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
Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, 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 Jan 25 2023, 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.
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
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)
Dietary changes (avoid bladder irritants such as acidic drinks, caffeine)
If Behavioral therapy fails, the following medications may be offered:
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
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
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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