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Comparative Study
. 2021 Feb;77(2):147-162.
doi: 10.1007/s00228-020-02994-x. Epub 2020 Oct 3.

Quality of anticholinergic burden scales and their impact on clinical outcomes: a systematic review

Angela Lisibach  1   2   3 , Valérie Benelli  4 , Marco Giacomo Ceppi  5   6 , Karin Waldner-Knogler  7 , Chantal Csajka  8   9 , Monika Lutters  4   10
Affiliations
Comparative Study

Quality of anticholinergic burden scales and their impact on clinical outcomes: a systematic review

Angela Lisibach et al. Eur J Clin Pharmacol. 2021 Feb.

Abstract

Purpose: Older people are at risk of anticholinergic side effects due to changes affecting drug elimination and higher sensitivity to drug's side effects. Anticholinergic burden scales (ABS) were developed to quantify the anticholinergic drug burden (ADB). We aim to identify all published ABS, to compare them systematically and to evaluate their associations with clinical outcomes.

Methods: We conducted a literature search in MEDLINE and EMBASE to identify all published ABS and a Web of Science citation (WoS) analysis to track validation studies implying clinical outcomes. Quality of the ABS was assessed using an adapted AGREE II tool. For the validation studies, we used the Newcastle-Ottawa Scale and the Cochrane tool Rob2.0. The validation studies were categorized into six evidence levels based on the propositions of the Oxford Center for Evidence-Based Medicine with respect to their quality. At least two researchers independently performed screening and quality assessments.

Results: Out of 1297 records, we identified 19 ABS and 104 validations studies. Despite differences in quality, all ABS were recommended for use. The anticholinergic cognitive burden (ACB) scale and the German anticholinergic burden scale (GABS) achieved the highest percentage in quality. Most ABS are validated, yet validation studies for newer scales are lacking. Only two studies compared eight ABS simultaneously. The four most investigated clinical outcomes delirium, cognition, mortality and falls showed contradicting results.

Conclusion: There is need for good quality validation studies comparing multiple scales to define the best scale and to conduct a meta-analysis for the assessment of their clinical impact.

Keywords: Clinical outcomes; Cumulative anticholinergic burden; Older people; Quality assessment; Validation.

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Conflict of interest statement

AL was funded by AbbVie AG Switzerland to participate at the European Symposium of Clinical Pharmacy (ESCP) in October 2019 in Ljubljana, Slovenia.

Figures

Fig. 1
Fig. 1
PRISMA flowchart. The identification of all published ABS and their validation studies (a detailed separate flowchart for the validation studies is depicted in Appendix 2)
Fig. 2
Fig. 2
Relationship of the anticholinergic burden scales (ABS) sorted by the year of publication (from 1978 to 2019). Example of reading the figure: The SCDL is included in the CrAS or the CrAS is included in the ADS
Fig. 3
Fig. 3
Count of validations per scale. Number of scale validations according to their level of evidence (total n=147). The bubble size is proportional to the number of validations per scale indicated as the numbers in the center of the bubble. Five ABS (AEC, AIS, BAADS, GABS and KABS) have not been validated yet
Fig. 4
Fig. 4
Found association of the validation studies with the most investigated clinical outcomes. Number of scale validations according to their evidence levels and grouped by the four most investigated clinical outcomes (total n = 118). The triangle size is proportional to the number of validations and an upward triangle means statistically significant association
See this image and copyright information in PMC

References

    1. Kersten H, Wyller TB. Anticholinergic drug burden in older people’s brain - How well is it measured? Basic Clin Pharmacol Toxicol. 2014;114:151–159. doi: 10.1111/bcpt.12140. - DOI - PubMed
    1. Wawruch M, Macugova A, Kostkova L, Luha J, Dukat A, Murin J, Drobna V, Wilton L, Kuzelova M. The use of medications with anticholinergic properties and risk factors for their use in hospitalised elderly patients. Pharmacoepidemiol Drug Saf. 2012;21(2):170–176. doi: 10.1002/pds.2169. - DOI - PubMed
    1. Collamati A, Martone AM, Poscia A, Brandi V, Celi M, Marzetti E, Cherubini A, Landi F. Anticholinergic drugs and negative outcomes in the older population: from biological plausibility to clinical evidence. Aging Clin Exp Res. 2016;28(1):25–35. doi: 10.1007/s40520-015-0359-7. - DOI - PubMed
    1. Laatikainen O, Sneck S, Bloigu R, Lahtinen M, Lauri T, Turpeinen M. Hospitalizations due to adverse drug events in the elderly-a retrospective register study. Front Pharmacol. 2016;7:358. doi: 10.3389/fphar.2016.00358. - DOI - PMC - PubMed
    1. Mangoni AA, Jackson SHD. Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol. 2003;57(1):6–14. doi: 10.1046/j.1365-2125.2003.02007.x. - DOI - PMC - PubMed

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