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Anticholinergic effects on cognitive impairment in the elderly

Results of a study were published last week looking at the cumulative use of strong anticholinergics on the development of dementia in the elderly (those aged 65 years). 1 The results revealed that long term use of one or several drugs with could be associated with an increased risk of dementia, including Alzheimer’s disease.1 Anticholinergics are used to treat the (OAB), as well as depression and allergy related conditions such as hay fever.

OAB affects over 7 million adults in the UK2 and can have a significant impact on quality of life. 3 It is also more common than angina and diabetes, 4, 5 and the symptoms can almost dominate people’s lives – they restrict their freedom of movement, prevent them from participating in activities they previously enjoyed, cause stress, embarrassment and anxiety. OAB is also linked to depression.3, 6, 7, 8

OAB is commonly treated by health care professionals with the use of anticholinergic medications. These target the muscarinic acetylcholine receptors in the bladder and have, for years, been the mainstay of pharmacological treatment for OAB.

There are many OAB drugs available and these differ in their likelihood to cause anticholinergic side effects outside of the bladder, which are known to include in elderly subjects.

The impact of treating OAB in the elderly and easing symptoms should not be underestimated as with this patient population it can cause loss of independence,6 be linked to falls (especially with regards to the need to visit the toilet at night) which in turn are associated with fractures.6 OAB in is therefore often associated with the progression of increasing frailty and dependence on others.

Many patients with OAB will continue to be treated successfully with , but if there are concerns regarding high anticholinergic burden (e.g. in elderly patients on multiple treatments), alternative treatments for OAB are available, and should be considered, and NICE guidelines should be referred to. 9

Betmiga (mirabegron) is a selective ?3-adrenoreceptor agonist that has been accepted for use by the SMC10 and is recommended by NICE11 as an option for treating patients with symptoms of OAB in whom antimuscarinic drugs are contraindicated, clinically ineffective, or have unacceptable side effects. This means that Betmiga belongs to a different class of OAB therapeutics which does not contribute to anticholinergic burden. The decision regarding prescribing the most beneficial treatment for patients suffering OAB symptoms shall be based on judgement of health care practitioners.

Source

1 Larson et al. Cumulative Use of Strong Anticholinergics and Incident Dementia. JAMA Intern Med 2015

2 Astellas Pharma Ltd. Data on File. STAR Number 363714 – January 2012

3 Coyne KS, Payne C, Bhattacharyya SK et al. The Impact of Urinary Urgency and Frequency on Health-Related Quality of Life in : Results from a National Community Survey. Value in Health 2004 7:4;455-463

4 British Heart Foundation. Prevalence of angina, by sex and age, England, Scotland, Wales and Northern Ireland, 2011; available at http://www.bhf.org.uk/research/heart-statistics/morbidity/prevalence.aspx (accessed April 2014)

5 Diabetes UK. Diabetes prevalence 2012, 2013; https://www.diabetes.org.uk/About_us/What-we-say/Statistics/Diabetes- prevalence-2012(accessed April 2014)

6 Peters, J et al. Quality in the Community – Practical advice to optimise care and reduce inefficiencies in the local management of Overactive Bladder. Pulse supplement. June, 2014

7 Reeves P, Irwin D, Kelleher C et al. The Current and Future Burden and Cost of Overactive Bladder in Five European Countries. European Urology 2006. 50:1050-1057

8 Ouslander JG. Management of overactive bladder. N Engl J Med 2004;350:786-99

9 National Institute for Health and Care Excellence. The management of urinary incontinence in women Clinical Guideline 171. 2013 10 SMC. Advice: mirabegron 25mg and 50mg prolonged-release tablets (Betmiga®) SMC No. (862/13)

11 National Institute for Health and Care Excellence. Mirabegron for treating symptoms of overactive bladder Technology Appraisal 290, 2013

Source: Astellas Pharma Ltd