AUGS Statement on Anticholinergic Medications for Overactive Bladder and Dementia Risk

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the components of behavioral therapy for the treatment of overactive bladder
2. Restate the medications that may be offered to treat overactive bladder

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Genoox, Inc., and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2019, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

Overactive bladder (OAB) is clinically diagnosed by symptoms of urinary urgency/urge incontinence, frequency and usually nocturia. Several studies have raised concerns about the role of anticholinergic medications in cognitive decline, dementia and Alzheimer’s disease. The risk was highest in patients taking the drugs with the most anticholinergic activity.

In response to these concerns AUGS recommends the following:

When behavioral therapies have failed, counsel patients on risks of cognitive impairment/dementia/Alzheimer’s vs benefits of quality of life improvements prior to instituting anticholinergic medication
Prescribe the lowest effective dose and consider a beta -3 agonist in patients at risk of cognitive decline
Consider changing or decreasing the doses of other anticholinergics such as antidepressants/antihistimines
Consider intradetrusor onabotulinum toxin A or neuromodulation for patients not desiring medication for OAB

KEY POINTS:

Behavioral therapy is the first line treatment for OAB and most effective if individualized to include multiple components

Modify bladder function (e.g., changing voiding habits, such as delayed voiding)
Pelvic floor muscle training and exercise (improve strength and control)
Biofeedback
Fluid management
Dietary changes (avoid bladder irritants such as acidic drinks, caffeine)
Weight Loss

If Behavioral therapy fails, the following medications may be offered:

Antimuscarinics
- Anticholinergic medication work by blocking acetylcholine at muscarinic receptors
- Muscarinic receptors occur throughout the body giving rise to potential anticholinergic effects including dry mouth, blurred vision, constipation and impaired cognition
- Brain penetration is greatest with oxybutynin, solifenacin and tolterodine
- Brain penetration is lower with newer agents such as 5-hydroxylmethyl tolterodine, darifenacin and trospium
Beta-3 agonists
- Act on adrenergic receptors
- Mirabegron is the first of a new class of drugs
- Clinical effectiveness of mirabegron is similar to that of tolterodine
- Dry mouth is similar to placebo and fewer arrhythmias than tolterodine

There are multiple recent studies, two of which specifically demonstrate an association between anticholinergics, dementia and Alzheimer’s disease, particularly in older individuals:

Gray et al. (JAMA Internal Medicine, 2015): Those in the highest exposure category (oxybutynin 5 mg taken daily > than 3 years) had 1.5 times more risk of having dementia or Alzheimer’s disease (entry criteria 65 and older)
Risacher et al. (JAMA Neurology, 2016): Reduced cognitive performance and brain glucose metabolism as well as increased brain atrophy was found in anticholinergic users compared to nonusers (average age of participants 73.3 years)

The American Geriatrics Society (AGS) Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults

Antimuscarinics are included in the Beers Criteria in Table 3 and Table 7 as PIMs to be avoided due to drug–disease or drug–syndrome interactions that may exacerbate the disease or syndrome
Specifically, anticholinergics are to be avoided in the context of dementia or cognitive impairment
Avoidance recommendation is rated as ‘strong’