Advertisement

Anticholinergic Medications and Parent-Reported Anticholinergic Symptoms in Neurologically Impaired Children

      Abstract

      Context

      Children with severe neurological impairment and polypharmacy are exposed to anticholinergic (AC) medications that may have anticholinergic side effects, but this is understudied. Anticholinergic Cognitive Burden (ACB) scores measure total anticholinergic burden for a medication regimen, and scores ≥3 have been associated with increased morbidity and mortality in adults.

      Objective

      We assessed the relationship between ACB scores and parent-reported anticholinergic symptoms in children.

      Methods

      Cross-sectional study of patients one to 18 years-old with ICD-defined severe neurological impairment and polypharmacy. At routine clinical visits, total ACB scores were computed for all medications. Parent-reported AC symptoms (constipation, drowsiness, difficulty concentrating, dry mouth, or urinary problems) were assessed. Multivariable logistic regression was used to test the association between total ACB scores ≥3 for scheduled medications and the presence of AC symptoms, adjusted for age and recent acute healthcare utilization.

      Results

      Among 123 unique patients, 87% were prescribed AC medications. Common AC medication classes included: systemic antihistamines (64%), anxiolytics (53%), antidepressants (30%), H2 blockers (22%), and muscle relaxants (20%). Total ACB scores ≥3 were observed in 44% for scheduled medications and in 63% of patients for scheduled plus PRN medications. Total ACB scores ≥3 were significantly associated with an increased odds of ≥1 anticholinergic symptoms for scheduled medications (OR: 3.1; 95% CI: 1.4, 6.7) and for scheduled plus PRN medications (OR: 2.9; 95% CI: 1.3, 6.4).

      Conclusion

      If replicated in larger populations, the association between elevated total ACB scores and anticholinergic side effects in children should prompt clinicians to consider deprescribing potentially unneeded anticholinergic medications.

      Key Words

      Abbreviations:

      AC (anticholinergic), ACB (Anticholinergic Cognitive Burden), PRN (pro re nata (as needed)), PRO-Sx (Parent-Reported Outcomes of Symptoms), SNI (severe neurological impairment.)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Pain and Symptom Management
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Feinstein JA
        • Hall M
        • Antoon JW
        • et al.
        Chronic medication use in children insured by medicaid: a multistate retrospective cohort study.
        Pediatrics. 2019; 143 (Epub 2019/03/28PubMed PMID: 30914443; PMCID: PMC6456893)https://doi.org/10.1542/peds.2018-3397
        • Feinstein JA
        • Friedman H
        • Orth LE
        • et al.
        Complexity of medication regimens for children with neurological impairment.
        JAMA Netw Open. 2021; 4 (Epub 20210802PubMed PMID: 34436607; PMCID: PMC8391103)e2122818https://doi.org/10.1001/jamanetworkopen.2021.22818
        • Feinstein JA
        • Feudtner C
        • Blackmer AB
        • et al.
        Parent-reported symptoms and medications used among children with severe neurological impairment.
        JAMA Netw Open. 2020; 3 (Epub 20201201PubMed PMID: 33306117; PMCID: PMC7733159)e2029082https://doi.org/10.1001/jamanetworkopen.2020.29082
        • Feinstein JA
        • Feudtner C
        • Valuck RJ
        • et al.
        Identifying important clinical symptoms in children with severe neurological impairment using parent-reported outcomes of symptoms.
        JAMA Pediatr. 2020; 174 (Epub 2020/10/13PubMed PMID: 33044500; PMCID: PMC7551220): 1114-1117https://doi.org/10.1001/jamapediatrics.2020.2987
        • Blackmer AB
        • Fox D
        • Arendt D
        • Phillips K
        • Feinstein JA.
        Perceived vs demonstrated understanding of the complex medications of medically complex children.
        J Pediatr Pharmacol Ther. 2021; 26 (Epub 20210104PubMed PMID: 33424502; PMCID: PMC7792139): 62-72https://doi.org/10.5863/1551-6776-26.1.62
        • Feinstein J
        • Dai D
        • Zhong W
        • Freedman J
        • Feudtner C.
        Potential drug-drug interactions in infant, child, and adolescent patients in children's hospitals.
        Pediatrics. 2015; 135 (Epub 20141215PubMed PMID: 25511114): e99-108https://doi.org/10.1542/peds.2014-2015
        • Feinstein JA
        • Feudtner C
        • Valuck RJ
        • Kempe A.
        The depth, duration, and degree of outpatient pediatric polypharmacy in Colorado fee-for-service Medicaid patients.
        Pharmacoepidemiol Drug Saf. 2015; 24 (Epub 20150807PubMed PMID: 26248529): 1049-1057https://doi.org/10.1002/pds.3843
        • Salahudeen MS
        • Duffull SB
        • Nishtala PS.
        Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review.
        BMC Geriatr. 2015; 15 (Epub 20150325PubMed PMID: 25879993; PMCID: PMC4377853): 31https://doi.org/10.1186/s12877-015-0029-9
        • Beutelstetter M
        • Livolsi A
        • Greney H
        • et al.
        Increased expression of blood muscarinic receptors in patients with reflex syncope.
        PLoS One. 2019; 14 (Epub 20190718PubMed PMID: 31318899; PMCID: PMC6638918)e0219598https://doi.org/10.1371/journal.pone.0219598
      1. Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medications in older people. Archives of internal medicine. 2007;167:781-7. Epub 2007/04/25.https://doi.org/10.1001/archinte.167.8.781. PubMed PMID: 17452540.

        • Feinstein JA
        • Russell S
        • DeWitt PE
        • et al.
        R package for pediatric complex chronic condition classification.
        JAMA Pediatr. 2018; 172 (Epub 2018/05/02PubMed PMID: 29710063; PMCID: PMC5933455): 596-598https://doi.org/10.1001/jamapediatrics.2018.0256
        • Thomson JE
        • Feinstein JA
        • Hall M
        • et al.
        Identification of children with high-intensity neurological impairment.
        JAMA Pediatr. 2019; 173 (Epub 2019/08/20PubMed PMID: 31424541; PMCID: PMC6704733): 989-991https://doi.org/10.1001/jamapediatrics.2019.2672
        • Thomson J
        • Hall M
        • Nelson K
        • et al.
        Timing of Co-occurring chronic conditions in children with neurologic impairment.
        Pediatrics. 2021; 147 (Epub 20210107PubMed PMID: 33414236; PMCID: PMC7849195)https://doi.org/10.1542/peds.2020-009217
        • von Elm E
        • Altman DG
        • Egger M
        • et al.
        The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies.
        Lancet. 2007; 370 (Epub 2007/12/08PubMed PMID: 18064739): 1453-1457https://doi.org/10.1016/S0140-6736(07)61602-X
        • Zhou H
        • Roberts PA
        • Dhaliwal SS
        • Della PR.
        Risk factors associated with paediatric unplanned hospital readmissions: a systematic review.
        BMJ Open. 2019; 9 (Epub 2019/01/31PubMed PMID: 30696664; PMCID: PMC6352831)e020554https://doi.org/10.1136/bmjopen-2017-020554
        • Bogler O
        • Roth D
        • Feinstein J
        • et al.
        Choosing medications wisely: Is it time to address paediatric polypharmacy?.
        Paediatr Child Health. 2019; 24 (Epub 20190105PubMed PMID: 31379430; PMCID: PMC6656947): 303-305https://doi.org/10.1093/pch/pxy188