Associação da carga anticolinérgica com o déficit cognitivo e funcional em idosos – projeto epidoso: comparação entre as escalas anticolinérgicas
Data
2023-12-04
Autores
Conti, Mônica de Souza Brito 
Orientadores
Ramos, Luiz Roberto
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Contextualização: Medicamentos anticolinérgicos (MAch) são comumente prescritos para idosos, e têm sido frequentemente associados a inúmeros eventos adversos, principalmente cognitivos e funcionais. O acúmulo do uso de MAch constitui a carga anticolinérgica (CAC), e diferentes escalas foram propostas para avaliar a farmacoterapia dos idosos e verificar desfechos clínicos adversos (negativos) nessa população. Objetivo: Avaliar por meio de quatro escalas anticolinérgicas, a prevalência do uso de MAch e a associação do uso e da CAC com o comprometimento cognitivo e funcional, depressão, quedas e internações nos idosos da coorte Epidoso II, tanto na linha de base quanto após o seguimento da coorte. Métodos: Trata-se de um estudo de coorte, em que foram analisados dados provenientes do Projeto Epidoso II. Investigou-se idosos de ambos os sexos com ≥60 anos. As variáveis independentes consideradas foram: variáveis sociodemográficas e econômicas, condições de saúde (polimorbidade, polifarmácia, uso de MPI), hábitos de saúde (consumo de cigarro e álcool) e desfechos clínicos adversos (comprometimento cognitivo – MEEM; incapacidade funcional – BOMFAQ, depressão – GDS-15, quedas, internações nos últimos 6 meses); e o conjunto das variáveis dependentes consideradas foram: a utilização de MAch e a CAC avaliadas pelas escalas Anticholinergic drug scale (ADS), Anticholinergic risk scale (ARS), Anticholinergic cognitive burden scale (ACB), Escala brasileira de medicamentos com atividade anticolinérgica (EBMAA). Foi realizada uma análise transversal e verificou-se a prevalência do uso de MAch, a quantificação da CAC, concordância entre as escalas, bem como, investigou-se fatores de risco e desfechos clínicos adversos associado ao uso de MAch e a CAC. E, na análise longitudinal averiguou-se a relação da incidência de desfechos clínicos adversos com uso de MAch. Os dados obtidos foram tratados estatisticamente com o STATA/SE 15.1 for Windows e foi adotado um nível de significância de 5% (p<0,05). A prevalência do uso de MAch foi calculada com o seu intervalo de confiança de 95% (IC), a concordância entre as escalas utilizou-se o teste KAPPA, a associação do uso de MAch com as variáveis pela razão de prevalência e a CAC com as variáveis foi realizado o teste Qui-Quadrado e o “odds ratio” (OR) IC 95%, e posteriormente, foi ajustado um modelo multivariado de regressão logística. Foram calculadas as taxas de incidência para os desfechos clínicos adversos, bem
ix
como, um modelo de regressão de Cox para estimar o “hazard ratio” e o IC 95% para a associação do uso de MAch e incidências dos desfechos clínicos adversos. Resultados: Dos 1205 idosos participantes da linha de base da coorte Epidoso II, 1143 (95%) idosos utilizavam medicamentos; destes, 612 idosos utilizavam MAch em ao menos uma das escalas. A prevalência de MAch foi de 53,5% (IC 95%: 50,6%; 56,5%), bem como, de cada escala: EBMAA 52,3% (n=598, IC 95%: 49,4%; 55,2%), ACB 42,9% (n=490, IC 95%: 40,0%; 45,8%), ADS 40,1% (n=458, IC 95%: 37,2%; 43,0%) e ARS 10,8% (n=123, IC 95%: 9,0%; 12,7%). A CAC ≥3 (alta AA) esteve presente em 190 (31%) idosos pela escala EBMAA, 153 (25%) pela escala ACB, 142 (23,2%) pela escala ADS e 67 (10,9%) pela ARS. Encontrou-se uma concordância quase perfeita entre as escalas ADS/ACB (0,835), ACB/EBMAA (0,827) e uma boa concordância entre as escalas ADS/EBMAA (0,770). Na análise multivariada, as variáveis: baixa escolaridade, polifarmácia, uso de MPI, multimorbidade, incapacidade funcional e depressão foram estatisticamente significativas com o uso de MAch. A CAC pela escala ARS teve uma associação significativa com as variáveis: sexo “feminino” e “uso de MPI”; pela escala ADS com as variáveis: sexo “feminino”, “idade ≥80 anos”, “uso de MPI”, “internações nos últimos 6 meses” e ser “etilista”; pela escala ACB com as variáveis: sexo “feminino”, “alta escolaridade”, “uso de MPI”, ser “etilista” e ter “incapacidade funcional (≥7 limitações)” e pela escala EBMAA com as variáveis: sexo “feminino”, “idade ≥80 anos”, “uso de MPI” e ser “etilista”. O uso de medicamentos com escores 2 e 3 nas escalas associou-se estatisticamente com as variáveis sexo “feminino” e “polifarmácia”. Na análise longitudinal, as variáveis com associação significativa com o uso de MAch foram: baixa escolaridade, prática de polifarmácia, uso de MPI e incapacidade funcional. Houve significância estatística para o uso de MAch como um fator de risco para a incidência dos desfechos clínicos adversos: “incapacidade funcional” e “depressão”. Conclusão: A utilização de escalas anticolinérgicas pode auxiliar na prescrição para idosos, prevenindo e reduzindo os eventos adversos, de forma a promover uma farmacoterapia eficaz e segura. Os resultados obtidos contribuirão para implementação de ferramentas e estratégias de ações em saúde, que auxiliarão na revisão da farmacoterapia do idoso, de forma a promover uma prescrição adequada e melhor qualidade de vida aos idosos, a fim de que vivam o maior tempo possível em seus domicílios com saúde, autonomia e independência.
Background: Anticholinergic medications (AchM) are commonly prescribed for the aged, and have been frequently associated with numerous adverse events, mainly cognitive and functional. The accumulation of AchM use constitutes the anticholinergic burden (AchB), and different scales have been proposed to evaluate pharmacotherapy in the aged and verify adverse (negative) clinical outcomes in this population. Objective: To evaluate, using four anticholinergic risk scales, the prevalence of AchM use and the association of use and AchB with cognitive and functional impairment, depression, falls and hospitalizations in the aged in the Epidoso II cohort, both at baseline and after the cohort follow-up. Methods: This is a cohort study, in which secondary data from the Epidoso II Project were analyzed. Aged of both sexes aged ≥60 years were investigated. The independent variables considered were: sociodemographic and economic variables, health conditions (polymorbidity, polypharmacy, use of PIM), health habits (cigarette and alcohol consumption) and adverse clinical outcomes (cognitive impairment – MMSE; functional disability – BOMFAQ; depression – GDS-15; falls; hospitalizations in the last 6 months); and the set of dependent variables considered were: the use of AchM and AchB evaluated by the Anticholinergic drug scale (ADS), Anticholinergic risk scale (ARS), Anticholinergic cognitive burden scale (ACB), Brazilian scale of medicines with anticholinergic activity (BSMAA). A cross-sectional analysis was carried out and the prevalence of AchM use, AchB quantification, agreement between the scales was verified, as well as risk factors or adverse clinical outcomes associated with the use of AchM and AchB were investigated. in the longitudinal analysis, the relationship between the incidence of adverse clinical outcomes and the use of MAch was investigated. The data obtained were statistically treated with STATA/SE 15.1 for Windows and a significance level of 5% (p<0.05) was adopted. The prevalence of MAch use was calculated with its 95% confidence interval (CI), the agreement between the scales was used using the KAPPA test, the association of the use of MAch with the variables by the prevalence ratio and the CAC with the variables was carried out the test Chi-Square and the “odds ratio” (OR) IC 95%, and subsequently, a multivariate logistic regression model was adjusted. Incidence rates for adverse clinical outcomes were calculated, as well as a Cox regression model to estimate the “hazard ratio” and the 95% CI for the association xii between the use of MAch and incidences of adverse events. Results: Of the 1205 aged participating in the Epidoso II cohort baseline, 1143 (95%) aged used medication; Of these, 612 aged used AchM in at least one of the scales. The prevalence of AchM was 53.5% (95%CI: 50.6%; 56.5%) and for each scale it was: BSMAA 52.3% (n=598, 95%CI: 49.4%; 55, 2%), ACB 42.9% (n=490, 95%CI: 40.0%; 45.8%), ADS 40.1% (n=458, 95%CI: 37.2%; 43.0%) and ARS 10.8% (n=123, 95%CI: 9.0%; 12.7%). The AchB ≥3 (high risk) was present in 190 (31%) aged according to the BSMAA scale, 153 (25%) according to the ACB scale, 142 (23.2%) according to the ADS scale and 67 (10.9%) according to the ARS. An almost perfect agreement was found between the ADS/ACB (0.835), ACB/BSMAA (0.827) scales and a good agreement between the scales ADS/BSMAA (0.770). In the multivariate analysis, the variables: low education, polypharmacy, use of PIM, multimorbidity, functional disability and depression were statistically significant with the use of AchM. CAC using the ARS scale had a significant association with the variables: “female” gender and “use of PIM”; using the ADS scale with the variables: “female” sex, “age ≥ 80 years”, “use of PIM”, “hospitalizations in the last 6 months” and being “alcoholic”; by the ACB scale with the variables: “female” sex, “high level of education”, “use of PIM”, being “alcoholic” and having “functional disability (≥7 limitations)” and by the EBMAA scale with the variables: “female” sex , “age ≥80 years”, “use of PIM” and being “alcoholic”. The use of medications with scores 2 and 3 on the scales was statistically associated with the variables “female” sex and “polypharmacy”. In the longitudinal analysis, the variables with a significant association with the use of Mach were: low education, practice of polypharmacy, use of PIM and functional disability. There was statistical significance for the use of MAch as a risk factor for the incidence of adverse clinical outcomes: “functional disability” and “depression”. Conclusion: The use of anticholinergic scales can assist in prescriptions for the aged, preventing and reducing adverse events, to promote effective and safe pharmacotherapy. The results obtained will contribute to the implementation of tools and strategies for health actions, which will assist in the review of pharmacotherapy for the aged, in order to promote adequate prescription and better quality of life for the aged, so that they can live as long as possible in their homes with health, autonomy and independence.
Background: Anticholinergic medications (AchM) are commonly prescribed for the aged, and have been frequently associated with numerous adverse events, mainly cognitive and functional. The accumulation of AchM use constitutes the anticholinergic burden (AchB), and different scales have been proposed to evaluate pharmacotherapy in the aged and verify adverse (negative) clinical outcomes in this population. Objective: To evaluate, using four anticholinergic risk scales, the prevalence of AchM use and the association of use and AchB with cognitive and functional impairment, depression, falls and hospitalizations in the aged in the Epidoso II cohort, both at baseline and after the cohort follow-up. Methods: This is a cohort study, in which secondary data from the Epidoso II Project were analyzed. Aged of both sexes aged ≥60 years were investigated. The independent variables considered were: sociodemographic and economic variables, health conditions (polymorbidity, polypharmacy, use of PIM), health habits (cigarette and alcohol consumption) and adverse clinical outcomes (cognitive impairment – MMSE; functional disability – BOMFAQ; depression – GDS-15; falls; hospitalizations in the last 6 months); and the set of dependent variables considered were: the use of AchM and AchB evaluated by the Anticholinergic drug scale (ADS), Anticholinergic risk scale (ARS), Anticholinergic cognitive burden scale (ACB), Brazilian scale of medicines with anticholinergic activity (BSMAA). A cross-sectional analysis was carried out and the prevalence of AchM use, AchB quantification, agreement between the scales was verified, as well as risk factors or adverse clinical outcomes associated with the use of AchM and AchB were investigated. in the longitudinal analysis, the relationship between the incidence of adverse clinical outcomes and the use of MAch was investigated. The data obtained were statistically treated with STATA/SE 15.1 for Windows and a significance level of 5% (p<0.05) was adopted. The prevalence of MAch use was calculated with its 95% confidence interval (CI), the agreement between the scales was used using the KAPPA test, the association of the use of MAch with the variables by the prevalence ratio and the CAC with the variables was carried out the test Chi-Square and the “odds ratio” (OR) IC 95%, and subsequently, a multivariate logistic regression model was adjusted. Incidence rates for adverse clinical outcomes were calculated, as well as a Cox regression model to estimate the “hazard ratio” and the 95% CI for the association xii between the use of MAch and incidences of adverse events. Results: Of the 1205 aged participating in the Epidoso II cohort baseline, 1143 (95%) aged used medication; Of these, 612 aged used AchM in at least one of the scales. The prevalence of AchM was 53.5% (95%CI: 50.6%; 56.5%) and for each scale it was: BSMAA 52.3% (n=598, 95%CI: 49.4%; 55, 2%), ACB 42.9% (n=490, 95%CI: 40.0%; 45.8%), ADS 40.1% (n=458, 95%CI: 37.2%; 43.0%) and ARS 10.8% (n=123, 95%CI: 9.0%; 12.7%). The AchB ≥3 (high risk) was present in 190 (31%) aged according to the BSMAA scale, 153 (25%) according to the ACB scale, 142 (23.2%) according to the ADS scale and 67 (10.9%) according to the ARS. An almost perfect agreement was found between the ADS/ACB (0.835), ACB/BSMAA (0.827) scales and a good agreement between the scales ADS/BSMAA (0.770). In the multivariate analysis, the variables: low education, polypharmacy, use of PIM, multimorbidity, functional disability and depression were statistically significant with the use of AchM. CAC using the ARS scale had a significant association with the variables: “female” gender and “use of PIM”; using the ADS scale with the variables: “female” sex, “age ≥ 80 years”, “use of PIM”, “hospitalizations in the last 6 months” and being “alcoholic”; by the ACB scale with the variables: “female” sex, “high level of education”, “use of PIM”, being “alcoholic” and having “functional disability (≥7 limitations)” and by the EBMAA scale with the variables: “female” sex , “age ≥80 years”, “use of PIM” and being “alcoholic”. The use of medications with scores 2 and 3 on the scales was statistically associated with the variables “female” sex and “polypharmacy”. In the longitudinal analysis, the variables with a significant association with the use of Mach were: low education, practice of polypharmacy, use of PIM and functional disability. There was statistical significance for the use of MAch as a risk factor for the incidence of adverse clinical outcomes: “functional disability” and “depression”. Conclusion: The use of anticholinergic scales can assist in prescriptions for the aged, preventing and reducing adverse events, to promote effective and safe pharmacotherapy. The results obtained will contribute to the implementation of tools and strategies for health actions, which will assist in the review of pharmacotherapy for the aged, in order to promote adequate prescription and better quality of life for the aged, so that they can live as long as possible in their homes with health, autonomy and independence.
Descrição
Citação
CONTI, Mônica de Souza Brito. Associação da carga anticolinérgica com o déficit cognitivo e funcional em idosos – projeto epidoso: comparação entre as escalas anticolinérgicas. 2023. 196 f. Tese (Doutorado em Saúde Coletiva) - Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, 2023.