores compared with those with low ACB scores (p < 0.005). Conclusion: It is crucial to understand the potential effects of ACB for rational drug use and optimum cancer management in older patients with cancer.

Lay abstract The elderly population is increasing rapidly worldwide, and most cancer patients are over the age of 65. In this age group, preexisting medical conditions other than cancer lead to the use of multiple drugs, which is defined as polypharmacy. Additionally, the anticholinergic burden (ACB) of the drugs affects cancer treatment in the elderly. This study investigated the frequency of polypharmacy and ACB in elderly patients with and without cancer and their relationship with geriatric syndromes such as depression, falls, nutritional and cognitive impairments. We found that ACB was higher in older patients without cancer than those with cancer and is related to increased falls, depressive symptoms, and impaired nutritional and functional status in older patients. Given the prevalence of cancer among older adults, it is crucial to understand the potential effects of the ACB for rational drug use and optimum cancer management in older patients with cancer.

Anticholinergic Medication Burden in Pediatric Prolonged Critical Illness: A Potentially Modifiable Risk Factor for Delirium.

OBJECTIVES: It is important to describe and understand the prevalence and risk factors for the syndrome of delirium in critical illness. Since anticholinergic medication may contribute to the development of delirium in the PICU, we have sought to quantify anticholinergic medication exposure in patients with prolonged admission. We have used Anticholinergic Drug Scale scores to quantify the magnitude or extent of this burden. DESIGN: Retrospective cohort study, January 2011 to December 2015. SETTING: Single academic medical center PICU. PATIENTS: Children under 18 years old with a PICU admission of 15 days or longer, requiring mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Daily Anticholinergic Drug Scale scores for the first 15 days of admission, in each of 88 subjects (total of 1,320 PICU days), were collected and assessed in relation to demographic data, severity of illness, and medication use. Median (interquartile range) of daily Anticholinergic Drug Scale score was 5 (interquartile range, 3-7). Anticholinergic Drug Scale score was not associated with age, sex, medical history, presenting Severity of Illness score, PICU length of stay, ventilator hours, or hospital mortality. Medications most frequently associated with high Anticholinergic Drug Scale score were low potency anticholinergic drugs such as morphine, midazolam, vancomycin, steroids, and furosemide, with the exception of ranitidine (Anticholinergic Drug Scale score 2). Patients receiving high doses of midazolam infusion had significantly higher Anticholinergic Drug Scale scores compared with those receiving lower or no midazolam dosing. CONCLUSIONS: A high number of medications with anticholinergic effects are administered to PICU patients receiving prolonged mechanical ventilation. These exposures are much higher than those reported in adult intensive care patients. Since anticholinergic drug exposure is associated with delirium, further study of this exposure in PICU patients is needed.

PLANT POISONING IN THAILAND: A 10-YEAR ANALYSIS FROM RAMATHIBODI POISON CENTER.

Plant poisoning is not uncommon in Thailand. The objective of this study was to determine the incidence, type, clinical manifestations, severity and outcomes of plant poisoned patients in Thailand over a 10-year period. We retrospectively reviewed data from the Ramathibodi Poison Center Toxic Exposure Surveillance System for 2001-2010. A total of 2,901 poisonous plant exposure cases were identified, comprising 3.1% of the 92,392 poison cases recorded during the study period. This was the fifth most common type of poisoning recorded. Children aged < 13 years comprised the largest percent (69.8%) of the cases. The major type of exposure was unintentional ingestion. Ninety-nine types of poisonous plants were recorded as the causative agents among 99.1%of the cases. Gastrointestinal symptoms were reported in 72.0% of cases with Jatropha curcas (physic nut) comprising 54.1% of these. Most patients had only minor signs and symptoms. The mortality rate among the total plant poisoning cases was 0.9%, with 26 deaths. Thirteen deaths occurred in children aged < 13 years. The greatest number of fatalities were due to ingestion of Manihot esculenta (cassava), primarily due to multi-system organ failure. Children aged < 13 years are at the greatest risk for plant poisoning in Thailand; mostly unintentional. Most cases were minor and the mortality rate was low. Jatropha curcas was the most common cause of poisoning and Manihot esculenta was the most common cause of death. Public education is important to minimize these poisonings.

Multiple anticholinergic medication use and risk of hospital admission for confusion or dementia.

OBJECTIVES: To identify the association between use of multiple anticholinergic medications and risk of hospitalization for confusion or dementia. DESIGN: Retrospective cohort study conducted over 2 years between July 2010 and June 2012, using administrative claims data from the Australian Department of Veterans' Affairs. SETTING: Australia. PARTICIPANTS: Australian veterans dispensed at least one moderately or highly anticholinergic medication in the year before study start. MEASUREMENTS: Cumulative anticholinergic use on each day of the study period was determined. The association between hospitalization for confusion or dementia and number of anticholinergic medications used at the time of admission was compared against times during which participants were not taking anticholinergic medications. Sensitivity analyses were undertaken limiting the outcome to admissions for acute confusion and excluding individuals taking antipsychotics. RESULTS: Adjusted results showed a significantly greater risk of hospitalization for confusion or dementia when individuals were taking two or more anticholinergic medications. The adjusted incident rate ratios (IRRs) were 2.58 (95% confidence interval (CI) = 1.91-3.48) for those taking two anticholinergics and 3.87 (95% CI = 1.83-8.21) for those taking three or more. Sensitivity analyses in which participants taking antipsychotic medications were excluded and the outcome was limited to acute confusion also found similar risks for those taking two (IRR 1.82, 95% CI = 1.18-2.80) and three or more (IRR = 3.98 95% CI = 1.50-10.58) anticholinergic medications. CONCLUSION: Taking more anticholinergic medications is associated with greater risk of hospitalization for confusion or dementia. Strategies to reduce anticholinergic medication burden are likely to translate into significant health benefits.

Incidence, predictors, and outcome of intermediate syndrome in cholinergic insecticide poisoning: a prospective observational cohort study.

CONTEXT: Clinical manifestations and outcome of cholinergic insecticide poisoning is well studied. There are limited data on neuroparalytic features, predictors, and impact on mortality of intermediate syndrome. METHODS: Patients admitted with history of insecticide exposure and cholinergic signs in a tertiary care center between April 2011 and March 2012 were followed up till recovery or death. While on standard care, development of intermediate syndrome was noted by neck and proximal muscle weakness, and/or signs of respiratory failure in the absence of cholinergic signs. RESULTS: In 176 patients studied, incidence of intermediate syndrome was 17.6% (n = 31) with mean time of appearance of 44.5 ± 22.1 h after exposure (range 26 h- 5 days). Intermediate syndrome occurred in organophosphorus and carbamate poisoning (38.7% and 41.9%) and lasted for 1-7 days. All patients with intermediate syndrome developed weakness of neck and proximal muscles during the course; neck muscle weakness was the initial feature in majority of patients with respiratory failure (20/26). Age ≥ 45 (RR 2.23, 95% CI 1.14-4.38, p = 0.02), and dimethyl organophosphorus compounds (RR 4.87, 95% CI 1.82-13.04, p = 0.01) were found to be associated with development of intermediate syndrome while multiple gastric lavage was protective (RR 0.44, 95% CI 0.22-0.87, p = 0.001). Receiver operating characteristic curves were plotted for International Program on Chemical Safety Poison Severity Score (IPCS PSS) and Glasgow coma scale (GCS) on admission (AUC/sensitivity/specificity 0.77/0.94/0.6 for IPCS PSS > 2 and 0.64/0.71/0.65 for GCS ≤ 10). Overall mortality was 28.4% (n = 50); 40% (n = 20/50) occurred among intermediate syndrome patients with respiratory failure. CONCLUSION: As with exposure to organophosphorus, carbamate also result in intermediate syndrome; risk may be high with age ≥ 45, admission score of PSS > 2, and GCS ≤ 10. It can be detected early by identifying neck muscle weakness which aids in anticipating respiratory failure. Multiple gastric lavages may be protective; needs larger studies for clarification.