THE ANTICHOLINERGIC BURDEN OF WOMENREFERRED TO UROGYNAECOLOGY
N. L. CURTISS1, M.BASU 2, J. DUCKETT 1;
1Gynaecology,Medway NHS Fndn. trust, Gillingham, United Kingdom, 2Gynaecology,Medway Maritime Hosp., Gillingham, United Kingdom.
Introduction: Overactive bladder(OAB) is a common reason for referral to urogynaecology services andshows increasing prevalence with age. Once conservative methods havebeen exhausted anticholinergics are the next line of management.Concerns have been raised about associations between the use ofanticholinergic drugs and dementia, other cognitive impairments andmortality [1-3]. The effects appear to be dose related with patientson more than one anticholinergic drug being at higher risk.Anticholinergic effects are not unique to anti-muscarinics prescribedfor OAB, other commonly prescribed medications have some potentialanti-cholinergic effect. One method of evaluating the risk of thecombined effect of several medications is the AnticholinergicCognitive Burden (ACB) scale, which scores drugs with anticholinergiceffects from 1 (where in vitro data suggests a possibleanticholinergic effects) to 3 (where there is evidence the medicationcan cause delirium) . An increase of 1 point on the ACB scale iscorrelated with a doubling of all-cause mortality  and a declinein the mini-mental state examination score of 0.33 points over 2years . There is also an association between higher cumulativeprescribing of anticholinergics and increased risk of dementia .The demographics of OAB mean that the population of women most likelyto suffer from OAB are also the ones most likely to be at risk fromthe cognitive adverse side effects of anticholinergics.
Objective:To evaluate the existing anticholinergic burden of women referred tourogynaecology services.
Methods: A detailed drug historywas taken from a consecutive cohort of 112 patients attending as newreferrals to a secondary care urogynaecology service from November2015. The name and where available doses of all medications womenwere taking upon referral to urogynaecology services were noted.Patients underwent careful symptomatic questioning, examination andinvestigations as appropriate to their presenting complaints. Theanticholinergic burden of each patient was scored and analysedaccording to their age and presenting complaint. Formal ethicalapproval was not applied for as this is a service evaluation undercurrent UK regulations.
Results: In total 112 patientmedication histories were evaluated and the ACB scored. The mean ageof the women was 55.6 years (range 21-92 years). 64.9% of the womenreferred had symptoms of OAB. In total the women were on 139different medications. The most commonly prescribed medications wereLanzoprazole (19), levothyroxine (14), omeprazole (11) andsolifenacin (13). The number of medications women were takingincreased with age as did their ACB score (fig 1).
When the women were divided intothose with OAB and without, the ages of the women were notsignificantly different but those with OAB were on statisticallysignificantly more medications and had a higher ACB (student t-test)see table 1.Table 1
Conclusions: The average number of medicationwomen referred to clinic are taking increases with age and once over80 years old the mean number of medications per patient was 6.8. TheACB score also increased with age. Women with OAB were on moremedications and had a higher ACB score at referral than those withother complaints. The prescription of anti-muscarinic medicationincreases the anticholinergic burden to arguably an unacceptablelevel for the majority of women with OAB.
References: 1.Journal of the American Geriatrics Society, 59: 1477-1483 2. BritishJournal of Clinical Pharmacology, 80(2), 209-220 3. JAMA InternalMedicine, 175(3), 401-407