03. Anticholinergic Reductions

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Now, let’s look at a completely different area—the treatment of dementia, which is always challenging. 

Here’s a study from a team of French researchers that produced 2 articles in 2018 showing that if one goes rigorously through the patient’s medication list looking for medications with anticholinergic effects and tries to remove as many of those medications as possible, it lo and behold leads to an improvement in behavioral symptoms in those patients with dementia. The logic kind of makes sense. We know that the mechanism of Alzheimer’s in particular is mediated in the cholinergic system in part, and that procholinergic augmentation can help to some degree in dementia. So, conversely, removing anticholinergic medications appears to have a similar effect. 

Now, this is a huge challenge; this is not easy. I actually have a dot phrase in the medical record system where I can drop in a standard reminder that the treatment of dementia involves nonmedication approaches, and I mention there that I recognize these may already have been tried extensively, even though often that’s really not been the case. So, starting with nonmedication approaches, I think having a list of those at hand is handy. There’s a 2010 review that I’ve listed in the references if you need a standard reference for the nonmedication approaches to the treatment of dementia.

Then, the next step then would be to go through the patient’s medications and look for anything with strong anticholinergic effects. There are a lot of different lists for this. In the American Geriatric literature, there is the Beers Criteria named after Dr. Mark Beers back in 1991, in case you’re wondering where that name came from. The Beers scale from the American Geriatric Society is also in our references here at the Psychopharmacology Institute. I’ve included their 2015 pocket list; their 2018 list is still in review.  

The French team in the process of this work, they lowered the anticholinergic burden by about 20% in two-thirds of the patients who were brought in to this study. They confined their analysis to the subgroup where they were able to do that. So, we’re looking just now at the patients whose anticholinergics were reduced by 20% or more. And in that group, there was a statistically significant improvement in behavioral control and reduction in the occupational disruptiveness score, which was measuring the impact on workload of caregivers. So, important changes occurred.

But in their second paper, they looked at who were the patients who got these benefits. And they described both a floor and a ceiling effect for the intervention. In other words, in patients whose dementia was only mild, there was no impact with this intervention, presumably kind of a floor effect. You can’t just push it down below when you’re already near the floor already. And similarly, for patients with very severe dementia, very near the ceiling of severity of symptoms, there wasn’t much effect there either. They just couldn’t produce much of a change.

So, the Quick Take summary: It probably makes sense to look for anticholinergic medications that might possibly be stopped in all patients with dementia but especially those with moderate symptoms, who might actually experience significant improvement, including in the perceived burden of caretakers, as part of our routine treatment in dementia.

Abstract

Reduction of the Anticholinergic Burden Makes It Possible to Decrease Behavioral and Psychological Symptoms of Dementia

YacineJaïdiM.D., M.Sc., VignonNonnonhou, M.D., Lukshe Kanagaratnam, M.D., Ph.D., Laurie Anne Bertholon, M.D., Sarah Badr, M.D., Vivien Noël, C.P., Jean-LucNovella, M.D., Ph.D., Rachid Mahmoudi, M.D., Ph.D.

Objective: The aim of this study was to evaluate the impact of a reduction of the anticholinergic burden (AB) on the frequency and severity of behavioral and psychological symptoms of dementia (BPSD) and their repercussions on the care team (occupational disruptiveness).

Methods: In this prospective, single-center study in an acute care unit for Alzheimer disease (AD) and related disorders, 125 elderly subjects (mean age: 84.4 years) with dementia presented with BPSD. The reduction of the AB was evaluated by the Anticholinergic Cognitive Burden Scale. BPSD were evaluated with the Neuropsychiatric Inventory–Nursing Home Version (NPI-NH). The effect of the reduction of the AB on the BPSD was studied using logistic regression adjusting for the variables of the comprehensive geriatric assessment.

Results: Seventy-one subjects (56.8%) presenting with probable AD, 32 (25.6%) mixed dementia (AD and vascular), 17 (13.6%) vascular dementia, and 5 (4.0%) Lewy body dementia were included. Reducing the AB by at least 20% enabled a significant decrease in the frequency × severity scores of the NPI-NH (adjusted odds ratio: 3.5; 95% confidence interval: 1.6–7.9) and of the occupational disruptiveness score (adjusted odds ratio: 9.9; 95% confidence interval: 3.6–27.3).

Conclusion: AB reduction in elderly subjects with dementia makes is possible to reduce BPSD and caregiver burden. Recourse to treatments involving an AB must be avoided as much as possible in these patients, and preferential use of nonpharmacologic treatment management plans is encouraged.

Reference

Jaïdi, Y., Nonnonhou, V., Kanagaratnam, L., Bertholon, L. A., Badr, S., Noël, V., Novella, J., & Mahmoudi, R. (2018). Reduction of the anticholinergic burden makes it possible to decrease behavioral and psychological symptoms of dementia. The American Journal of Geriatric Psychiatry, 26(3), 280-288.