Reducing Anticholinergic Burden for Older Adults With Overactive Bladder in LTC

Manju T Beier, Pharm D, BCGP, FASCP, senior partner, Geriatric Consultant Resources LLC, and adjunct associate professor of pharmacy, The University of Michigan, Ann Arbor, MI, discusses the overall prevalence and risks associated with overactive bladder among older adults in long-term care, as well as offers insight on successful initiatives to reduce anticholinergic burden.

This interview is part of the series,"Navigating Clinical Challenges, Improving Care for Patients With Overactive Bladder."

Read the full transcript:

Welcome back to Pop Health Perspectives, a conversation with the population health learning network, where we combine expert commentary and exclusive insight into key issues in population health management, and more.

In this episode, Dr Beier discusses the challenges of caring for older adults with overactive bladder (OAB) and shares insight on successful initiatives to reduce anticholinergic burden. Thank you for joining us today, Dr Beier.

Thank you Edan for this opportunity to talk about OAB in the long-term care (LTC) setting. My name is Dr Manju Beier and I am a board certified geriatric pharmacist practicing in geriatrics pharmacotherapy, practice, research, and education for the last 30 years. I also have had an adjunct associate professor appointment at the College of Pharmacy, University of Michigan since 2000. Although, I've been involved with them for many years, even beyond that, and do some teaching and research and education.

I have practiced in LTC, ambulatory care, been in the hospital practice, been in pharmaceutical industry, and have been full-time in academia—so all over the place. But I would say for the last 30 years I've been in geriatrics and also a member of several professional pharmacy associations, including American Society of Consultant Pharmacists, and that will have a bearing on the things we'll talk about a little bit later in the program.

Fantastic. Thank you, Dr Beier, and thank you for taking the time to speak with us today. Can you talk about the overall prevalence and burden of OAB and urinary incontinence (UI) among the patient population in LTC? What makes caring for frail older adults (OAs) more challenging?

OAB and UI are used interchangeably but for purposes of discussion, we'll just throw them both together. OAB is really a symptom complex, and instead of calling it a disease condition, some people would call it a geriatric syndrome. And the OAB symptom complex includes frequency, urgency, urge incontinence, and many of the lower urinary tract symptoms that we see frequently in OAs. Incontinence in general, maybe about 25% of the US population over the age of 40 years, when the symptoms are present, but as people get older the prevalence increases. And in LTC where the average age is 85 to 90 years, over the last maybe 5 to 10 years, the prevalence is much higher.

The incidence in terms of men and women over the ages of 80 years is essentially similar. There is a difference in the younger population. It has huge clinical implications and functional implications, and tied together with that, it has financial implications as well for the nursing home industry and all of us practicing in LTC. The clinical implications, certainly OAB can contribute to falls—and this has been well established—contribute to affecting cognition, which is actually more of a complex issue in terms of what came first because dementia is a comorbidity frequently seen in the setting of OAB. UTIs in general happen much more in the setting of UI as well.

Increased dependence in activities in daily living in terms of the burden for caregivers in LTC is an added burden as well, maybe possibly contributing to increase in emergency room admissions and hospitalizations. It does have a fair number of consequences to have OAB. And then conversely, there are many comorbidities that are associated with OAB. We just mentioned dementia and cognitive decline. We know that upwards of 70% to 80% of LTC residents, especially in skilled nursing facilities (SNFs) have dementia and the complex interaction of OAB and dementia is prevalent and has a bearing on how we treat and manage and what pharmacologic agents we utilize.

Thank you, Dr Beier. And you touched on this a little bit, but data show that medically complex OAs with OAB have a greater comorbidity burden than those without OAB. Can you talk about the effect that this has on the LTC facilities and the staff that need to care for these residents?

Yes, absolutely. As we mentioned, the prevalence of OAB rises in LTC facility population, upwards of the age of 80 years. And when these patients have comorbid dementia, comorbid depression, comorbid diabetes, that increases not just the clinical burden of some of the things we mentioned, like falls and UTIs and admission into the ER, admission to the hospital, but also there is a lack of mobility. There are issues with functional mobility and dexterity, the urge to get to the bathroom, so to speak. And so there are falls and fractures associated with it, as we mentioned. Pressure ulcers—especially in moderate to advanced dementia—when you have UI, it can lead to pressure sores and pressure ulcers as well. It does increase the caregiver burden.

I would say that many presentations in geriatric professional societies, whether it's the nurse practitioners or pharmacists or AMDA, American Medical Directors Association, many presentations talk about the increased burden of OAB and what it has on the facility in terms of clinical, as well as financial implications. And in terms of hours of time devoted to the care of these residents to increase the quality of life and decrease the potential negative consequences that we talked about.

Great. Thank you. Speaking about the actual care that is implemented to take care of this patient population, what does the current treatment landscape and guidelines for patients with OAB look like?

The guidelines have not radically changed over the last 5 to 10 years I would say. Behavioral modifications are really the first line, if you will, scheduled toileting and bladder training. And then if they have a combination of stress incontinence and urge incontinence, especially in women, pelvic exercises, if cognitively, they are okay to receive instructions to do that. And even in men, pelvic floor exercises are important. Just like in many other diseases that we talk about, like dementia, when as dementia progresses, we have behavioral and psychological symptoms of dementia, the first line is always behavioral modification, nonpharm therapies.

Analogously in OAB, the first line is behavioral modification—again, prompted voiding, scheduled toileting, pelvic floor exercises. And that's essentially what the guidelines will tell you as well.

And second comes pharmacotherapy. And now we have two different pharmacotherapeutic classes in the management of OAB. They're not therapeutically interchangeable because they're distinct pharmacological classes based on the pharmacology of bladder and the entire system. And then of course you can use them in combination as well. The first line is behavioral modifications. Second line is pharmacotherapy, but certainly you can use them in conjunction in terms of guidelines.

An ongoing concern in LTC and post-acute care settings are the risks of polypharmacy and appropriate medication usage and growing anticholinergic burden. In your experience, what are some of the most effective methods to address these risks?

That really speaks to the heart of the issue where people like myself that have expertise in geriatric pharmacotherapy and geriatric pharmacology and medication management in OAs, the polypharmacy issue comes up all the time. Polypharmacy. Really, what does it mean? It means many drugs. It really doesn't tell you if the drugs are of the appropriate kind. But what we want to do is to decrease the number of medications the patient is on, the older adult, regardless of the setting—especially in LTC, because there's an increased burden during med pass and SNFs specifically, passing meds and sticking to the guidelines of appropriate administration is important. Polypharmacy is very, very important. And that is why in the last 5 to 10 years, I would say there's been a movement. It's not really rocket science. It's called deprescribing.

Deprescribing is something that we do and we have been doing for 20 to 30 years when we do a medication regimen review of what are the medications the patient is on, an older adult, whether they're in an SNF, assisted living, whether they're out in the community or when they go to the clinic or a doctor's office. What does deprescribing mean? Deprescribing is really a cognitive thought process where you think about what medications can you possibly take away if the indication doesn't exist, if the efficacy is subefficacious, if there are side effects, if there are tolerability issues, adverse drug reactions, the drug has stopped working? If somebody has peptic ulcer and you put them on, what we call, a proton pump inhibitor ad infinitum of, or the entire time, that is not appropriate either because the guidelines tell 8 weeks of therapy or 6 weeks of therapy or 12 weeks of therapy. It's very easy to put a drug on board, but it takes a lot of time and effort and joint discussions to take the medication away.

And that's what deprescribing is all about. It's easier said than done. We all need to be on board. I mean, this is not a very simple calculation. It's the patient, the family, the various members of the interdisciplinary team, the care team in LTC, they have to be on board.

It's a topic close to my heart. I have chaired the deprescribing task force at American Society of Consultant Pharmacists since 2018. It was not a task force that was an established committee. It was something that I really wanted to do, so then I became chair by default, and I'm still a chair 4 years later and we're doing some really good things. And one of the things that has come out of it is what we call The Choosing Wisely Initiative. The Choosing Wisely statements, I should say, that have been submitted to a national initiative in the United States called choosingwisely.org, which is an initiative that was started by the American Board of Internal Medicine and many societies around the country, upwards of 200 societies have submitted the top 5 lists of "do not recommend" and "do not do" in terms of the choosing wisely conversation. At American Society of Consultant Pharmacists, we submitted 5 of our statements in May of 2021, less than a year ago. We are working on the other 5. And 2 of the submitted 5 are associated with this conversation.

The reason I bring them up with this long winded story is that 2 of those choosing wisely statements impact anticholinergic burden. Why are we bringing up anticholinergic burden? It's because one of the therapeutic classes of medications that we have are the OAB drugs, so-called antimuscarinics. They've been around for a long time, medications like Oxybutynin, and Tolterodine fall in that therapeutic class.

And for a long time, we haven't had a second therapeutic class to address the issue of OAB and incontinence. And of course there are many kinds of incontinence. We need to be cognizant that you don't want to treat stress incontinence with an OAB drug. You want to be very sure what kind of incontinence you're treating before you initiate pharmacotherapy, but it's nice to have this second class, which is the beta-3 adrenergic agonist class in which we have two medications. One was approved back in 2012, mirabegron. And one was recently marketed in 2021—Vibegron. And so we do have two medications that act very differently than the antimuscarinics and the antimuscarinic drugs that I mentioned by definition are anticholinergic. They have the anticholinergic side effects like effect on cognition, increase somnolence, dry mouth, dry eyes, constipation, which are very troublesome side effects in the older adult patient, especially the frail OAs, especially in the context of dementia.

Some of the medications that are used to treat dementia symptomatically—because we don't have a curative medications for dementia—are what are called cholinesterase inhibitors, like donepezil and rivastigmine. Now, if you look in the package insert of donepezil and rivastigmine, one of the side effects that they have is UI. If you are treating dementia with a cholinesterase inhibitor drug, and the patient starts exhibiting signs and symptoms of UI/OAB, then there is a knee jerk reaction sometimes to prescribe an OAB drug—the antimuscarinic—and they antagonize each other pharmacologically. We call it a prescribing cascade as well. Two of the 5 Choosing Wisely statements address that particular conundrum of mitigating anticholinergic burden.

Since for a long time, we've only had antimuscarinics, many of the patients that you see that are treated for OAB in the nursing home setting for urge incontinence and nocturia and so on, if they do have OAB in terms of ruling some of the other reasons out for incontinence are antimuscarinics and not everybody's treated with it because we all know that there are tremendous side effects associated with this class. And that is why it's, again, as I mentioned, it's nice to have the second therapeutic class introduced recently to treat OAB.

Fantastic. Well, thank you so much for all of your thoughtful responses to my questions. That's the majority of them, but I always like to ask, is there anything I haven't asked you about or anything that you'd like to add?

One of the things that we need to continue to do despite the fact that we do have a second class is that it's not just the antimuscarinic OAB drugs that increase anticholinergic burden. There are many other medications outside of this OAB class and there are many scales out there to estimate anticholinergic burden and the most important thing that's happened in the last 5 to 10 years is the very strong association with anticholinergic side effects, especially with higher doses of anticholinergic medications, and for a long period of time is the association of dementia, which people are slowly beginning to fathom and understand and cogently think about.

We want to mitigate the anticholinergic burden. In our patients already, there is a high preponderance of dementia. You do not want to have anticholinergic medications for a long period of time and there are many scales out there to estimate anticholinergic burden.

A simple scale that I talk about in my sessions is through the Canadian deprescribing network. It's very simple. It's ACBCALC.com, which is anticholinergicburdencalculator.com. It's a very simple way to estimate because it's not just one drug with anticholinergic side effects. You could have 3, and so your burden increases. You want to always try to deescalate, deprescribe, and mitigate the anticholinergic burden. That's the long and the short of it is why we have such an emphasis. Literally, I've been, like I said, practicing for 30 years. Even when I was in pharmacy school, we talked about anticholinergic burden. It's more come to the forefront because of the strong association with dementia now.

Thank you so much again for answering my questions today. I really appreciate it.

Thank you. I think that we covered the material well, especially what can we possibly do, at least from my standpoint, which is more in terms of pharmacotherapy. Thank you again.

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