Is 'Being Spaced Out Lately' Due to Medication? — Why Anticholinergics Lower Cognitive FIM

Pharmacist-Driven FIM Improvement Series #3

“I can't remember names”
“I don't know today's date”
“I get the location of the restroom wrong”

Such symptoms can become noticeable
during the rehabilitation period.

In fact, PTs, OTs, and STs also sometimes share information,

“They aren't following instructions lately... I wonder why?”
“I think they were following instructions better at the beginning...”

which may not quite reach the level of a formal consultation,
but is still a form of information sharing.

“Maybe their dementia is progressing...”

This is a common assumption, but before concluding that,
I want you to check the
usage status of anticholinergic drugsis.

In the previous article, I covered over-sedation caused by sleep medications and its impact on FIM.

This time, I will focus on“anticholinergic effects,”
which directly impact cognitive FIM,and summarize the evaluation and intervention points
from a pharmacist's perspective.

■ What are anticholinergic effects?

Anticholinergic effects are
actions that suppress the function ofacetylcholine, a neurotransmitter.

Acetylcholine is an important neurotransmitter in the brain
involved in cognitive functions such asmemory, learning, and attention.important neurotransmitter.

Therefore, when using drugs with anticholinergic effects,
the following symptoms may appear.

• Memory impairment (inability to learn new things)

• Attention deficit (inability to concentrate, feeling spaced out)

• Disorientation (confusion about time and place)

• Executive dysfunction (difficulty with planning and judgment)

These are all symptoms that directly impact the cognitive items of FIM (comprehension, expression, social interaction, problem-solving, and memory).

■ Which medications have anticholinergic effects?

Let's organize the medications commonly seen in convalescent rehabilitation wards that have anticholinergic effects, along with the strength of those effects.

① Medications with strong anticholinergic effects (Caution required!)

• Anti-Parkinsonian drugs: Artane (trihexyphenidyl), Akineton (biperiden), etc.

• Overactive bladder medications: Vesicare (solifenacin), Polakis (oxybutynin), etc.

• First-generation antihistamines: Restamin (diphenhydramine), Polaramine (d-chlorpheniramine), etc.

② Medications with 'secondary' anticholinergic effects (Watch out for oversights!)

Although their primary purpose is not anticholinergic,
this group has strong secondary effects.

• Tricyclic antidepressants: Tryptanol (amitriptyline), Anafranil (clomipramine), etc.

• H2 receptor antagonists: Gaster (famotidine), etc. (cognitive decline has been reported, especially in the elderly)

■ Impact on Cognitive FIM

The Japanese Society of Hospital Pharmacists guidelines also introduce
'Anticholinergic Burden (ACB)'.

Even if the effect of each individual medication is weak,
the concept is that when they overlap (accumulate), they have a serious negative impact on cognitive function.

The impact on Cognitive FIM in convalescent rehabilitation is as follows.

1. Decline in 'Problem Solving': Unable to remember rehabilitation schedules or dressing procedures.

2. Decline in 'Social Interaction': Conversations do not connect, emotions become unstable.

3. Decline in 'Expression/Comprehension': Unable to convey one's intentions, therapist's instructions are not understood.

■ What pharmacists should check upon admission

I think the checkpoints that pharmacists should be involved in can be summarized into the following three points.

1. Awareness of the ACB Score

Check if multiple anticholinergic drugs are
being used concurrently.
Combinations of "stomach medicine (H2 blockers)," "rhinitis medicine,"
and "overactive bladder medication"
are common.

What I often encounter are drugs for overactive bladder.
There are cases where they have been continued for years (the longest was over 10 years!) since before admission.

While there are drugs with fewer anticholinergic effects available recently,
my impression is that many drugs with a high anticholinergic burden are still used when taken over a long period.

2. Conflict with Dementia Medications

Check if a "cancellation effect" is occurring,
where the patient is taking an anticholinergic drug
while also taking a cholinesterase inhibitor
such as Aricept (donepezil).

3. Indiscriminate Administration Since the Acute Phase

It is necessary to check if drugs started for temporary agitation or frequent urination in the acute phase are being continued unnecessarily.

• Anticholinergics are continued without evaluation even after the indwelling urinary catheter is removed

• Antipsychotics started temporarily for delirium in the acute phase are still being continued now that the patient has calmed down

I encounter situations like this occasionally.

■ Example of a Proposal to a Physician

When the influence of anticholinergic drugs is suspected,
I make the following proposal.

"The patient is showing a plateau in their cognitive FIM. The XX (anticholinergic drug) currently being taken is increasing the ACB score, which may be affecting cognitive function. I believe we can expect an improvement in cognitive FIM by considering a switch to YY, which has fewer anticholinergic effects, or by discontinuing it."

I haven't experienced any spectacular results like "The FIM went up by X points!" yet, but I was still happy when I heard from the rehab staff, "They seem to be following instructions better lately!"

However, there are times when it cannot be discontinued for therapeutic reasons.
Not every proposal is accepted.

Even so, while continuously observing the patient,
gauging the right timing for a review is something I believe is very important.

■ Summary

• Anticholinergic drugs suppress acetylcholine in the brain, directly lowering cognitive FIM.

• It is the pharmacist's role to maintain an ACB (Anticholinergic Cognitive Burden) perspective and identify 'duplication' of medications.

• Always check for 'action competition' with drugs like Aricept.

• Propose to the physician that this is not 'dementia progression' but rather 'drug-induced reversible decline'.

'Feeling spacey lately'
If the cause is medication,
there may be a possibility for improvement.

Next time (#4), we will explain 'drug-induced diarrhea (PPIs, etc.)' which physically halts rehabilitation.

▶︎ Click here for the series on rehabilitation medications