Elderly patients with adaptive disorder diagnosis in psychogeriatry interconsultation: clinical profile and therapeutic approach.

Adaptive disorder is a frequent diagnosis but poorly studied in the elderly population hospitalized. Despite it is considerate benign and non-subsidiary entity of improvement through pharmacological treatment. It can evolve in a difficult way and the pharmacological treatment is widespread. The use of drugs could be harmful the elderly population with pluripathology and polypharmacy.

Ancianos con trastorno adaptativo en la interconsulta de psicogeriatría: perfil clínico y abordaje terapéutico / Elderly patients with adaptive disorder diagnosis in psychogeriatry interconsultation: clinical profile and therapeutic approach

Introducción. El trastorno adaptativo es una entidad clínica frecuente pero muy escasamente estudiada en población anciana hospitalizada por causas somáticas. A pesar de su doble consideración como entidad benigna y no subsidiaria de mejoría mediante tratamiento farmacológico, su evolución puede ser tórpida y el empleo de psicofármacos está muy extendido. En una población anciana con pluripatología y polifarmacia, el uso de fármacos podría ser nocivo. Métodos. Estudio descriptivo retrospectivo de 123 pacientes con diagnóstico de trastorno adaptativo atendidos por la Interconsulta de Psicogeriatría de un hospital de tercer nivelen los años 2016 y 2017. Se valoran antecedentes, manejo al diagnóstico y durante el seguimiento posterior hasta el año. Resultados. Un 75,9% del total de pacientes recibieron tratamiento farmacológico al diagnóstico de trastorno adaptativo, mientras que solo un 22,8% son derivados a Psicología clínica. Al alta, solo 50% de los pacientes son derivados a Salud Mental. El 13,8% de los pacientes fueron exitus antes del alta de hospitalización. El 72,6% precisaron durante el año de seguimiento un nuevo reingreso hospitalario, y de este grupo, el 16,6% precisó escalada en la dosis de psicofármacos. Conclusiones. Además de aportar datos sobre el manejo clínico de este perfil complejo y frecuente de pacientes, este trabajo sirve como punto de partida para futuras líneas de investigación que puedan aportar luz sobre un aspecto muy pobremente reflejado en la bibliografía médica actual a pesar del envejecimiento inexorable de la población. (AU)

Introduction. Adaptive disorder is a frequent diagnosisbut poorly studied in the elderly population hospitalized. Despite it is considerate benign and non-subsidiary entityof improvement through pharmacological treatment. It canevolve in a difficult way and the pharmacological treatmentis widespread. The use of drugs could be harmful the elderly population with pluripathology and polypharmacy. Methods. A retrospective descriptive study, total of 123patients diagnosed with adaptive disorder and attended bythe Psychogeriatric Liaison in a third-level hospital between2016 and 2017. Medical history, management at diagnosis andfollow-up until one year after discharge were collected on. Results. At the diagnosis of adaptative disorder the75.9% of all patients received pharmacological treatment, while only 22.8% were referred to psychology. Only 50% ofpatients were referred to mental health upon discharge. The13.8% of patients died before discharge from hospital. During the follow-up year, the 72.6% required a new hospital admission. And of this group, the 16.6% required increasingthe dose of drugs. Conclusions. This study provides data on the clinical management of this complicated and frequent profile ofpatients. In addition, this work is a starting point for future lines of research that can shed light on an aspect very poorly reflected in the current medical literature despite the aging of the population. (AU)

Psychogeriatric care in times of COVID. Lessons learned and proposals for similar situations.

The objective is to describe the problems related to outpatient psychogeriatric care in the context of the SARS-CoV-2 pandemic, as well as the proposed and implemented solutions for optimizing care for elderly people with mental disorders during the pandemic, that can also be applied in emerging similar situations in the future.

Atención psicogeriátrica en tiempos de COVID. Lecciones aprendidas y propuestas para situaciones similares / Psychogeriatric care in times of Covid. Lessons learned and proposals for similar situations

Introducción: El objetivo es describir los problemas relacionados con la atención psicogeriátrica ambulatoria en elcontexto de la pandemia SARS-CoV-2, así como las soluciones propuestas e implementadas para optimizar la atencióna las personas mayores con trastornos mentales durante lapandemia, que también pueden aplicarse en situaciones similares emergentes en el futuro.Metodología. Se recogió información sobre prestaciónde asistencia sanitaria y problemas clínicos en la práctica psicogeriátrica durante un año de la pandemia de COVID-19como base para propuestas de actuación por consenso depsiquiatras expertos en psicogeriatría. Entorno: servicios deatención psicogeriátrica ambulatoria en la Comunidad deMadrid.Resultados. Se identificaron ocho temas relacionadoscon las dificultades en la prestación de la atención psicogeriátrica (acceso a los servicios, adherencia al tratamiento, derivaciones y contacto, continuidad de cuidados, aislamiento,residencias de ancianos y pruebas de laboratorio) y se llegóa un acuerdo sobre 14 posibles soluciones. Además, se identificaron 7 problemas clínicos de especial relevancia (duelo,sueño, tratamientos psicofarmacológicos, deterioros físico,cognitivo-conductual y social, y violencia) y se propusieron17 posibles soluciones.Conclusiones. La pandemia de SARS-CoV-2 supone unelevado riesgo vital para la población geriátrica. Medidascomo el confinamiento y la limitación de contactos, ejercenun riesgo directo para la salud mental y un riesgo indirectodebido a las mayores dificultades para acceder a la atenciónpsicogeriátrica. Es necesario detectar estas situaciones e implementar cambios en la manera de proporcionar atención aesta población altamente vulnerable. Proponemos una seriede posibles soluciones a las situaciones problemáticas detectadas que pueden ser de ayuda en diferentes contextos deatención psicogeriátrica. (AU)

Introduction: The objective is to describe the problemsrelated to outpatient psychogeriatric care in the contextof the SARS-CoV-2 pandemic, as well as the proposed andimplemented solutions for optimizing care for elderly peoplewith mental disorders during the pandemic, that can also beapplied in emerging similar situations in the future.Methods. Data on healthcare provision and clinical problemsin psychogeriatric practice over the course of one year ofthe COVID-19 pandemic were collected as the basis forproposals for action by a consensus of psychiatrists expertin psychogeriatrics. Setting: Outpatient psychogeriatric careservices in the Madrid region, Spain. Results. Eight topics relating to difficulties in the provisionof psychogeriatric care were identified (access to services,treatment adherence, referrals and contact, continuity ofcare, isolation, nursing homes and laboratory tests) andagreement was reached on 14 possible solutions. In addition,7 clinical problems of particular relevance were identified(bereavement, sleep, psychopharmacological treatments,physical, cognitive-behavioural and social deterioration, andviolence) and 17 possible solutions proposed.Conclusions. The SARS-CoV-2 pandemic poses a highrisk to life for the geriatric population. Measures suchas lockdowns and limiting contacts, exert a direct risk tomental health and an indirect risk due to greater difficultiesin accessing psychogeriatric care. It is necessary to detectthese situations and implement changes in how care isprovided to this highly vulnerable population. We proposea series of possible solutions to the problematic situationsdetected that may be helpful in a variety of psychogeriatriccare contexts. (AU)

Clinical Trajectories of Neuropsychiatric Symptoms in Mild-Moderate to Advanced Dementia.

BACKGROUND: There is high prevalence of neuropsychiatric symptoms (NPS) among dementia patients. NPS are correlated with dementia progression, functional decline, early institutionalization, and death. There is scarce evidence on the progression of NPS in the latest stages of dementia. OBJECTIVE: To describe the prevalence of NPS in mild-moderate to severe dementia and to reveal the progression of each NPS over time. METHODS: We studied 317 patients (77.3% female, average age: 81.5 years) with a DSM-IV-TR diagnosis of dementia. This is a cross-sectional, and a prospective longitudinal study with 78-month follow-up. We assessed cognitive status (Mini-Mental State Examination and Severe Mini-Mental State Examination), dementia severity (Global Deterioration Scale and Clinical Dementia Rating), and psychopathological measures (Neuropsychiatric Inventory, APADEM-Nursing Home, Apathy Inventory, Cornell Scale for Depression in Dementia, and Cohen-Mansfield Agitation Inventory). RESULTS: Overall prevalence of NPS was 94.6%, being apathy the most prevalent (66.7%) and the one whose severity increased the most with progression of dementia. Agitation/aggression, irritability, and sleeping and eating disorders also increased over time. Delusions and depressive symptoms decreased in severity with disease progression. In severe dementia, female displayed more depressive symptoms and eating disorders, while male displayed more agitation/aggression and sleep disturbances. CONCLUSION: NPS in dementia follow a heterogeneous course. Apathy is the most prevalent NPS and the one that worsens most significantly over time. The course of some NPS differs between sexes. Further research is required to understand the evolution of NPS at advanced stages of dementia.

Debut de clínica maniaca en trastorno neurocognitivo mayor / First appearance of mania in major neurocognitive disorder

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Terapia electroconvulsiva de mantenimiento y recuperación de la disfunción cognitiva: a propósito de un caso de trastorno depresivo recurrente / Maintenance electroconvulsive therapy and cognitive disfunction recovery: A case of recurrent major depressive disorder

Objetivo: Cuestionar que la terapia electroconvulsiva (TEC) sea perjudicial a nivel cognitivo a medio y largo plazo en el trastorno depresivo recurrente.Caso clínicoSe presenta el caso de una mujer de 75 años con trastorno depresivo recurrente, resistente e intolerante a varios psicofármacos, descartada previamente para TEC por sospecha de deterioro cognitivo, pero incluida en junio de 2016 en el programa de TEC de mantenimiento (TEC-M), tras 10 sesiones de TEC aguda.ResultadosTras más de 30 sesiones de TEC-M la paciente se mantiene eutímica, recibiendo una sesión trimestral de TEC y mostrando recuperación de la disfunción cognitiva tanto en la valoración subjetiva como mediante test de screening.ConclusionesLa TEC-M es eficaz en ancianos con depresión y puede mejorar e incluso normalizar la función cognitiva. (AU)

Aim: Challenge the idea that electroconvulsive therapy (ECT) is cognitively detrimental in the medium and long term in recurrent depressive disorder.Clinical caseWe introduce the case of a 75-year-old woman with recurrent major depressive disorder, resistant and intolerant to various antidepressant drugs, previously ruled out for ECT due to suspected cognitive decline, but included in June 2016 in the maintenance-electroconvulsive therapy (M-ECT program), after 10 sessions of acute ECT.OutcomesAfter more than 30 sessions of M-ECT, the patient remains euthymic, receiving a quarterly session of ECT and showing recovery from cognitive dysfunction both in the subjective assessment and through the screening test.Main findingsM-ECT is effective in the elderly with major depression, and may improve and even normalize cognitive function. (AU)

CHROME Criteria and Quality of Life: A Pilot Study from Maria Wolff-Albertia.

BACKGROUND: Over- and potentially inappropriate prescribing of psychotropic medications is a major public health concern among people with dementia. OBJECTIVE: Describe the CHemical Restraints avOidance MEthodology (CHROME) criteria and evaluate its effects on psychotropic prescribing and quality of life (QoL). METHODS: Observational, prospective, two-wave study conducted in two nursing homes. A multicomponent program to eliminate chemical restraints and attain quality prescription of psychotropic medications was implemented. CHROME's diagnostic criteria comprise constellations of behavioral and psychological symptoms of dementia under six primary syndromic diagnoses. Since pharmacologic treatment is aimed at only one syndrome, polypharmacy is avoided. Psychotropic prescription, QoL, neuropsychiatric symptoms (NPS), and other clinical measurements were collected before and one year after the intervention. Results are presented for all residents (n = 171) and for completer subjects (n = 115). RESULTS: Mean age (SD) of the residents was 87.8 (5.7), 78.9% were women, and 68.5% suffered advanced dementia. Psychotropic prescriptions decreased from 1.9 (1.1) to 0.9 (1.0) (p < 0.0005). Substantive reduction in prescribing frequency was observed for antidepressants (76.9% pre-intervention, 33.8% post-intervention) and for atypical neuroleptics (38.8% pre-intervention, 15.1% post-intervention). There was improvement in patient's response to surroundings (p < 0.0005) and total NPS (p < 0.01), but small worsening occurred in social interaction (p < 0.02, completer subjects). Safety measurements remained stable. CONCLUSION: CHROME criteria appear to optimize psychotropic prescriptions, avoid chemical restraints, and allow external verification of quality prescriptions. Extensive use seems feasible, related to substantial reduction of prescriptions, and of benefit for people with dementia as de-prescriptions are not associated to increased NPS or QoL loss.

Early-Onset Dementia Associated with a Heterozygous, Nonsense, and de novo Variant in the MBD5 Gene.

The haploinsufficiency of the methyl-binding domain protein 5 (MBD5) gene has been identified as the determinant cause of the neuropsychiatric disorders grouped under the name MBD5-neurodevelopment disorders (MAND). MAND includes patients with intellectual disability, behavioral problems, and seizures with a static clinical course. However, a few reports have suggested regression. We describe a non-intellectually disabled female, with previous epilepsy and personality disorder, who developed early-onset dementia. The extensive etiologic study revealed a heterozygous nonsense de novo pathogenic variant in the MBD5 gene. This finding could support including the MBD5 gene in the study of patients with atypical early-onset dementia.

Syndrome-Based Prescription to Optimize Psychotropics: Are CHROME Criteria a Game Changer?

A variety of medical and social factors have contributed over the last decades to the overuse of psychotropic drugs in people with dementia. One social factor is probably the frequent failure to provide adequate person-centered care, be it in the community or in institutional settings. This unfortunate reality has been reacted upon with numerous guidelines to reduce prescriptions of the most dangerous drugs (e.g., neuroleptics). Each psychotropic drug prescription can in principle be assessed around three dimensions: (a) adequate, (b) inadequate, and (c) chemical restraint. The CHemical Restraints avOidance MEthodology (CHROME) defined chemical restraint as any prescription based on organizational convenience, rather than justified with medical diagnosis. Two validation studies revealed that one of the main medical reasons of over- and miss-prescriptions was symptom-based prescription. By switching to syndrome-based prescription, a large proportion of drugs could be de-prescribed and some re-adjusted or kept. Paucity of research and weakness of data are not conclusive about the adequacy of specific drugs for the myriad of cases presented by patients with dementia and comorbid conditions. Clinical practice, however, leads us to believe that even under optimal care conditions, psychotropics might still contribute to quality of life if based on an adequate diagnosis. This article explains the rationale that underlies a syndromic approach aimed at optimizing psychotropic treatment in people with dementia whose significant suffering derives from their thought, affective, or behavioral problems. The results of previous validation studies of this new methodology will be discussed and conclusions for future results will be drawn.

Depression in Alzheimer's Disease: A Delphi Consensus on Etiology, Risk Factors, and Clinical Management.

Background: Alzheimer's disease (AD) and other forms of dementia are among the most common causes of disability in the elderly. Dementia is often accompanied by depression, but specific diagnostic criteria and treatment approaches are still lacking. This study aimed to gather expert opinions on dementia and depressed patient management to reduce heterogeneity in everyday practice. Methods: Prospective, multicenter, 2-round Modified Delphi survey with 53 questions regarding risk factors (11), signs and symptoms (7), diagnosis (8), and treatment (27) of depression in dementia, with a particular focus on AD. The questionnaire was completed by a panel of 37 expert physicians in neurodegenerative diseases (19 neurologists, 17 psychiatrists, and 1 geriatrician). Results: Consensus was achieved in 40 (75.5%) of the items: agreement in 33 (62.3%) and disagreement in 7 (13.2%) of them. Among the most relevant findings, depression in the elderly was considered an early sign (prodromal) and/or a dementia risk factor, so routine cognitive check-ups in depressed patients should be adopted, aided by clinical scales and information from relatives. Careful interpretation of neuropsychological assessment must be carried out in patients with depression as it can undermine cognitive outcomes. As agreed, depression in early AD is characterized by somatic symptoms and can be differentiated from apathy by the presence of sadness, depressive thoughts and early-morning awakening. In later-phases, symptoms of depression would include sleep-wake cycle reversal, aggressive behavior, and agitation. Regardless of the stage of dementia, depression would accelerate its course, whereas antidepressants would have the opposite effect. Those that improve cognitive function and/or have a dual or multimodal mode of action were preferred: Duloxetine, venlafaxine/desvenlafaxine, vortioxetine, tianeptine, and mirtazapine. Although antidepressants may be less effective than in cognitively healthy patients, neither dosage nor treatment duration should differ. Anti-dementia cholinesterase inhibitors may have a synergistic effect with antidepressants. Exercise and psychological interventions should not be applied alone before any pharmacological treatment, yet they do play a part in improving depressive symptoms in demented patients. Conclusions: This study sheds light on several unresolved clinical challenges regarding depression in dementia patients. Further studies and specific recommendations for this comorbid patient population are still needed.

Focus on Depression in Parkinson's Disease: A Delphi Consensus of Experts in Psychiatry, Neurology, and Geriatrics.

Major and minor forms of depression are significant contributors to Parkinson's disease morbidity and caregiver burden, affecting up to 50% of these patients. Nonetheless, symptoms of depression are still underrecognized and undertreated in this context due to scarcity of evidence and, consequently, consistent clinical guideline recommendations. Here, we carried out a prospective, multicentre, 2-round modified Delphi survey with 49 questions about the aetiopathological mechanisms of depression in Parkinson's disease (10), clinical features and connections with motor and nonmotor symptoms (10), diagnostic criteria (5), and therapeutic options (24). Items were assessed by a panel of 37 experts (neurologists, psychiatrists, and a geriatrist), and consensus was achieved in 81.6% of them. Depressive symptoms, enhanced by multiple patient circumstances, were considered Parkinson's disease risk factors but not clinical indicators of motor symptom and disease progression. These patients should be systematically screened for depression while ruling out both anhedonia and apathy symptoms as they are not necessarily linked to it. Clinical scales (mainly the Geriatric Depression Scale GDS-15) can help establishing the diagnosis of depression, the symptoms of which will require treatment regardless of severity. Efficacious and well-tolerated pharmacological options for Parkinson's comorbid depression were selective serotonin reuptake inhibitors (especially sertraline), dual-action serotonin and norepinephrine reuptake inhibitors (venlafaxine, desvenlafaxine, and duloxetine), multimodal (vortioxetine, bupropion, mirtazapine, and tianeptine), and anti-Parkinsonian dopamine agonists (pramipexole, ropinirole, and rotigotine). Tricyclic antidepressants and combining type B monoamine oxidase inhibitors with serotonergic drugs have serious side effects in these patients and therefore should not be prescribed. Electroconvulsive therapy was indicated for severe and drug-refractory cases. Cognitive behavioural therapy was recommended in cases of mild depression. Results presented here are useful diagnostic and patient management guidance for other physicians and important considerations to improve future drug trial design.

Pathological Correlations of Neuropsychiatric Symptoms in Institutionalized People with Dementia.

BACKGROUND: Comprehensive clinicopathological studies of neuropsychiatric symptoms (NPS) in dementia are lacking. OBJECTIVE: To describe the pathological correlations of NPS in a sample of institutionalized people with dementia. METHODS: We studied 59 people who were consecutively admitted to a nursing home and donated their brain. Correlations between pathological variables and NPS upon admission (n = 59) and at one-year follow-up assessment (n = 46) were explored and confirmed using bivariate and multivariate statistical methods. RESULTS: Mean (SD) age at admission was 83.2 (6.4) years and mean (SD) age at demise was 85.4 (6.6); 73% of the subjects were female and 98% presented advanced dementia. The most frequent etiological diagnosis was Alzheimer's disease (AD; 74.6% clinical diagnosis, 67.8% pathological diagnosis). The pathological diagnosis of AD was associated with aggression (ß est 0.31), depression (ß est 0.31), anxiety (ß est 0.38), and irritability (ß est 0.28). Tau stage correlated with aggressive symptoms (ß est 0.32) and anxiety (ßest 0.33). Coexistence of AD and Lewy body pathology was associated with depression (ß est 0.32), while argyrophilic grains were associated with eating symptoms (ß est 0.29). Predictive models were achieved for apathy, including cognitive performance, basal ganglia ischemic lesions, and sex as predictors (R2 0.38) and for sleep disorders, including pathological diagnosis of AD and age at demise (R2 0.18) (all p-values <0.05, unadjusted). CONCLUSION: AD was the main pathological substrate of NPS in our sample of very elderly people with advanced dementia. However, correlations were mild, supporting a model of focal/asymmetric rather than diffuse brain damage, along with relevance of environmental and other personal factors, in the genesis of those symptoms.

Depression in the Elderly. Consensus Statement of the Spanish Psychogeriatric Association.

INTRODUCTION: Present knowledge about depression in the elderly is still scarce and often controversial, despite its high frequency and impact. This article reports the results and most relevant conclusions of a Delphi-based consensus on geriatric depression promoted by the Spanish Psychogeriatric Association. METHODS: A 78-item questionnaire was developed by 7 highly specialized geriatric psychiatrists and was evaluated using the Modified Delphi technique in two rounds answered by 35 psychiatrists with an extensive expertise in geriatric depression. The topics and number of questions (in brackets) covered were: concepts, clinical aspects, and risk factors (12); screening and diagnosis (7); psychotic depression (17); depression and dementia (5); antidepressant drug treatment (18); non-pharmacological biological treatments (5); psychotherapeutic treatments (4); comorbidity and preventive aspects (6); professional training needed (4). In addition, the expert panel's opinion on the antidepressants of choice in 21 common comorbid conditions and on different strategies to approach treatment-resistant cases in terms of both efficacy and safety was assessed. RESULTS: After the two rounds of the Delphi process, consensus was reached for 59 (75.6%) of the 78 items. Detailed recommendations are included in the text. Considering pharmacological treatments, agomelatine was the most widely mentioned drug to be recommended in terms of safety in comorbid conditions. Desvenlafaxine, sertraline, and vortioxetine, were the most frequently recommended antidepressants in comorbid conditions in general. Combining parameters of efficacy and safety, experts recommended the following steps to address cases of treatment resistance: 1. Escalation to the maximum tolerated dose; 2. Change of antidepressant; 3. Combination with another antidepressant; 4. Potentiation with an antipsychotic or with lamotrigine; 5. Potentiation with lithium; 6. Potentiation with dopamine agonists or methylphenidate. DISCUSSION AND CONCLUSIONS: Consensus was reached for a high number of items as well as for the management of depression in the context of comorbid conditions and in resistant cases. In the current absence of sufficient evidence-based information, our results can be used to inform medical doctors about clinical recommendations that might reduce uncertainty in the diagnosis and treatment of elderly patients with depressive disorders.

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The "CHROME criteria": Tool to optimize and audit prescription quality of psychotropic medications in institutionalized people with dementia.

OBJECTIVE: Describe and validate the CHROME (CHemical Restraints avOidance MEthodology) criteria. DESIGN: Observational prospective longitudinal study. SETTING: Single nursing home in Las Palmas de Gran Canaria, Spain. PARTICIPANTS: 288 residents; mean age: 81.6 (SD 10.6). 77.4% had dementia. INTERVENTION: Multicomponent training and consultancy program to eliminate physical and chemical restraints and promote overall quality care. Clinicians were trained in stringent diagnostic criteria of neuropsychiatric syndromes and adequate psychotropic prescription. MEASUREMENTS: Psychotropic prescription (primary study target), neuropsychiatric syndromes, physical restraints, falls, and emergency room visits were semi-annually collected from December 2015 to December 2017. Results are presented for all residents and for those who had dementia and participated in the five study waves (completer analysis, n=107). RESULTS: For the study completers, atypical neuroleptic prescription dropped from 42.7% to 18.7%, long half-life benzodiazepines dropped from 25.2% to 6.5%, and hypnotic medications from 47.7% to 12.1% (p<0.0005). Any kind of fall evolved from 67.3 to 32.7 (number of falls by 100 residents per year). Physicians' diagnostic confidence increased, while the frequency of diagnoses of neuropsychiatric syndromes decreased (p<0.0005). CONCLUSIONS: Implementing the CHROME criteria reduced the prescription of the most dangerous medications in institutionalized people with dementia. Two independent audits found no physical or chemical restraint and confirmed prescription quality of psychotropic drugs. Adequate diagnosis and independent audits appear to be the keys to help and motivate professionals to optimize and reduce the use of psychotropic medication. The CHROME criteria unify, in a single compendium, neuropsychiatric diagnostic criteria, prescription guidelines, independent audit methodology, and minimum legal standards. These criteria can be easily adapted to other countries.

Anticholinergic Drugs in Geriatric Psychopharmacology.

Drugs with anticholinergic action are widely prescribed in the elderly population due to their potential clinical benefits. However, these benefits are limited by adverse effects which may be serious in particular circumstances. This review presents different aspects of the use of anticholinergics in old age with a focus in psychogeriatric patients. We critically review published data on benefits and disadvantages of anticholinergics, which are often controversial. Prevalence, pathophysiology and measurement methods of the anticholinergic action of drugs are discussed. We also present the most important drawbacks resulting from its use, including effects on cognition in healthy and cognitively impaired people, in aged schizophrenia patients, emergence of delirium and psychiatric symptoms, influence in functionality, hospitalization, institutionalization and mortality, and the potential benefits and limitations of their discontinuation. Finally, we suggest practical recommendations for the safe use of anticholinergics in clinical conditions affecting elderly patients, such as dementia, schizophrenia and acute hallucinatory episodes, depression, anxiety, Parkinson's disease, cardiovascular conditions and urinary incontinence.

Effects of commonly prescribed drugs on cognition and mild cognitive impairment in healthy elderly people.

BACKGROUND: Chronic drug intake has been associated with negative and positive cognitive effects in elderly people, although subjacent conditions may be confounding factors. AIM: To study the effects on cognitive performance of commonly prescribed medications in a cohort of cognitively normal older adults. METHODS: Medication intake was recorded during two years in 1087 individuals 70-85 years old, without neurological or psychiatric conditions. The influence of every drug, drug family and therapeutic group on six cognitive scores and on the conversion to mild cognitive impairment over two years was ascertained by cross-sectional and longitudinal analyses controlling for demographic and clinical variables. RESULTS: Small effects of several drugs on information processing were found in cross-sectional analyses but only confirmed for a positive effect of vitamin D in case-control analyses. Longitudinal analyses showed no drug effects on the cognitive slopes. Several hypotensive drugs reduced, whereas bromazepam and glucose lowering drugs increased, the conversion rate to mild cognitive impairment with very small effects (R2=0.3-1%). CONCLUSIONS: Cognitively healthy elderly individuals show minimal negative effects on information processing associated with chronic intake of some drugs probably related to the subjacent condition. Some drugs slightly affect the rate of conversion to mild cognitive impairment. Positive effects of vitamin D, chondroitin, atorvastatin and antihypertensive drugs, and negative effects of antidepressants and benzodiazepines, should be further explored in studies with longer follow-up.