Podcast Summary
Medications and Cognitive Impairment: Awareness of anticholinergic medications and their potential impact on cognitive function is crucial for healthcare professionals to ensure optimal patient care and satisfaction.
Certain medications can cause cognitive impairment, sundowning, and delirium, leading to decreased job satisfaction and quality of life for patients. This is a personal passion of the podcast host, who shares his experience of encountering such cases frequently during his work in a hospital. He emphasizes the importance of being aware of anticholinergic medications, which can contribute to these issues. The podcast episode features a discussion with medical students about this topic, including how they researched and compiled information on various medications and their effects on cognitive function. They introduce terms related to this issue, share relevant studies, and provide examples. This information is presented in an Excel sheet, which allows users to easily look up medications and determine if they pose a risk for cognitive issues. Overall, the episode aims to help healthcare professionals, therapists, and psychiatrists identify and address medications that may be causing cognitive impairment in their patients, ultimately improving patient care and satisfaction.
Neurological conditions impacting brain function: Sundowning causes behavioral issues, mild cognitive impairment signals pre-dementia, delirium is acute and often overlooked, and all impact daily life.
Various neurological conditions, such as sundowning, mild cognitive impairment, and delirium, can significantly impact brain function and daily life. Sundowning, a neuropsychiatric symptom, can lead to wandering, screaming, hallucinations, and is often associated with anticholinergic medications, fatigue, hunger, sleep disorders, or inadequate light exposure. Mild cognitive impairment, a pre-dementia phase, is characterized by cognitive decline but still allowing patients to perform activities of daily living. Dementia, a broader category, is a slow decline in cognitive function, and Alzheimer's dementia is a type, marked by early memory impairment and later executive functioning decline. Delirium, which can look like depression, is acute onset, usually resolves with treatment, but some cases can be prolonged or hypoactive. A study found that hypoactive delirium is often overlooked and misdiagnosed, emphasizing the importance of considering medication burden and medical issues when assessing cognitive function.
Delirium: An Acute Brain Attack in Older Adults: Delirium is a common complication for older adults, particularly during hospital stays and after surgeries, causing confusion, hallucinations, and changes in behavior. Lasting effects and support from loved ones can aid recovery.
Delirium can be thought of as an acute brain attack, similar to a heart attack, and it's a common complication in older adults, particularly during hospital stays and after surgeries. About a third of patients over the age of 70 experience delirium during an acute inpatient stay, and up to half may have had it before coming to the hospital. Delirium can last for different periods of time, including months, and can persist after discharge. It's important for families to be aware of delirium and its symptoms, such as confusion, hallucinations, and changes in behavior, as it can be distressing and potentially dangerous. Creating a familiar environment and maintaining connections with loved ones can help improve outcomes for patients with delirium. Delirium is a common complication, particularly for older adults, and can have long-lasting effects. It's important for healthcare providers and families to be aware of its symptoms and take steps to manage and support those affected.
Understanding Delirium in Older Adults: Beyond Hyperactivity: Delirium in older adults can present subtly as hypoactivity, often overlooked. It's associated with increased mortality, complications, and cognitive impairment. Use the Confusion Assessment Method (CAM) to screen for delirium and address underlying causes for better patient outcomes.
Delirium, a common condition among older adults in healthcare settings, is often misunderstood due to its varying presentations, with only a quarter of cases being hyperactive and easily diagnosable. Hypoactive delirium, on the other hand, can be subtle and overlooked, leading to missed opportunities for timely intervention. Delirium is associated with increased risk of death, hospital complications, and prolonged cognitive impairment. As providers, it's crucial to be aware of the signs of delirium, such as disturbances in attention, memory deficits, and language problems. The Confusion Assessment Method (CAM) can be used as a simple screening tool to help identify potential cases of delirium. Given the significant morbidity associated with delirium, it's essential to consider this diagnosis in patients, especially those who seem confused or disoriented, and to take appropriate steps to address any underlying causes, often including medication reviews. As healthcare professionals, expanding our understanding of delirium and its various presentations can lead to better patient outcomes and improved quality of care.
Assessing Delirium: Clock Test and Medical History: Assessing delirium requires a clock test and medical history. Identify cognitive function changes through clock test and potential causes from medical history. Address underlying issues for improved health.
Assessing delirium involves a combination of observing a patient's ability to understand time and their medical history. The clock assessment is a quick and easy way to observe cognitive function, while a thorough medical history can help identify potential causes such as medications, electrolyte disturbances, infections, and other disorders. Reduced sensory input, including isolation, can also contribute to delirium. When assessing a patient, it's essential to consider all possible causes and address any underlying issues to improve their overall health and wellbeing.
Paying attention to anticholinergic medications is vital for delirium evaluation: Up to 75% of delirium cases may go unnoticed, emphasizing the importance of assessing anticholinergic drug burden in medication lists to prevent misdiagnosis or missed opportunities for treatment.
When evaluating a patient for delirium, it's crucial to pay close attention to their medication list, specifically those with anticholinergic burden. Anticholinergic drugs, as well as those with anticholinergic overlap like antihistamines, antidepressants, and even some SSRIs, can contribute to delirium. It's essential to be aware of this, as up to 75% of delirium cases may go unnoticed by healthcare teams. As a responsible medical professional, it's our duty to ensure thorough assessments during day shifts, as night teams may overlook delirium due to altered or drowsy patients. The Excel sheet mentioned in the discussion, which ranks medications based on their anticholinergic burden, is a practical and helpful tool for identifying such drugs. This information comes from various studies, with the basis of the table originating from an article by Salahuddin et al in 2015.
Assessing Anticholinergic Burden with Rating Scales: Researchers have developed rating scales to assess anticholinergic burden of medications, which can help minimize adverse effects in elderly patients. Anticholinergic scores are calculated by summing the scores of all medications a subject is receiving.
Researchers have developed rating scales to assess the anticholinergic burden of prescribed and over-the-counter medications, which could be useful for minimizing anticholinergic-induced adverse effects in elderly patients. Ryan and Adrianna discussed several studies, including the Carnahan study from 2006. In this study, researchers aimed to replicate a pilot study that linked anticholinergic drug scale scores with serum anticholinergic activity. They measured serum anticholinergic activity using a radio receptor assay and rated each drug's anticholinergic action on a 0 to 3 scale. By summing the scores of all medications a subject was receiving, they calculated the total anticholinergic score. Mapping across multiple studies, including the Carnahan study, allowed for a comprehensive assessment of anticholinergic effects, ranging from serum activity to cognitive outcomes. The resulting table provides a practical tool for providers to quickly look up a drug's anticholinergic burden and consider alternatives for the same indication.
Studies link anticholinergic medication use to impaired cognitive performance and increased risk of mild cognitive impairment: Multiple studies suggest that using anticholinergic medications can lead to cognitive impairment and increase the risk of mild cognitive impairment in older adults, emphasizing the need to monitor and minimize their use for cognitive health.
Multiple studies have shown a significant association between anticholinergic medication use and impaired cognitive performance, as well as an increased risk of mild cognitive impairment. For instance, a study in 2006 using the Anticholinergic Burden Classification scale found that over 80% of anticholinergic users had mild cognitive impairment compared to 35% in nonusers. Another study in 2008 developed a clinician-read anticholinergic score scale and found that cumulative exposure to anticholinergic medications was associated with poor performance on memory and executive function. These findings highlight the importance of monitoring and minimizing anticholinergic medication use in older adults to maintain cognitive health.
Assessing Anticholinergic Risk from Medications: Studies show that higher anticholinergic activity of medications and total anticholinergic burden increase the risk of adverse effects, particularly in older adults. Tools like the Anticholinergic Risk Scale (ARS) help assess anticholinergic potential and predict risk.
The use of anticholinergic medications, which block the action of the neurotransmitter acetylcholine, can lead to increased risk of adverse effects. Researchers have developed tools like the Anticholinergic Risk Scale (ARS) to assess the anticholinergic potential of medications and predict the risk of adverse effects. For instance, the CHU 2008 study used a competitive radio receptor binding assay to measure the anticholinergic activity of 107 commonly used medications in older adults and found that higher anticholinergic activity was associated with increased risk of adverse effects. Another study, Bustani 1 in 2008, suggested that the total anticholinergic burden, as measured by the sum of anticholinergic scores of all medications taken, could be used to identify patients at risk of cognitive impairment. The Ert 2010 study found that both the duration of anticholinergic drug use and the total anticholinergic load were associated with cognitive decline. These studies underscore the importance of being aware of the anticholinergic potential of medications and considering alternative options when the total anticholinergic burden becomes too high. For example, amitriptyline, a tricyclic antidepressant, is sometimes prescribed for pain conditions but can add to the anticholinergic burden and potentially lead to adverse effects.
Medications with high anticholinergic burden can harm cognitive function: Older adults and those with pre-existing cognitive issues should be cautious with medications like amitriptyline and diphenhydramine due to their significant anticholinergic effects, which can negatively impact cognitive function. Consider alternative options with a lower anticholinergic burden to minimize risk.
Certain medications, such as amitriptyline and diphenhydramine, have a high anticholinergic burden and can negatively impact cognitive function. This is particularly important to consider in older adults or those with pre-existing cognitive issues. Studies consistently rate these medications as having a 3 out of 3 anticholinergic burden, meaning they have significant anticholinergic effects. Other medications, like nortriptyline and promethazine, have conflicting results, with some studies reporting anticholinergic effects and others not. As a healthcare provider, it's crucial to be aware of these potential side effects and monitor patients closely when starting these medications. It's also essential to consider alternative options with a lower anticholinergic burden to minimize the risk of cognitive dysfunction.
Medications with Anticholinergic Effects and Cognitive Impairment: Some medications, like anticholinergics and antipsychotics, can contribute to cognitive impairment due to their anticholinergic effects, but the extent of these effects varies between studies. It's essential to consider methodologies and specific measures used in each study when evaluating the impact of these medications on cognitive function.
Certain medications, specifically anticholinergics like metoclopramide and antipsychotics such as quetiapine and olanzapine, have noticeable anticholinergic effects that could potentially contribute to cognitive impairment. However, the extent of these effects can vary between studies, and it's essential to consider the methodologies and specific measures used in each study. For instance, metoclopramide, which is used to treat gastroparesis, was rated as having anticholinergic activity by some studies but not others. Antipsychotics like quetiapine and olanzapine, which are used to decrease delirium, were also found to have anticholinergic effects, with varying scores from different studies. While some studies suggest that less cholinergic medications could be considered to reduce the anticholinergic burden, it's important to note that side effects and benefits should be weighed when making treatment decisions. For example, paroxetine, an antidepressant with anticholinergic effects, may help with anxiety early on but can cause issues as the treatment continues. Instead, alternatives like sertraline or fluoxetine may be preferred. Ultimately, it's crucial to consider the big picture and the specific context of each patient when making treatment decisions.
Medications contributing to delirium: Oxybutynin, Fluorosemide, Baclofen, and Benzodiazepines can lead to delirium. Providers should consider reducing dosages or exploring alternatives to minimize risk.
Certain medications, such as oxybutynin, Fluorosemide, Baclofen, and Benzodiazepines, can contribute to delirium in patients. Oxybutynin, used for bladder issues, has anticholinergic effects and can lead to cognitive dysfunction. Fluorosemide, a loop diuretic, can also cause delirium. Baclofen, used for muscle relaxants, can be switched to Robaxin for a safer alternative. Benzodiazepines, while not having anticholinergic effects, can cause cognitive effects. Providers should be aware of these potential side effects and consider reducing dosages or exploring alternative medications to minimize the risk of delirium. For therapists, understanding the impact of medications on delirium is essential to providing comprehensive care. Overall, recognizing the various causes of delirium and the medications that contribute to it is crucial for optimizing patient care.