Pharmacologic Anisocoria With Azelastine: The Importance of a Good Anamnesis.

Unilateral pharmacologic mydriasis is one of the differential diagnoses of anisocoria. This is a clinical case of a 37-year-old male patient admitted to the ophthalmology emergency department with unilateral mydriasis, an infrequent side effect of the antihistaminic drug azelastine. A comprehensive medical history including ocular medication was essential to avoid the need for additional tests and to exclude life-threatening conditions responsible for a similar presentation.

Unintentional Jimson Weed Poisoning in a Family: A Case Report.

This case report reveals a rare incident of unintended Jimson weed (Datura stramonium) exposure within a family in the United States. In this narrative, a pregnant 36-year-old Asian woman and her family unknowingly ingested homemade soup infused with Jimson weed leaves. This led to symptoms such as vomiting, dry mouth, blurred vision, flushed skin, breathing difficulties, and hallucinations. While the woman and her daughter quickly recovered, the husband's severe hallucinations required intensive care. The episode underscores the vital importance of accurate plant identification, particularly in homegrown produce. Recognizing and understanding anticholinergic poisoning symptoms becomes crucial for timely diagnosis and intervention, preventing such occurrences. This case serves as a poignant reminder of the potential risks concealed within our everyday environments.

Rheology of saliva in health and disease.

BACKGROUND: Saliva is a complex fluid that lubricates the oropharynx and facilitates chewing, swallowing, and vocalization. Viscoelasticity is critical for the ability of saliva to fulfill these functions. Xerostomia, or a sensation of dry mouth, occurs in 17-26% of the population. Although many equate xerostomia with hyposalivation, high-risk patients frequently report oral dryness in the absence of decreased salivary flow. OBJECTIVE: This study aims to determine if xerostomia is associated with alterations in the rheological properties of saliva in addition to decreased salivary production. METHODS: The study population included patients with post-radiation xerostomia, patients with anticholinergic-induced xerostomia and healthy controls. Salivary volumetric flow rate was measured, shear viscosity was measured using oscillatory rheometry, and extensional viscosity was measured using capillary thinning methods. Groups were compared using descriptive statistics and univariate analysis. RESULTS: A total of 36 subjects were included: 15 with post-radiation xerostomia, 9 with anticholinergic-induced xerostomia and 12 controls. Salivary volumetric flow was significantly decreased in post-radiation and anticholinergic-induced patients compared to controls. On capillary thinning testing, saliva from xerostomia patients had significantly greater extensional viscosity compared to controls. However, saliva from the three groups showed no significant difference in the complex viscosity or the storage or loss modulus of saliva with oscillatory rheology. CONCLUSIONS: Xerostomia is associated with decreased salivary volumetric flow and quantitative changes in the rheologic properties of saliva.

Association between anticholinergic burden and anticholinergic adverse outcomes in the elderly: Pharmacological basis of their predictive value for adverse outcomes.

The use of anticholinergic drugs and other drugs with anticholinergic activity is highly prevalent in older people. Cumulative anticholinergic effects, known as anticholinergic burden, are associated with important peripheral and central adverse effects and outcomes. Several methods have been developed to quantify anticholinergic burden and to estimate the risk of adverse anticholinergic effects. Serum anticholinergic activity (SAA) and anticholinergic burden scoring systems are the most commonly used methods to predict the occurrence of important negative outcomes. These tools could guide clinicians in making more rational prescriptions to enhance patient safety, especially in older people. However, the literature has reported conflicting results about the predictive ability of these tools. The majority of these instruments ignore relevant pharmacologic aspects such as the doses used, differential muscarinic receptor subtype affinities, and blood-brain barrier permeability. To increase the clinical relevance of these tools, mechanistic and clinical pharmacology should collaborate. This narrative review describes the rational and pharmacological basis of anticholinergic burden tools and provides insight about their predictive value for adverse outcomes.

Anticholinergic and sedative medications exposure in older patients: a cross-sectional study.

Background The Drug Burden Index is a risk assessment tool used to quantify anticholinergic and sedative medications burden of older patients. There have been no previously published reports the exposure of anticholinergic and sedative medications in China. Objective We investigated the prevalence and correlates risk factors of anticholinergic and sedative medications in hospitalized older patients with polypharmacy in China. Settings The Department of Geriatrics in a tertiary care teaching hospital. Methods A retrospective analysis of patient medical records of hospitalized older patients with polypharmacy was undertaken at a large university teaching hospital in China. Polypharmacy was defined as the regular use of more than five medications. Prescribing of anticholinergic and sedative medications was identified using the medication list of the Drug Burden Index, and logistic regression analysis determined associations between drug exposure and independent variables. Main outcome measure Anticholinergic and sedative medications identified by the Drug Burden Index. Results A total of 383 patients were included in this study, with an average age of 82.6 ± 7.0 years and included 72.9% (279/383) male patients. Of the study participants, 23.8% (91/383) were prescribed anticholinergic and sedative medications. Of the 106 medicines identified by the Drug Burden Index, the most frequently prescribed medications were estazolam in 51.9% (55/106), terazosin in 14.1% (15/106), loratadine in 10.4% (11/106), and cetirizine in 5.7% (6/106); these four medications accounted for 82.1% of the anticholinergic and sedative medications. Drug exposure was associated with age ≥ 80 years (OR 2.246; 95% CI 1.100-4.586), the number of prescribed medications (OR 1.102; 95% CI 1.018-1.193), and symptoms of insomnia (OR 28.990; 95% CI 14.197-59.200). Conclusions The findings of this study showed that the prevalence of anticholinergic and sedative exposure in hospitalized older patients with polypharmacy in China. The prevalence of exposure of anticholinergic and sedative medications was 23.8%. According to the Drug Burden Index estazolam and terazosin were the most common medications in the sedative or anticholinergic drug class, respectively.

Scopolamine Use in the Perioperative Patient: A Systematic Review.

Scopolamine is an antiemetic agent used for postoperative nausea and vomiting prevention; however, it has anticholinergic effects (eg, bradycardia, dry mouth, dizziness, visual disturbances). Avoiding scopolamine use in specific populations is crucial to prevent adverse effects and harm to patients. This systematic review describes the anticholinergic effects of scopolamine in perioperative patient populations. After searching the available literature, we reviewed the eligible articles to determine whether they met the inclusion criteria (eg, full text, English language, included a discussion of scopolamine's anticholinergic effects in perioperative patients). Twenty-six articles were included in this review. We used The Johns Hopkins Research Evidence Appraisal Tool to appraise the literature. The results of this literature review reveal that clinicians should avoid administering scopolamine to certain perioperative patient populations (ie, pediatric, older adult).

Heat Waves, Drugs with Anticholinergic Effects, and Outcomes in Older Hospitalized Adults.

OBJECTIVES: To determine whether heat waves (HWs) affect exposure to drugs with anticholinergic effects (DACEs) on admission and the effect of such on length of stay (LOS) and in-hospital mortality in older adults. DESIGN: Retrospective. SETTING: Metropolitan teaching hospital. PARTICIPANTS: Individuals aged 65 and older with at least one chronic condition (n = 307) admitted to a medical ward during five consecutive HWs (≥5 consecutive days of a maximum temperature of ≥35 °C or ≥3 consecutive days of a maximum temperature of ≥40 °C) recorded between 2007 and 2009. Individuals admitted before or after each HW, matched for HW period, age, and day of the week admitted, served as controls (n = 1,114). MEASUREMENTS: Data on clinical and demographic characteristics, Charlson Comorbidity Index (CCI), total medication and DACE exposure on admission (any DACE, number of DACEs, or Anticholinergic Risk Scale (ARS) score), LOS, and in-hospital mortality were collected using electronic medical data. RESULTS: No significant differences in total medications, DACE exposure, CCI, number of daily admissions, LOS, or in-hospital mortality were observed between the HW and control groups. DACE exposure (ARS) predicted longer LOS during non-HW (ß = 0.70, standard error (SE) = 0.27, P = .01) but not HW (ß = 0.02, SE = 0.46, P = .96) periods. ARS did not predict mortality during non-HW (odds ratio (OR) = 1.02, SE = 0.12, P = .87) or HW (OR = 1.21, SE = 0.23, P = .31) periods. CONCLUSION: The effect of DACE exposure on LOS, but not mortality, is different between HW and non-HW periods in older hospitalized adults. This should be considered when assessing the effect of DACEs in pharmacoepidemiological studies.

Drugs with anticholinergic effects and cognitive impairment, falls and all-cause mortality in older adults: A systematic review and meta-analysis.

AIM: The aim was to investigate associations between drugs with anticholinergic effects (DACEs) and cognitive impairment, falls and all-cause mortality in older adults. METHODS: A literature search using CINAHL, Cochrane Library, Embase and PubMed databases was conducted for randomized controlled trials, prospective and retrospective cohort and case-control studies examining the use of DACEs in subjects ≥65 years with outcomes on falls, cognitive impairment and all-cause mortality. Retrieved articles were published on or before June 2013. Anticholinergic exposure was investigated using drug class, DACE scoring systems (anticholinergic cognitive burden scale, ACB; anticholinergic drug scale, ADS; anticholinergic risk scale, ARS; anticholinergic component of the drug burden index, DBIAC ) or assessment of individual DACEs. Meta-analyses were performed to pool the results from individual studies. RESULTS: Eighteen studies fulfilled the inclusion criteria (total 124 286 participants). Exposure to DACEs as a class was associated with increased odds of cognitive impairment (OR 1.45, 95% CI 1.16, 1.73). Olanzapine and trazodone were associated with increased odds and risk of falls (OR 2.16, 95% CI 1.05, 4.44; RR 1.79, 95% CI 1.60, 1.97, respectively), but amitriptyline, paroxetine and risperidone were not (RR 1.73, 95% CI 0.81, 2.65; RR 1.80, 95% CI 0.81, 2.79; RR 1.39, 95% CI 0.59, 3.26, respectively). A unit increase in the ACB scale was associated with a doubling in odds of all-cause mortality (OR 2.06, 95% CI 1.82, 2.33) but there were no associations with the DBIAC (OR 0.88, 95% CI 0.55, 1.42) or the ARS (OR 3.56, 95% CI 0.29, 43.27). CONCLUSIONS: Certain individual DACEs or increased overall DACE exposure may increase the risks of cognitive impairment, falls and all-cause mortality in older adults.

Poisoned after Dinner: Dolma with Datura Stramonium.

Datura stramonium, which is also known as Thorn Apple or Jimson Weed, is an alkaloid containing plant that is entirely toxic. The active toxic constituents of the plant are atropine, scopolamine and hyoscyamine. It has been abused worldwide for hundreds of years because of its hallucinogenic properties. Previous reports have shown that herbal medication overdose and accidental food contamination are ways it can cause poisoning. Herein we present a family that had three of its members poisoned after eating a traditional meal "dolma" made of datura flowers. None had fatal complications and all were discharged healthy. Datura stromonium may be used accidentally as a food ingredient. Since its poisonous effects are not known, people should be informed and warned about the effects of this plant.

Anticholinergic drugs and their effects on delirium and mortality in the elderly.

AIM: To investigate the use of drugs with anticholinergic properties (DAPs) and their associations with delirium and mortality among elderly patients with comorbidities. METHODS: 425 patients (≥70 years of age) in geriatric wards and nursing homes were assessed. The use of DAPs was retrieved from their medical records. Delirium was diagnosed according to the DSM-IV criteria. RESULTS: Of the 341 patients (80.2%) treated with multiple DAPs (≥2), 92 patients (27.0%) suffered from delirium, whereas 14 of 84 patients (16.7%) without DAP treatment had delirium (p = 0.050). In a logistic regression analysis with age, gender, and Charlson Comorbidity Index as covariates, DAP treatment did not predict delirium (odds ratio 1.67, 95% confidence interval 0.87-3.21). The 2-year mortality was 49.3% (n = 168) in DAP users and 35.7% (n = 30) in non-users, respectively (p = 0.026). In the Cox proportional hazard model adjusted for age, gender, and comorbidity, DAPs did not predict mortality (hazard ratio 1.12, 95% confidence interval 0.75-1.68). CONCLUSION: The use of DAPs is very frequent among frail inpatients with comorbidities, but their use has no independent prognostic significance.