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Aims: To evaluate if documentation of Anticholinergic burden (ACB) score is in accordance with the NICE guidelines. To calculate the Anticholinergic burden (ACB) score for patients referred to memory clinic if not documented. Methods: I conducted retrospective analysis using a systematic sampling method and a proforma on patient’s electronic medical record to ascertain if the ACBs of patients were documented when being reviewed. Information was obtained from both SystmOne tabbed journals, SystmOne medications list, and referral letters (to determine ACB score documentation and calculation). Two scoring systems were used to calculate ACB: ACB calculator (https://www.acbcalc.com/) and POMH data collection tool. Results: Of the 92 patients referred to memory service, 30 patients were analysed and only 3 had documented ACB burden score (10%). Using the ACB scale. 13 individuals had ACB score of ≥2 which was 43% of patients analysed. Using POMH, 9 individuals had ACB score of ≥2 which was 30% of patients analysed. Most common medication involved in individuals with ACB ≥3 was amitriptyline (67% using the POMH calculator and 37% using the ACB calculator) and all were commenced in primary care. If documented, this score would be classified as high risk and necessitate a medical review in line with the guidelines. Conclusion: To regularly document Anticholinergic burden score for elderly patients referred to service. Patients with high burden score may require a medication review with documented evidence of either: Discussion about reducing the dose; or stopping or switching the anticholinergic medicine. Currently, no scoring system is recommended, to use an agreed system. Reducing drugs with high ACB can also lead to less polypharmacy. In addition, concomitant use with anticholinesterase inhibitors may reduce the effectiveness. Reaudit second cycle in 6 months.

Article Title: Central Neuromodulators in Irritable Bowel Syndrome: Why, How, and When

Background Anticholinergic drugs put elderly patients at a higher risk for falls, cognitive decline, and delirium as well as peripheral adverse reactions like dry mouth or constipation. Prescribers are often unaware of the drug-based anticholinergic burden (ACB) of their patients. This study aimed to develop an anticholinergic burden score for drugs licensed in Germany to be used by clinicians at prescribing level. Methods A systematic literature search in pubmed assessed previously published ACB tools. Quantitative grading scores were extracted, reduced to drugs available in Germany, and reevaluated by expert discussion. Drugs were scored as having no, weak, moderate, or strong anticholinergic effects. Further drugs were identified in clinical routine and included as well. Results The literature search identified 692 different drugs, with 548 drugs available in Germany. After exclusion of drugs due to no systemic effect or scoring of drug combinations ( n  = 67) and evaluation of 26 additional identified drugs in clinical routine, 504 drugs were scored. Of those, 356 drugs were categorised as having no, 104 drugs were scored as weak, 18 as moderate and 29 as having strong anticholinergic effects. Conclusions The newly created ACB score for drugs authorized in Germany can be used in daily clinical practice to reduce potentially inappropriate medications for elderly patients. Further clinical studies investigating its effect on reducing anticholinergic side effects are necessary for validation.

Data gathered from the COVID-19 Clinical Neuroscience Study has demonstrated that COVID-19 infection is associated with post-acute objectively measurable cognitive deficits. This is significant not only for COVID-19 but for other post-infectious cognitive syndromes. This cohort and others have indicated that age, covid severity and education status are important baseline predictors of greater cognitive deficits post COVID-19 illnessExtant literature has shown that anticholinergic burden, frailty and multimorbidity are associated with cognitive decline. We therefore hypothesised that clinical frailty score, multimorbidity and anticholinergic drug burden are also associated with poorer cognitive outcomes in this same group of COVID-19 patients, and could be used to refine a predictive model of post-infection associated cognitive impairment.Multivariate analysis using Kruksal-Wallis testing amongst a cohort of 310 patients with COVID-19 has not shown these parameters to correlate with worse cognitive scores. Limitations to this analysis include cognitive data being collected at a singular time point post-acute infection.Identification of risk factors for those patients at greatest risk of cognitive impairment following acute systemic infection such as COVID-19 has implications for other post-infectious cognitive syndromes and for future pandemics. Further longitudinal cognitive assessment will prove valuable in demonstrating potential associations with such variables.rachaelmatthews1990@gmail.com

PurposeThe purpose of the study is to conduct a systematic review of studies examining the association between anticholinergic burden and mortality in older individuals.MethodsA literature search was performed to identify relevant studies, using MEDLINE, EMBASE, PsycINFO and CENTRAL, from January 1990 to December 2018. We included studies of patients with a mean age of 65 years or older where the anticholinergic burden was estimated using anticholinergic risk assessment tools, and associations between anticholinergic load and mortality were investigated. The primary outcome of interest was the association between anticholinergic burden and mortality.ResultsTwenty-seven studies were included. These were three cross-sectional, one nested case-control and 23 prospective or retrospective cohort studies. Most studies were determined to be of good quality. A total of 15 studies reported a positive correlation between anticholinergic burden and mortality, while the remaining 10 studies did not report a significant association. Eighteen out of 27 studies (80%) had a short follow-up period of 1 year or less. Among the five high-quality studies that met all the domains of the quality assessment criteria, four showed a positive association.ConclusionThe variation in results could relate to the quality of the studies, follow-up period, anticholinergic risk assessment tool used and the study setting. Sixty-three percent (n = 17) of all the included studies, but almost all of the high-quality studies with an extended follow-up, reported a positive correlation between anticholinergic burden and mortality. Further high-quality research, using standardized measures and with adequate follow-up periods, is required to confirm the relationship between anticholinergic burden and mortality.

Background Drugs with anticholinergic properties are associated with cognitive adverse effects, especially in patients vulnerable to central muscarinic antagonism. A variety of drugs show weak, moderate or strong anticholinergic effects. Therefore, the cumulative anticholinergic burden should be considered in patients with cognitive impairment. This study aimed to develop a Swedish Anticholinergic Burden Scale (Swe-ABS) to be used in health care and research. Methods A systematic literature review was conducted in PubMed and Ovid Embase to identify previously published tools quantifying anticholinergic drug burden (i.e., exposure). Drugs and grading scores (0–3, no to high anticholinergic activity) were extracted from identified lists. Enteral and parenteral drugs authorized in Sweden were included. Drugs with conflicting scores in the existing lists were assessed by an expert group. Two drugs that were not previously assessed were also added to the evaluation process. Results The systematic literature search identified the following nine anticholinergic burden scales: Anticholinergic Activity Scale, Anticholinergic Burden Classification, updated Anticholinergic Cognitive Burden scale, Anticholinergic Drug Scale, Anticholinergic Load Scale, Anticholinergic Risk Scale, updated Clinician-rated Anticholinergic Scale, German Anticholinergic Burden Scale and Korean Anticholinergic Burden Scale. A list of drugs with significant anticholinergic effects provided by The Swedish National Board of Health and Welfare was included in the process. The suggested Swe-ABS consists of 104 drugs scored as having weak, moderate or strong anticholinergic effects. Two hundred and fifty-six drugs were listed as having no anticholinergic effects based on evaluation in previous scales. In total, 62 drugs were assessed by the expert group. Conclusions Swe-ABS is a simplified method to quantify the anticholinergic burden and is easy to use in clinical practice. Publication of this scale might make clinicians more aware of drugs with anticholinergic properties and patients’ total anticholinergic burden. Further research is needed to validate the Swe-ABS and evaluate anticholinergic exposure versus clinically significant outcomes.

PurposeOlder 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.MethodsWe 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.ResultsOut 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.ConclusionThere 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.

Background: Lupin beans, a yellow legume seed from the Lupinus plant, are commonly used in Southern Europe, Latin America, and the Middle East. Despite their bitter taste, lupin beans are highly nutritious and rich in protein, making them popular snacks. The bitter taste is due to the presence of over 150 quinolizidine alkaloids, with Lupanine being the predominant alkaloid. If not properly debittered before ingestion, lupin toxicity and anticholinergic symptoms can occur. Case Presentation: A 49-year-old healthy Egyptian man presented with symptoms such as dry mouth, unsteadiness, constipation, and urinary retention for 6 hours. After investigation, it was discovered that he had consumed 400 g of bitter lupin beans within a 1-hour period, around 4-6 hours before the symptom onset. The patient was oriented, conscious, and alert, showing no signs of pain or distress. His vital signs were normal, and he had normal cardiovascular, pulmonary, gastrointestinal, and neurological examinations. His eye examination revealed fixed, dilated pupils bilaterally, blurry vision, and normal eye movement bilaterally. Laboratory tests were normal. The patient received Ringer's lactate intravenously and was closely monitored in the emergency department. Over a 3-hour period, all symptoms and signs resolved with fluid management alone, and the patient was discharged home following his improvement. Conclusion: This report highlights the importance of history taking in diagnosing food-related diseases and emphasizes that physicians should consider lupin toxicity as a differential diagnosis in cases presenting with anticholinergic symptoms.