Anticholinergic Drug Burden and Risk of Incident MCI and Dementia: A Population-based Study.

OBJECTIVE: We investigated whether anticholinergic drug use was related to developing mild cognitive impairment (MCI) or dementia in older adults at the population level. METHODS: We used an Anticholinergic Rating (ACR) scale, Clinical Dementia Rating, APOE genotype, and number of prescription medications. We examined time to incident MCI and incident dementia in a population-based cohort (n=1959). We assessed whether developing MCI or dementia was associated with (1) any anticholinergic drug use, (2) total ACR score, or (3) number of anticholinergic drugs taken. RESULTS: Taking any anticholinergic drug was significantly associated with higher risk of developing MCI; however, higher ACR score or higher number of anticholinergic drugs, compared with lower, were not associated with greater risk of developing MCI. We found no significant relationship between anticholinergic use and developing dementia. The relationship between anticholinergic use and cognitive outcome was not affected by APOE genotype. CONCLUSIONS: Among cognitively normal older adults in a population-based sample, anticholinergic drug use is independently associated with subsequently developing MCI, but not dementia. Thus, anticholinergic drug use may influence risk of MCI that is nonprogressive to dementia and potentially be a modifiable risk factor for MCI.

Trends in the Use of Medications and Supplements to Treat or Prevent Dementia: A Population-based Study.

OBJECTIVE: To examine older adults' use over time of agents to treat or prevent dementia or enhance memory. DESIGN: Longitudinal community study with 10-year annual follow-up (2006-2017). SETTING: Population-based cohort. PARTICIPANTS: A total of 1982 individuals with a mean (SD) age of 77 (7.4) years at baseline. MEASUREMENTS: Demographics, self-report, direct inspection of prescription antidementia drugs and nonprescription supplements, cognitive and functional assessments, Clinical Dementia Rating (CDR®) Dementia Staging Instrument. RESULTS: Supplement use was reported by 27% to 42% of participants over 10 years. Use was associated with younger age, high school or greater education, good to excellent self-reported health, higher memory test scores, and absence of cognitive impairment or dementia (CDR=0). Over the same period, about 2% to 6% of participants took prescription dementia medications over 10 years. Use was associated with lower memory test scores, at least mild cognitive impairment (CDR≥0.5), fair to poor self-rated health, and high school or lesser education. CONCLUSIONS: The use of both prescription drugs and supplements increased over time, except for decreases in ginkgo and vitamin E. Prescription drug use appeared in line with prescribing guidelines. Supplement use was associated with higher education and better self-rated health; it persists despite a lack of supportive evidence.

Factors associated with adherence to medication regimens in older primary care patients: the Steel Valley Seniors Survey.

OBJECTIVE: The aim of this study was to explore associations between 2 specific cognitive domains and aspects of medication management among older primary care patients. METHODS: A sample of patients aged >or=65 years drawn from several small-town primary care practices was carefully characterized by cognitive testing and use of prescription medications. Two primary outcome variables were examined: (1) self-reports of setting up schedules to manage their own medications and (2) overall research assessment of adherence to prescribed medications. Predictor variables included scores on tests of verbal memory (Hopkins Verbal Learning Test) and executive function (Part B of the Trail Making Test); prescription insurance status; number of medications; and dosing frequency, adjusting for age, sex, and level of education. Multiple logistic regression and generalized estimating equation models were used for multivariable analyses. RESULTS: The analytic sample included 343 patients (238 women, 105 men; mean [SD] age, 77.52 [6.71] years). Higher scores on the verbal memory test were independently associated with successfully setting up a medication schedule, after adjusting for covariates (compared with scores in the <10th percentile, odds ratio [OR] for scores between the 10th and 50th percentiles: 5.02 [95% CI, 2.22-11.33; P < 0.001]; OR for scores in the >50th percentile: 6.52 [95% CI, 2.76-15.42; P < 0.001]). Higher scores on the executive function test were associated with treatment adherence (compared with scores in the <10th percentile, OR for scores between the 10th and 50th percentiles: 3.25 [95% CI, 1.13-9.33; P = 0.03]; OR for scores in the >50th percentile: 4.32 [95% CI, 2.76-15.68; P = 0.02]). Compared with using or=5 drugs was also associated with poor adherence (OR: 0.45 [95% CI, 0.21-0.95; P = 0.04]) as measured by research nurses' assessment of adherence. CONCLUSIONS: In this sample of older patients assessed for medication management, independent cognitive processes were associated with the ability to set up a medication schedule and overall adherence to prescriptions. Better verbal memory functioning was strongly and independently associated with setting up a medication schedule, while better executive functioning was strongly and independently associated with being fully adherent to prescription instructions. Deficits in either cognitive ability could result in medication errors due to nonadherence.

Use of lipid-lowering drugs in older adults with and without dementia: a community-based epidemiological study.

OBJECTIVES: To compare the use of lipid-lowering drugs in community-dwelling older adults with and without dementia. DESIGN: Comparison of lipid-lowering drug use by demented cases and nondemented controls based on secondary analysis of data from a longitudinal epidemiologic study. SETTING: Longitudinal study of a largely rural, low- socioeconomic-status, community-based cohort of older persons residing in the mid-Monongahela Valley of South-west Pennsylvania (the Monongahela Valley Independent Elders Survey). PARTICIPANTS: Eight hundred forty-five individuals of mean +/- standard deviation (SD) age of 80.5 +/- 4.6, participating in the fifth biennial wave of data collection. MEASUREMENTS: Demographics; medical history; medication regimen (including examination of prescription bottle labels); self-report of most recent visit to primary care physician (PCP); and standardized clinical assessment to determine presence of dementia, including Clinical Dementia Rating (CDR). RESULTS: One hundred seventy participants (20.1% of total subject cohort) had dementia, with a CDR of 0.5 or greater. Mean ages of demented and nondemented individuals were 83.5 +/- 5.1 and 79.8 +/- 4.2, respectively. Similar proportions, 87.7% and 89.5%, of these groups reported PCP visits in the previous year. Of the total sample, 9.4% (3.5% of the demented and 10.8% of the nondemented) were taking lipid-lowering drugs. After adjustment for age, sex, education, visit with PCP within the past year, and potential confounding clinical and lifestyle variables (self-reported heart disease, stroke or transient ischemic attacks, hypertension, smoking, and alcohol consumption), dementia was associated with a lower likelihood of taking a lipid-lowering drug (odds ratio = 0.39, 95% confidence interval = 0.16-0.95). In post hoc subgroup analyses, similar results were found when restricting lipid-lowering drugs to statins alone but were not statistically significant. Drug use was not associated with severity of dementia (CDR = 0.5 vs CDR >or= 1). CONCLUSIONS: Demented individuals were less likely than their nondemented counterparts to be taking lipid-lowering drugs. This finding could reflect different prescribing patterns by physicians for demented and nondemented patients or a possible protective effect of these drugs against dementia.

Detection and management of cognitive impairment in primary care: The Steel Valley Seniors Survey.

OBJECTIVES: To identify characteristics of older primary care patients who were cognitively impaired and who underwent mental status testing by their physicians. DESIGN: Cross-sectional and retrospective analysis. SETTING: Seven small-town primary care practices. PARTICIPANTS: A total of 1,107 patients with a mean+/-standard deviation age of 76.3+/-6.6, screened using the Mini-Mental State Examination (MMSE); medical records reviewed. MEASUREMENTS: Demographics, MMSE, medical record information. Odds ratios (OR) with 95% confidence intervals (CI), adjusted for age, sex, and education. RESULTS: Thirty-one percent of the sample had MMSE scores of less than 25. Among these patients, physicians documented memory loss in only 23% which was significantly more often than in the higher scoring group (OR=1.9, 95% CI=1.3-2.8), basic activity of daily living (ADL) impairment in 7.9% (OR=2.4, 95% CI=1.3-4.4), instrumental ADL (IADL) impairment in 6.7% (OR=2.2, 95% CI=1.1=4.2), dementia in 12.2% (OR=3.7, 95% CI=2.0-6.8), and prescription of cholinesterase inhibitors in 7.6% (OR=4.4, 95% CI=1.9-10.2). Physicians recorded mental status testing largely in patients with research MMSE scores of 24 to 28, significantly more often when they also documented memory loss (OR=3.8, 95% CI=2.5-5.6) or impaired IADLs (OR=2.7, 95% CI=1.4-5.2), diagnosed dementia (OR=4.9, 95% CI=2.8-8.6), referred to specialists (OR=6.3, 95% CI=2.5-16.2) or social services (OR=3.6, 95% CI=1.8-7.3), or prescribed cholinesterase inhibitors (OR=8.5, 95% CI=4.2-17.5). CONCLUSION: Physicians noted impairment in a minority of impaired patients. They tested mental status in those with documented cognitive and functional difficulties, in very mildly impaired patients, and in those for whom they intervened.

An introductory pharmacy practice experience providing pharmaceutical care to elderly patients.

OBJECTIVE: To develop, integrate, and assess an introductory pharmacy practice experience (IPPE) in providing pharmaceutical care to patients at senior centers (Silver Scripts). DESIGN: First-year pharmacy students learned and practiced the pharmaceutical care process in the classroom to prepare for participation in the Silver Scripts program, in which the students, under faculty mentorship, conducted comprehensive medication reviews for senior citizens attending senior centers in Pittsburgh, Pennsylvania. ASSESSMENT: Students, preceptors, and senior center staff members indicated the experience was positive. Specifically, first-year students felt they gained benefit both from an educational standpoint and in their own personal growth and development, while staff contacts indicated the patients appreciated the interaction with the students. CONCLUSION: The Silver Scripts experience is a model for linking classroom experiences and experiential learning. The cycle of experiencing, reflecting, and learning has provided not only a meaningful experience for our P1 students but also a worthwhile focused review of seniors' medication use. This experience could be used as a model for other colleges and schools of pharmacy and their communities.

Sustained benzodiazepine use in a community sample of older adults.

OBJECTIVES: To identify factors associated with sustained benzodiazepine use in older adults. DESIGN: Twelve-year cohort study. SETTING: Community-based epidemiological survey. PARTICIPANTS: One thousand three hundred forty-two individuals aged 65 and older. MEASUREMENTS: Demographics, medication use, depressive symptoms, sleep complaints, alcohol use, and smoking assessed at 2-year intervals; descriptive analysis to characterize benzodiazepine users and identify factors associated with sustained benzodiazepine use (use at two consecutive waves); and longitudinal lag-time analysis to determine characteristics that predicted sustained use. RESULTS: Initially, 5.5% of men and 9.8% of women were using benzodiazepines. Users were significantly more likely than nonusers to be female and less educated, report more depressive and anxiety symptoms, use more prescription medications, have lower self-rated health, have difficulty maintaining sleep, and be less likely to consume alcohol. Approximately 50%, 44%, and 25% of these users aged 65 to 74, 75 to 84, and 85 and older, respectively, were sustained users at follow-up. Being female, using two or more nonbenzodiazepine prescription medications, and smoking were independently associated with subsequent sustained benzodiazepine use. CONCLUSION: At the population level, women, smokers, and users of at least two prescription drugs have higher probabilities of sustaining benzodiazepine use once started. This information can facilitate risk assessment and counseling of older adults before prescribing benzodiazepines.

Discrepancies in information provided to primary care physicians by patients with and without dementia: the Steel Valley Seniors Survey.

OBJECTIVE: The objective of this study was to examine associations between discrepancies in health information provided to primary care providers and severity of impairment in older patients with and without dementia. METHODS: This study included brief assessment and medical record review of 1,107 patients with a mean (standard deviation) age of 76.3 (6.6) years (range: 65-100 years) in seven small-town primary care practices. In 358 patients, detailed in-home assessment included demographics; dementia by Clinical Dementia Rating (CDR) scale; and frequencies of memory complaints, falls, and inadvertent medication nonadherence determined from medical records and standardized in-home research assessments. Main outcome variables were trends in discrepancies between chart reviews and research assessments. Main explanatory variable was CDR box total scores. RESULTS: Proportions of patients reporting memory complaints and falls, and evidence of inadvertent nonadherence, in the charts and by research assessment increased with CDR. Discrepancies between medical record and research assessment, were also associated with CDR, showing linear trends for memory complaints and inadvertent nonadherence and a quadratic trend for falls. CONCLUSION: Memory complaints, falls, and inadvertent medication nonadherence increase with dementia severity. The levels of discrepancy between information patients provided to their physicians and information they provided in response to detailed, standardized assessments, also varied with dementia severity. Physicians should be alert to the possibility of receiving unreliable health information from even mildly demented patients, whether or not dementia has been detected.

Sedative-hypnotic use of diphenhydramine in a rural, older adult, community-based cohort: effects on cognition.

OBJECTIVE: The authors sought to identify patterns and associations of prescription and over-the-counter sedative-hypnotic use in an older, rural, blue-collar, community-based cohort in southwestern Pennsylvania over 10 years. METHODS: A group of 1,627 individuals age 65 and over were recruited and assessed during 1987-1989 and re-assessed during approximately biennial waves. Data included sleep medications, demographics, depressive symptoms, sleep complaints, and cognitive functioning (Mini-Mental State Exam [MMSE]). RESULTS: At Waves 1 through 5, the mean age of the cohort increased from 73.4 to 80.5 years. Use of prescription sedative-hypnotics (primarily benzodiazepines) increased from 1.8% to 3.1%, and over-the-counter sedative-hypnotic use (primarily diphenhydramine) increased from 0.4% to 7.6%. At Wave 5 (1996-1998), 8.17% of the sample reported using diphenhydramine as a sleep aid. After adjusting for age and sex, diphenhydramine use was associated with higher education and more depressive symptoms, the latter becoming nonsignificant after controlling for initial insomnia. MMSE became significantly associated with diphenhydramine use when 143 subjects with dementia were excluded from the analysis. CONCLUSION: As the cohort aged, prescription sedative-hypnotic use remained relatively stable, whereas over-the-counter sedative use, principally diphenhydramine, increased substantially. The association of this drug with cognitive impairment in persons without dementia highlights its potential for causing adverse reactions in older adults.