Anticholinergic deprescribing interventions for reducing risk of cognitive decline or dementia in older adults with and without prior cognitive impairment.

BACKGROUND: Anticholinergics are medications that block the action of acetylcholine in the central or peripheral nervous system. Medications with anticholinergic properties are commonly prescribed to older adults. The cumulative anticholinergic effect of all the medications a person takes is referred to as the anticholinergic burden. A high anticholinergic burden may cause cognitive impairment in people who are otherwise cognitively healthy, or cause further cognitive decline in people with pre-existing cognitive problems. Reducing anticholinergic burden through deprescribing interventions may help to prevent onset of cognitive impairment or slow the rate of cognitive decline. OBJECTIVES: Primary objective • To assess the efficacy and safety of anticholinergic medication reduction interventions for improving cognitive outcomes in cognitively healthy older adults and older adults with pre-existing cognitive issues. Secondary Objectives • To compare the effectiveness of different types of reduction interventions (e.g. pharmacist-led versus general practitioner-led, educational versus audit and feedback) for reducing overall anticholinergic burden. • To establish optimal duration of anticholinergic reduction interventions, sustainability, and lessons learnt for upscaling • To compare results according to differing anticholinergic scales used in medication reduction intervention trials • To assess the efficacy of anticholinergic medication reduction interventions for improving other clinical outcomes, including mortality, quality of life, clinical global impression, physical function, institutionalisation, falls, cardiovascular diseases, and neurobehavioral outcomes. SEARCH METHODS: We searched CENTRAL on 22 December 2022, and we searched MEDLINE, Embase, and three other databases from inception to 1 November 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of interventions that aimed to reduce anticholinergic burden in older people and that investigated cognitive outcomes. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, extracted data, and assessed the risk of bias of included studies. The data were not suitable for meta-analysis, so we summarised them narratively. We used GRADE methods to rate our confidence in the review results. MAIN RESULTS: We included three trials with a total of 299 participants. All three trials were conducted in a cognitively mixed population (some cognitively healthy participants, some participants with dementia). Outcomes were assessed after one to three months. One trial reported significantly improved performance on the Digit Symbol Substitution Test (DSST) in the intervention group (treatment difference 0.70, 95% confidence interval (CI) 0.11 to 1.30), although there was no difference between the groups in the proportion of participants with reduced anticholinergic burden. Two trials successfully reduced anticholinergic burden in the intervention group. Of these, one reported no significant difference between the intervention versus control in terms of their effect on cognitive performance measured by the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) immediate recall (mean between-group difference 0.54, 95% CI -0.91 to 2.05), CERAD delayed recall (mean between-group difference -0.23, 95% CI-0.85 to 0.38), CERAD recognition (mean between-group difference 0.77, 95% CI -0.39 to 1.94), and Mini-Mental State Examination (mean between-group difference 0.39, 95% CI -0.96 to 1.75). The other trial reported a significant correlation between anticholinergic burden and a test of working memory after the intervention (which suggested reducing the burden improved performance), but reported no effect on multiple other cognitive measures. In GRADE terms, the results were of very low certainty. There were no reported between-group differences for any other clinical outcome we investigated. It was not possible to investigate differences according to type of reduction intervention or type of anticholinergic scale, to measure the sustainability of interventions, or to establish lessons learnt for upscaling. No trials investigated safety outcomes. AUTHORS' CONCLUSIONS: There is insufficient evidence to reach any conclusions on the effects of anticholinergic burden reduction interventions on cognitive outcomes in older adults with or without prior cognitive impairment. The evidence from RCTs was of very low certainty so cannot support or refute the hypothesis that actively reducing or stopping prescription of medications with anticholinergic properties can improve cognitive outcomes in older people. There is no evidence from RCTs that anticholinergic burden reduction interventions improve other clinical outcomes such as mortality, quality of life, clinical global impression, physical function, institutionalisation, falls, cardiovascular diseases, or neurobehavioral outcomes. Larger RCTs investigating long-term outcomes are needed. Future RCTs should also investigate potential benefits of anticholinergic reduction interventions in cognitively healthy populations and cognitively impaired populations separately.

Depression, Anxiety, and Stress Among Medical Students During COVID-19 at Sultan Qaboos University in Oman.

Introduction With the spread of COVID-19 around the world, several interventions have been reported to be useful to control disease transmission. However, the impact of the pandemic on the mental health of medical students is underreported in the Arab world. This study aimed to explore the rates of depression, anxiety, and stress among medical students at Sultan Qaboos University (SQU) and to identify the factors associated with a higher risk of these mental disruptions. Method This was a cross-sectional study where medical students were approached to answer an online questionnaire via emails from the administrative affairs in the College of Medicine in SQU from 16/01/2021 to 18/05/2021. A 21-item depression, anxiety, and stress (DASS-21) scale was used as a self-reporting tool to measure the negative feelings of depression, anxiety, and stress. Results Out of 700 students, 184 (26.3%) students responded fully to the study questionnaire. More than half of the participants were females (58.7%, n=108), and the mean (SD) age was 20.31 (1.642). Most students were Omani (93.5%, n=172), and 34.2% (n=63) lived in Muscat. More than half of the students (51.6%) were in phase 2 of the academic years, in which the majority were considered within the cohort ≥2017 (81%, n=149), with a mean (SD) GPA of 2.9 (1.5). Scores from the DASS-21 scale showed that 29.4% vs 27.2% vs 14.7% had extremely severe depression vs anxiety and vs stress. The proportion of students who reported lower GPAs was significantly associated with higher scores of severe-to-extremely-severe depression (P=0.001), anxiety (P=<0.001), and stress (P=0.001). Living in Muscat vs other regions was associated with severe anxiety and stress (P=0.038 and P=0.007, respectively). Conclusion Similar to a few studies in Oman, this study confirms the high rates of depression, anxiety, and stress among medical students during the COVID-19 pandemic. Results may be utilized to alert decision-makers, student academic council, and academic authority to the need to adopt a preventive mental health policy and design guidelines with resilience measures for college students, including prolonged cognitive-behavioral interventions and recovery programs.

Perceptions of Primary Care Providers on Public Health Services in Primary Care in Oman: A Qualitative Study.

Background The integration of public health functions in primary care is not well-defined in the literature. This paper examines the perceptions of healthcare workers on public health services in primary care, as well as the challenges and views on strengthening the integration of public health functions in a primary care setting in Oman. Methodology This qualitative study (employing a face-to-face interview) was conducted in a primary healthcare setting in Muscat from January 1, 2022, to May 31, 2022. This study is based on interpretative phenomenological analysis using purposeful sampling. Participants were interviewed to answer the study questions. The targeted participants included directors and other official personnel, physicians, nurses, pharmacists, nutritionists, health educators, and lab technicians. Verbal consent was obtained from the participants before the interview, and all responses were anonymously audio recorded, transcribed verbatim, and analyzed using thematic analysis. Results A total of 10 primary care providers were interviewed once for 30 minutes over a two-week period. All participants were females apart from one male participant. The study included three physicians, five nurses, one pharmacist, and one nutritionist. All participants had over 10 years of experience as primary care providers at the time of the interview. The main themes were a lack of awareness of public health services in a primary care setting, challenges to practicing public health in a primary care setting, and recommendations to strengthen the integration of public health services in primary care. In general, there were inconsistent views on public health services in a primary care setting, and the interactions between the functions were not clear. Participants reported an absence of clear guidelines, training, and competencies for public health in a primary care setting. Building public health capacities and reforming the health system were highly recommended to integrate public health into primary health care. Conclusions Understanding how public health and primary care interact is crucial to improve population health. Building competencies and supportive health systems are required for the effective integration of public health in primary care settings.

Evaluation of risk factors for unanticipated hospital admission following ambulatory surgery - An observational study.

Context: Unanticipated admissions following ambulatory surgery significantly affect hospital admission and operation room flow. Most of the factors responsible for unanticipated admission following ambulatory surgery were preventable. It is, therefore, crucial to improve patient selection criteria and to identify the risk factors for unanticipated admission during preoperative period. These unanticipated admissions have now been considered as quality care indicator and a target to improve healthcare costs. Aims: To assess the reasons and risk factors for unanticipated hospital admission after ambulatory surgery. Settings and Design: Security Forces Hospital, Riyadh, Kingdom of Saudi Arabia. Methods and Materials: In this case-control study, cases who were re-admitted within 48 hours following ambulatory surgery were included. The convenience sampling was used to identify controls. Data including patients' demographics, type of anesthesia and surgery, any intraoperative or postoperative complications, etc., were extracted. Statistical Analysis Used: Descriptive statistics is used to summarize the study variables. Mean and standard deviation were used for quantitative variables. Percentage and frequencies were used for qualitative variables. Univariate and multivariate logistic regressions were used to assess risk factors for unanticipated hospital admission after ambulatory surgery. Results: There were 153 cases and 147 controls in this study. The study found postoperative pain as the most common reason for re-admission after ambulatory surgery followed by bleeding, fever, and asthma exacerbation. Multivariate logistic regression showed age, BMI more than 40, and presence of respiratory disease as risk factors (P < 0.05). Conclusions: Age, high BMI more than 40, and presence of respiratory disease increase the risk of unanticipated hospital admission after ambulatory surgery.

Anticholinergic burden for prediction of cognitive decline or neuropsychiatric symptoms in older adults with mild cognitive impairment or dementia.

BACKGROUND: Medications with anticholinergic properties are commonly prescribed to older adults with a pre-existing diagnosis of dementia or cognitive impairment. The cumulative anticholinergic effect of all the medications a person takes is referred to as the anticholinergic burden because of its potential to cause adverse effects. It is possible that a high anticholinergic burden may be a risk factor for further cognitive decline or neuropsychiatric disturbances in people with dementia. Neuropsychiatric disturbances are the most frequent complication of dementia that require hospitalisation, accounting for almost half of admissions; hence, identification of modifiable prognostic factors for these outcomes is crucial. There are various scales available to measure anticholinergic burden but agreement between them is often poor. OBJECTIVES: Our primary objective was to assess whether anticholinergic burden, as defined at the level of each individual scale, was a prognostic factor for further cognitive decline or neuropsychiatric disturbances in older adults with pre-existing diagnoses of dementia or cognitive impairment. Our secondary objective was to investigate whether anticholinergic burden was a prognostic factor for other adverse clinical outcomes, including mortality, impaired physical function, and institutionalisation. SEARCH METHODS: We searched these databases from inception to 29 November 2021: MEDLINE OvidSP, Embase OvidSP, PsycINFO OvidSP, CINAHL EBSCOhost, and ISI Web of Science Core Collection on ISI Web of Science. SELECTION CRITERIA: We included prospective and retrospective longitudinal cohort and case-control observational studies, with a minimum of one-month follow-up, which examined the association between an anticholinergic burden measurement scale and the above stated adverse clinical outcomes, in older adults with pre-existing diagnoses of dementia or cognitive impairment.   DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, and undertook data extraction, risk of bias assessment, and GRADE assessment. We summarised risk associations between anticholinergic burden and all clinical outcomes in a narrative fashion. We also evaluated the risk association between anticholinergic burden and mortality using a random-effects meta-analysis.  We established adjusted pooled rates for the anticholinergic cognitive burden (ACB) scale; then, as an exploratory analysis, established pooled rates on the prespecified association across scales.  MAIN RESULTS: We identified 18 studies that met our inclusion criteria (102,684 older adults). Anticholinergic burden was measured using five distinct measurement scales: 12 studies used the ACB scale; 3 studies used the Anticholinergic Risk Scale (ARS); 1 study used the Anticholinergic Drug Scale (ADS); 1 study used the Anticholinergic Effect on Cognition (AEC) Scale; and 2 studies used a list developed by Tune and Egeli.  Risk associations between anticholinergic burden and adverse clinical outcomes were highly heterogenous. Four out of 10 (40%) studies reported a significantly increased risk of greater long-term cognitive decline for participants with an anticholinergic burden compared to participants with no or minimal anticholinergic burden. No studies investigated neuropsychiatric disturbance outcomes. One out of four studies (25%) reported a significant association with reduced physical function for participants with an anticholinergic burden versus participants with no or minimal anticholinergic burden. No study (out of one investigating study) reported a significant association between anticholinergic burden and risk of institutionalisation. Six out of 10 studies (60%) found a significantly increased risk of mortality for those with an anticholinergic burden compared to those with no or minimal anticholinergic burden. Pooled analysis of adjusted mortality hazard ratios (HR) measured anticholinergic burden with the ACB scale, and suggested a significantly increased risk of death for those with a high ACB score relative to those with no or minimal ACB scores (HR 1.153, 95% confidence interval (CI) 1.030 to 1.292; 4 studies, 48,663 participants). An exploratory pooled analysis of adjusted mortality HRs across anticholinergic burden scales also suggested a significantly increased risk of death for those with a high anticholinergic burden (HR 1.102, 95% CI 1.044 to 1.163; 6 studies, 68,381 participants).   Overall GRADE evaluation of results found low- or very low-certainty evidence for all outcomes.  AUTHORS' CONCLUSIONS: There is low-certainty evidence that older adults with dementia or cognitive impairment who have a significant anticholinergic burden may be at increased risk of death. No firm conclusions can be drawn for risk of accelerated cognitive decline, neuropsychiatric disturbances, decline in physical function, or institutionalisation.

Hyperprolactinemia in Adults Treated With Anti-psychotic Drugs Attending Tertiary Hospitals in Oman: An Observational Study.

INTRODUCTION: Hyperprolactinemia is a common side effect associated with the use of anti-psychotic medications. This study aimed at exploring the rate of hyperprolactinemia induced by anti-psychotic drugs in adult patients admitted to Sultan Qaboos University Hospital (SQUH) and Al Masarra hospital (AMH). Additionally, factors associated with higher prolactin levels in anti-psychotic patients were explored. METHODS: Bespoke XL sheets on age, gender, region (place of stay), BMI, diagnosis, type of drugs, dose, symptoms, and prolactin levels were recorded from the existing health information system. All adult patients who were on anti-psychotic medication between January 2016 and June 2019 were included. Patients diagnosed with pre-existing endocrine conditions, pregnant females, and those with high prolactin levels at baseline were excluded. RESULTS: A total of 1103 cases were included in this study of which 34.1% were from the SQUH vs 65.9% from AMH. The mean (SD) age of the study population was 35.6 (12.1), 56.7% were females and 58.7% cases were from Muscat. The common diagnoses were schizophrenia (59.3%) and bipolar affective disorder (14.7%). High prolactin levels existed in 68.3% of the cases from which 59.6% were treated with atypical anti-psychotic drugs. The proportion of cases with high prolactin levels in AMH was significantly different (higher) compared to cases in SQUH (76.9% vs 51.6%, P<0.001). The most common symptoms were painful breasts (55.2%), galactorrhoea (10.5%), amenorrhea (14.3%) and irregular periods (20.0%). Type of drugs used [haloperidol (typical) vs risperidone (atypical) anti-psychotics (P<0.001)], older vs younger age (P=0.03), and presence vs absence of symptoms (P<0.001) were predictors for the high prolactin levels. CONCLUSION: Similar to evidence from the west, results from this study showed a high rate of hyperprolactinemia in adults treated with anti-psychotics. More work is required to standardize anti-psychotic management and monitoring guidelines for psychotic patients across all psychiatric hospitals in Oman.

Risk of General Anesthesia in Pediatric Skin Procedures with Projection on Tumescent Anesthesia.

BACKGROUND: Uses of general anaesthesia in outpatient invasive procedures have increased, especially in dermatology. Being uncooperative, children often require general anaesthesia, since surgical skin operations are mostly painful. AIM: The purpose of this study is to evaluate the safety, significant adverse events, and the complication rates related to general anaesthesia, when used among pediatric population undergoing skin procedures. METHODS: We conducted a first retrospective cohort study of patient chart review during the period from September 1, 2017 through September 2019. All patients admitted for pediatric skin procedures during this period have participated in our study. We reviewed selected charts to document any unexpected admissions, adverse events, or complications. Surgical outcomes and anaesthesia complications were reviewed by three anesthesiologists. We assessed inter-rater reliability. RESULTS: A total of 211 procedures were reported for 211 patients with 19 diagnoses. No adverse events related to anaesthesia were recognized, apart from minor complications noticed in twelve patients. The kappa value range is between 0.78 and 1.00 (95% C.I., 0.46809 to 1.00). CONCLUSION: Dermatologist and pediatricians can safely do necessary procedures under general anaesthesia with the supervision of pediatric-trained anesthesiologists while considering other safety and risk precautions and the pediatric age group.