Review Paper on Penetrating Brain Injury: Ethical Quandaries in the Trauma Bay and Beyond.

OBJECTIVE: The aim of this review was to review the ethical and multidisciplinary clinical challenges facing trauma surgeons when resuscitating patients presenting with penetrating brain injury (PBI) and multicavitary trauma. BACKGROUND: While there is a significant gap in the literature on managing PBI in patients presenting with multisystem trauma, recent data demonstrate that resuscitation and prognostic features for such patients remains poorly described, with trauma guidelines out of date in this field. METHODS: We reviewed a combination of recent multidisciplinary evidence-informed guidelines for PBI and coupled this with expert opinion from trauma, neurosurgery, neurocritical care, pediatric and transplant surgery, surgical ethics and importantly our community partners. RESULTS: Traditional prognostic signs utilized in traumatic brain injury may not be applicable to PBI with a multidisciplinary team approach suggested on a case-by-case basis. Even with no role for neurosurgical intervention, neurocritical care, and neurointerventional support may be warranted, in parallel to multicavitary operative intervention. Special considerations should be afforded for pediatric PBI. Ethical considerations center on providing the patient with the best chance of survival. Consideration of organ donation should be considered as part of the continuum of patient, proxy and family-centric support and care. Community input is crucial in guiding decision making or protocol establishment on an institutional level. CONCLUSIONS: Support of the patient after multicavitary PBI can be complex and is best addressed in a multidisciplinary fashion with extensive community involvement.

Cohort antler size signals environmental stress in a moderate climate.

Research in northern latitudes confirms that climate teleconnections exert important influences on ungulate fitness, but studies from regions with milder climates are lacking. We explored the influence of the Pacific Decadal Oscillation (PDO), Northern Atlantic Oscillation (NAO), and El Niño-Southern Oscillation (ENSO) on male, 2.5-year-old white-tailed deer (Odocoileus virginianus) antler and body mass in Mississippi, USA, a region with mild winters and warm, humid summers. Explanatory variables were seasonal averages of each climate index extending back to 3 years prior to account for possible maternal and lag effects. Seasonal climate indices from the period of gestation and the first year of life were correlated with deer morphometrics. Reduced antler mass was largely correlated (R2 = 0.52) with PDO values indicating dry conditions during parturition and neonatal development and NAO values indicating warmer than normal winters during gestation and the first year of life. Body mass was less correlated (R2 = 0.16) to climate indices, responding negatively to warmer winter weather during the first winter of life. Climate may promote variable fitness among cohorts through long-term effects on male competition for dominance and breeding access. Because broad-scale climate indices simplify complex weather systems, they may benefit management at larger scales. Although this study compared climate with morphological variables, it is likely that demographic characteristics can likewise be modeled using climate indices. As climate change in this region is projected to include greater variability in summer precipitation, we may see concomitantly greater variability in fitness among cohorts of white-tailed deer.

Rutting and rambling: Movement characteristics reveal partial migration in adult male white-tailed deer at a latitude void of chronic and severe environmental fluctuations.

White-tailed deer (Odocoileus virginianus) are generally considered a home-ranging species, although northern populations may migrate between summer and winter ranges to balance resource requirements with environmental stressors. We evaluated annual home range characteristics of adult bucks (n = 30) fitted with GPS collars from 2017 to 2021 in central Mississippi with time series segmentation and Kernel Density Estimation (KDE) to determine if individuals employed varying movement strategies. We found 67% of bucks displayed a "sedentary" strategy characterized by a single KDE home range polygon with a mean size of 361 ha. The remaining 33% of bucks employed a "mobile" strategy characterized by multiple home range segments with a mean size of 6530 ha. Sedentary bucks went on an average of 5.9 excursions annually while mobile bucks went on 0.8. Excursion timing for both strategies peaked in breeding season and early spring. Mobile buck home ranges were separated by a mean distance of 7.1 km and mean duration in one home range segment before traveling to another was 78 days. Our study provides the first evidence that partial migration may apply to a larger proportion of lower-latitude deer populations than originally thought, though the environmental justification for this partial migration is not clear.

Predicting chronic wasting disease in white-tailed deer at the county scale using machine learning.

Continued spread of chronic wasting disease (CWD) through wild cervid herds negatively impacts populations, erodes wildlife conservation, drains resource dollars, and challenges wildlife management agencies. Risk factors for CWD have been investigated at state scales, but a regional model to predict locations of new infections can guide increasingly efficient surveillance efforts. We predicted CWD incidence by county using CWD surveillance data depicting white-tailed deer (Odocoileus virginianus) in 16 eastern and midwestern US states. We predicted the binary outcome of CWD-status using four machine learning models, utilized five-fold cross-validation and grid search to pinpoint the best model, then compared model predictions against the subsequent year of surveillance data. Cross validation revealed that the Light Boosting Gradient model was the most reliable predictor given the regional data. The predictive model could be helpful for surveillance planning. Predictions of false positives emphasize areas that warrant targeted CWD surveillance because of similar conditions with counties known to harbor CWD. However, disagreements in positives and negatives between the CWD Prediction Web App predictions and the on-the-ground surveillance data one year later underscore the need for state wildlife agency professionals to use a layered modeling approach to ensure robust surveillance planning. The CWD Prediction Web App is at https://cwd-predict.streamlit.app/ .

Comparison of rehabilitation outcomes following vascular-related and traumatic spinal cord injury.

BACKGROUND: Previous studies have noted similar outcomes between vascular-related spinal cord injury (VR-SCI) and those with traumatic SCI (T-SCI), despite significant difference in their demographics and clinical presentation (age, level of injury (LOI), and degree of incompleteness). OBJECTIVES: To review demographic and clinical presentation of VR-SCI and to compare outcomes with a matched group with T-SCI. Design Analysis of 10-year prospective data collection including 30 consecutive patients admitted to an SCI rehabilitation unit with VR-SCI and comparison with 573 patients with T-SCI. Outcomes were further analyzed comparing VR-SCI to T-SCI (n=30), matched for age, LOI, and ASIA (American Spinal Injury Association) Impairment Scale (AIS). SETTING: A level 1 tertiary university trauma center. MAIN OUTCOME MEASURES: Functional independence measure (FIM) score changes from admission to discharge. Secondary outcome measures included admission and discharge FIM scores, FIM efficiency, rehabilitation length of stay (LOS), and discharge disposition. RESULTS: Overall, individuals with VR-SCI were more likely (P<0.0001) to be older (mean age 57.2 vs. 40.0 years) and have paraplegia (87 vs. 48%) than those with T-SCI. Common etiologies for VR-SCI were post-surgical complication (43%), arteriovenous malformation (17%), aortic dissection (13%), and systemic hypotension (13%). Common region of injury and AIS classification in VR-SCI was thoracic (73%) and AIS C (33%). Common SCI-related complications in VR-SCI included neurogenic bowel/bladder (93%), urinary tract infection (73%), pain (67%), pressure ulcers (47%), and spasticity (20%). Matched-group outcome comparisons did not reveal significant differences in FIM change, FIM efficiency, LOS, or disposition between VR-SCI and T-SCI. CONCLUSION: VR-SCI leads to significant disability and is associated with common secondary SCI complications as well as medical co-morbidities. This study notes differing demographic and injury characteristics between VR-SCI and T-SCI groups. However, when matched for these differences, rehabilitation functional outcomes were not significantly different between the two groups.

Posterior cord syndrome: Demographics and rehabilitation outcomes.

Context/Objectives: To describe demographics, clinical characteristics, and functional outcomes of patients with incomplete spinal cord injuries and posterior cord syndrome (PCS).Design: Five-year retrospective case series.Setting: Spinal cord injury (SCI) rehabilitation unit at a Level 1 tertiary university medical center.Participants: 9 patients with incomplete cord injuries diagnosed with PCS admitted to rehabilitation within the past 5 years.Outcome measures: Functional Independence Measure (FIM) motor scores, length of stay (LOS), discharge disposition.Results: Incidence of PCS was 2% with an average age of 62.0 years. The most common etiology for PCS was spinal cord compression from localized tumors (78%). Seven (78%) patients had paraparesis. All patients had an American Spinal Injury Association impairment scale (AIS) classification of AIS D. SCI-related complications most commonly included: neuropathic pain (78%), spasticity (44%), and neurogenic bladder (78%). Average LOS on the rehabilitation unit was 28 days. Average admission and discharge FIM motor scores were significantly improved (P = 0.001) from 41 to 65, respectively. Two-thirds (67%) of patients were able to walk at least 150 feet with a rolling walker prior to discharge. Most (78%) patients were discharged to home. Continence improved from admission to discharge from 22% vs 56% (bladder) and 67% vs 78% (bowel).Conclusions: We can conclude that PCS most often results in paraparesis due to tumor compression. Typical SCI-related medical complications are encountered. These patients often experience significant functional improvements during SCI rehabilitation with the majority also having bladder and bowel continence allowing them to return home at discharge.

Dual lesion spinal cord injury in a polytrauma patient: a case report.

INTRODUCTION: Dual lesion spinal cord injury (SCI) is the presence of two distinct regions of injury to the spinal cord, which can occur simultaneously or as a sequela of initial injury. Dual lesion SCI appears to be a rather rare occurrence with a paucity of cases described. As such, there is limited information available regarding presentation, evaluation, long-term rehabilitation management, and prognostication of these patients. CASE PRESENTATION: Presented is a case of a 25-year-old woman with a gunshot wound injury to the T5 vertebra with associated cord damage, initially classified as T6 ASIA Impairment Scale (AIS) B. A subsequent cervical spinal stroke, in the setting of cord edema, resulted in a motor incomplete cervical SCI. As such, she underwent additional functional decline. DISCUSSION: Patients with dual lesion SCI present with unique challenges in evaluation and management. This case highlights key factors for the acute care and rehabilitation teams to consider when addressing these challenges.

Sexual Harassment during Residency Training: A Cross-Sectional Analysis.

The reality of sexual harassment is unmasking in many fields, and medical trainees constitute a vulnerable and at-risk group. We report the prevalence of sexual harassment among GI, internal medicine, and pediatric residents, with a focus on identifying underlying reasons for lack of victim reporting. A modified previously validated Department of Defense survey on sexual harassment was e-mailed to 261 GI, 132 pediatric, and 271 internal medicine program directors. Three hundred eighty-one residents responded to the survey. Female trainees were more likely to be subject to sexual harassment (83% vs 44%, P <0 .0001). Offensive and/or suggestive jokes and comments were the most common type of harassment experienced. Most residents were unlikely to report the offender (87% females, 93% males). Although 77 per cent of residents believed they would be supported by their program if they reported a sexual harassment event, only 43 per cent were aware of institutional support in place for victims at their program. Although there is a persistently high incidence of harassment in training, the avenues in which to report it are largely unknown and underused. Further research should focus on evidence-based interventions to encourage reporting and to design institutional programs for victims of sexual harassment.

Stop the Bleed: Is Mass Education the Best Approach?

The Stop the Bleed (STB) course teaches trainees prehospital hemorrhage control with a focus on mass education. Identifying populations most likely to benefit can help save on the significant cost and limited resources. In this study, we attempted to identify those populations and performed a cost analysis. Trainees underwent STB education and completed a survey on completion to assess demographics and prior experiences where STB skills could have been useful. Five hundred seventy-one trainees categorized as first responders (14%), students (56%), and the working public (30%) completed the survey. Most trainees found the lecture and simulation helpful, 96 per cent and 98 per cent, respectively. There were significant differences among groups who had previously been in situations where the STB course would have been helpful (88% first responders versus 40% students versus 43% public workers) (P < 0.001). Teaching a class of 10 students costs approximately $455; the cost can be as high as $1246 for a class of 50 students. Most STB trainees found the course helpful. First responders are most likely to be exposed to situations where course information could be helpful. Focusing on specific high-yield groups rather than mass education might be a more efficient approach to STB education.

The use of ABC score in activation of massive transfusion: The yin and the yang.

BACKGROUND: Hemorrhage is the most common cause of early death in trauma patients. Massive transfusion protocols (MTPs) have been designed to accelerate the release of blood products but can result in waste if activated inappropriately. The Assessment of Blood Consumption (ABC) score has become a widely accepted score for MTP activation. In this study, we compared the use of ABC criteria to physician judgment in MTP activation. METHODS: Adult trauma patients treated at University of Louisville Trauma Center from January 2016 to December 2016 were studied. Activation via ABC score was assessed retrospectively from emergency department (ED) data. Location, timing of activation, percent of patients using more than 5 units of packed red blood cells, amount of product waste, factors associated with early activation by physicians, and mortality were analyzed. RESULTS: Three thousand four hundred twenty-one patients were included in this study. Only 33% of the patients who would have had MTP activation based on the ABC criteria used more than 5 units of blood products within 24 hours of admission compared with 65% of the patients in whom clinical judgment was used. Seventy-six percent of all MTP activations from clinical judgment would have been activated by the ABC criteria in the ED. Fifty-five percent of all MTP activations via clinical judgment were activated in the operating room and 41% in the ED. Eighty-one percent of activations that occurred in the operating room by physician judgment could have been activated earlier in the ED if the ABC criteria had been used. However, ABC score can lead to higher potential fresh frozen plasma waste (588 vs. 84 units) compared with physician judgment. CONCLUSIONS: The ABC criteria overestimate need for massive transfusion and can lead to increased product waste compared with physician judgment, but its use leads to earlier MTP activation. Criteria to trigger MT activation should rely on both clinical acumen and validated prediction tools. LEVEL OF EVIDENCE: Prognostic, level III.

Incidence and outcomes of spinal cord injury clinical syndromes.

BACKGROUND/OBJECTIVE: To examine and compare demographics and functional outcomes for individuals with spinal cord injury (SCI) clinical syndromes, including central cord (CCS), Brown-Sequard (BSS), anterior cord (ACS), posterior cord (PCS), cauda equina (CES), and conus medullaris (CMS). DESIGN: Retrospective review. SETTING: Tertiary care, level 1 trauma center inpatient rehabilitation unit. PARTICIPANTS: Eight hundred thirty-nine consecutive admissions with acute SCIs. MAIN OUTCOMES MEASURES: Functional independence measure (FIM), FIM subgroups (motor, self-care, sphincter control), length of stay (LOS), and discharge disposition. RESULTS: One hundred seventy-five patients (20.9%) were diagnosed with SCI clinical syndromes. CCS was the most common (44.0%), followed by CES (25.1%) and BSS (17.1%). Significant differences (P < or = 0.01) were found between groups with regard to age, race, etiology, total admission FIM, motor admission FIM, self-care admission and discharge FIM, and LOS. Statistical analysis between tetraplegic BSS and CCS revealed significant differences (P < or = 0.01) with respect to age (39.7 vs 53.2 years) and a trend toward significance (P < or = 0.05) with regard to self-care admission and discharge FIM. No significant differences (P < or = 0.01) were found when comparing CMS to CES. CONCLUSIONS: SCI clinical syndromes represent a significant proportion of admissions to acute SCI rehabilitation, with CCS presenting most commonly and representing the oldest age group with the lowest admission functional level of all SCI clinical syndromes. Patients with cervical BSS seem to achieve higher functional improvement by discharge compared with patients with CCS. Patients with CMS and CES exhibit similar functional outcomes. Patients with ACS and PCS show functional gains with inpatient rehabilitation, with patients with ACS displaying the longest LOS of the SCI clinical syndromes. These findings have important implications for the overall management and outcome of patients with SCI.

Incidence, etiology, and risk factors for fever following acute spinal cord injury.

OBJECTIVE: To identify the incidence, etiology, and risk factors for fevers in individuals with traumatic spinal cord injury (SCI). DESIGN: A retrospective review of the medical records of consecutive adult traumatic SCI patients over a 2-year period was performed. SETTING: The study was performed at a tertiary care, Level I trauma center. PARTICIPANTS: Consecutive adult traumatic SCI admissions to acute care (n = 48) and rehabilitation (n = 40) were included in the study. MAIN OUTCOME MEASURES: Incidence, etiology, mean maximum temperature elevation, and duration of fevers (temperature >99.9 F) were measured. RESULTS: The incidence of fever was 60.4% and 50% (acute care and rehabilitation, respectively). Total number of fevers was 58 and 66, acute and rehabilitation, respectively. Respiratory and urinary tract were the most common identifiable fever etiologies. Unidentified fever etiologies were numerous in both the acute and rehabilitation groups, representing 66% and 56% of cases, respectively. Significant differences (P < 0.05) were found between identified vs unidentified fever etiology groups for mean maximal temperature (102.5 degrees F vs 101.1 degrees F on acute and 101.5 degrees F vs 100.7 degrees F on rehabilitation), duration of fever (10.3 days vs 2.2 on acute and 2.8 days vs 1.3 on rehabilitation), fevers above 101.4 degrees F (75% vs 29% on acute and 40% vs 8% on rehabilitation), cause of injury (gunshot wound on acute care) and completeness of injury (American Spinal Injury Association classification A on rehabilitation). CONCLUSIONS: This study suggests that fevers occur commonly in patients with SCI, with respiratory and genitourinary system etiologies most commonly identified. Unidentified etiologies were common and were associated with lower temperature elevation and shorter fever duration. Injury etiology and completeness of injury may comprise additional risk factors. These factors should be taken into account when initiating cost-efficient fever workup in individuals with SCI.

Assistive technology and computer adaptations for individuals with spinal cord injury.

Spinal cord injury (SCI) commonly occurs in individuals during important years for formation of vocational goals, resulting in low post-injury employment rates and higher costs to society. Individuals with SCI who are employed have improved quality of life. Assistive technology, often available at modest cost, can help individuals with SCI to compensate for functional limitations, overcome barriers to employability, enhance technical capacities and computer utilization, and improve ability to compete for gainful employment.

Age-related outcomes in persons with spinal cord injury: a summary paper.

Etiology and level of injury often discriminate between age groups for persons with spinal cord injury, complicating the understanding of what role age actually has on outcomes. The age of the patient is sometimes used as a factor in determining the appropriateness of a referral to inpatient rehabilitation. When role of age is unclear or misunderstood, though, the referral and admission decision is subject to discrimination and ageism. This paper presents information that may assist in making more appropriate decisions. By reviewing the results of four studies examining the role of age-at-injury on the outcomes of persons with spinal cord injury, including such factors of functional improvement and discharge disposition, the overall effects of age can better be understood and more appropriate conclusions drawn.

Comparison of medical complications following nontraumatic and traumatic spinal cord injury.

BACKGROUND: Nontraumatic spinal cord injury (NT/SCI) has been shown to represent a significant proportion of individuals admitted for SCI rehabilitation. Although medical complications of patients with traumatic SCI (T/SCI) have been well studied, there is a paucity of literature regarding those with nontraumatic SCI. Our objective was to compare the incidence of secondary SCI medical complications in patients with nontraumatic and traumatic SCI. DESIGN: A 2-year prospective data comparison of 117 patients with SCI admitted to a regional SCI rehabilitation unit and tertiary university medical center was undertaken. NT/SCI was defined as spinal stenosis, tumorous compression, vascular ischemia, and infectious etiologies. METHODS: Outcome measures included secondary SCI medical complications, injury characteristics, demographics, and rehabilitation outcomes. Statistical analyses were conducted between the 38 NT/SCI and 79 T/SCI who met admission criteria for acute inpatient rehabilitation. RESULTS: Statistically significant differences (P<.05) between nontraumatic and traumatic SCI were noted for deep venous thrombosis (7.9% vs 22.8%), pressure ulcers (21.1% vs 41.8%), autonomic dysreflexia (0% vs 24.1%), pneumonia (2.6% vs 26.6%), orthostatic hypotension (5.3% vs 36.7%), spasticity (21.1% vs 44.3%), and wound infections (16% vs 3%). Similar incidences were found for depression (23.7% vs 26.6%), urinary tract infections (52.6% vs 67.1%), heterotopic ossification (2.6% vs 7.6%), pain at admission (55.3% vs 62.0%), and gastrointestinal bleed (2.6% vs 2.5%). In addition, significant differences were noted between NT/SCI and T/SCI for age (55 years vs 39 years), rehabilitation length of stay (26.4 days vs 43.0 days), and neurologically complete injury (5.3% vs 45.6%). CONCLUSION: This study indicates that patients with NT/SCI present with different incidences of secondary SCI medical complications when compared with individuals with T/SCI. These data, along with differences in demographics, clinical presentation, and rehabilitation outcomes, have important implications for the medical, rehabilitation management, and long-term outcome of individuals with NT/SCI.

Spinal stenosis vs traumatic spinal cord injury: a rehabilitation outcome comparison.

OBJECTIVE: Nontraumatic spinal cord injury (NT/SCI), which can occur secondary to spinal stenosis, has been shown to represent a significant proportion of individuals admitted for SCI rehabilitation. The objective of this study was to compare demographics and outcomes of patients with spinal stenosis-induced SCI (SS/SCI) with those with traumatic spinal cord injury (T/SCI) following inpatient rehabilitation. DESIGN: This 7-year prospective review compared 81 patients with SS/SCI and 102 patients with T/SCI admitted to an SCI rehabilitation unit with similar levels and completeness of injury. Main outcome measures included rehabilitation hospital length of stay (LOS), Functional Independence Measure (FIM) scores, FIM change, FIM efficiency, rehabilitation charges, and discharge rates to home. RESULTS: Results indicate that, when compared with the T/SCI, patients with SS/SCI had a significantly (P < .05) higher mean age (64.1 years vs 44.4 years), were more often female (39% vs 20%), and tended to present with paraplegia vs tetraplegia (69% vs 46%) and with motor incomplete SCI vs incomplete SCI (100% vs 49%). When comparing etiologies of SCI within tetraplegic and paraplegic groups, results showed that individuals with tetraplegic SS/SCI had a significantly (P < .05) shorter rehabilitation LOS (25.7 vs 35.9 days), and lower FIM change (24.5 vs 32.5) and FIM efficiency (1.0 vs 1.3); however, no statistical differences were noted for discharge FIM scores and discharge to home rates. Individuals with paraplegic SS/SCI also had significantly lower FIM change (20.2 vs 28.7); however no significant differences were noted for rehabilitation LOS, charges, FIM efficiency, or discharge-to-home rates. CONCLUSIONS: The findings indicate that patients with SS/SCI present with less severe clinical impairments (motor incomplete and paraplegia) in comparison with patients with T/SCI. Clinically similar SS/SCI groups were noted to achieve rates of functional gain and community discharge comparable with T/SCI patients. Although patients with T/SCI achieved greater overall functional improvement, patients with SS/SCI had shorter rehabilitation LOS and lower rehabilitation charges. These findings have important implications for the interdisciplinary rehabilitation process in the overall management and outcome of individuals with NT/SCI.

The Loss Inventory: preliminary reliability and validity data for a new measure of emotional and cognitive responses to disability.

PURPOSE: To examine the utility, reliability and validity of a new scale, The Loss Inventory (LI) for measuring symptoms unique to grief following disablement. METHODS: Prospective survey study in which two self-report measures, the LI and Zung Self-Rating Depression Scale, were administered to 103 hospitalized rehabilitation patients. Correlational analyses, t tests, t score conversions of raw data, and analysis of variance used to determine reliability (internal consistency) of the LI and compare means of scores across several variables. RESULTS: Cronbach's Alpha=0.90 for the LI. The Zung and the LI correlated 0.59 but study subjects were significantly (p<0.001) more likely to score higher on the LI than on the Zung. Certain LI items were significantly more frequently endorsed by depressed patients. Significant gender and ethnic differences were found. CONCLUSIONS: Rehabilitation patients sampled in this study were no more likely to be depressed than most people. Grief symptoms reported following functional losses are similar to those reported by persons who have experienced the death of someone close. The Loss Inventory reliably measures these grief symptoms. Gender and ethnicity affect the manner in which grief symptoms are reported. The LI may improve mental health clinicians' diagnostic accuracy in rehabilitation and medical settings.

The use of medications with known or potential anticholinergic activity in patients with dementia receiving cholinesterase inhibitors.

OBJECTIVES: To assess the prevalence of prescribed medications with anticholinergic activity given concurrently with acetylcholinesterase-inhibitor therapy in long-term care residents with dementia and to recommend dose adjustment or discontinuation of these medications with anticholinergic activity. DESIGN: Prospective case series. SETTING: Long-term care facilities in Indiana. PATIENTS: Geriatric residents in long-term care facilities were included if they were receiving both an agent with anticholinergic activity as determined by radioreceptor assay and an acetylcholinesterase inhibitor. INTERVENTIONS: Recommendations were made to the resident's physician suggesting substitution, dose reduction, or discontinuation of the agent with anticholinergic activity. MAIN OUTCOME MEASURES: The number of residents with a recommended change in their anticholinergic medication regimen as a result of the consultant pharmacist's recommendation. RESULTS: Of the 2,021 long-term care residents evaluated, 498 (25%) were receiving an acetylcholinesterase inhibitor. Of the 498 residents receiving acetylcholinesterase inhibitor therapy, 103 (20.7%) were receiving concurrent medications with anticholinergic activity. The most commonly prescribed medication with anticholinergic activity was furosemide, an agent with "possible" or low anticholinergic effects. One hundred forty-six medications with anticholinergic activity were used in these 103 residents. Overall, adjustments to the agents with anticholinergic activity were completed in 24 (16.4%) cases. The majority of medications prescribed had "possible" anticholinergic activity (62.3%) compared with those prescribed with "definite" anticholinergic activity (37.7%). No medication dose adjustments or discontinuations were frequent, regardless of whether the medication was deemed to have "definite" (29.1%) or "possible" (31.9%) anticholinergic activity. Medication changes or discontinuations occurred in 13 (23.6%) agents with "definite" and 11 (12.1%) agents with "possible" anticholinergic activity. CONCLUSIONS: Medications with anticholinergic activity may interfere with the beneficial effects of acetylcholinesterase inhibitors. Attention should be placed, however, on agents with moderate or strong anticholinergic activity or the use of multiple medications with anticholinergic activity. Health care providers should consider the risk versus benefit of using agents with anticholinergic activity in someone with cognitive impairment receiving an acetylcholinesterase inhibitor.