Seenae Eum1, S Kristian Hill2, Leah H Rubin3, Ryan M Carnahan4, James L Reilly5, Elena I Ivleva6, Sarah K Keedy7, Carol A Tamminga6, Godfrey D Pearlson8, Brett A Clementz9, Elliot S Gershon7, Matcheri S Keshavan10, Richard S E Keefe11, John A Sweeney12, Jeffrey R Bishop13. 1. Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, 308 Harvard St. S.E., Minneapolis, MN 55455, USA. 2. Department of Psychology, Rosalind Franklin University of Medicine and Science, 3333 Green Bay Road, North Chicago, IL 60064, USA. 3. Department of Psychiatry, University of Illinois at Chicago, 912 S. Wood Street, Chicago, IL 60612, USA. 4. Department of Epidemiology, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA. 5. Department of Psychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, 710 N Lake Shore Drive, Chicago, IL 60611, USA. 6. Department of Psychiatry, University of Texas, Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390, USA. 7. Department of Psychiatry and Behavioral Neuroscience, University of Chicago, 5841 S. Maryland Ave., Chicago, IL 60637, USA. 8. Department of Psychiatry, School of Medicine, Yale University, 300 George St., New Haven, CT 06511, USA. 9. Department of Psychology, University of Georgia, 125 Baldwin St., Athens, GA 30602, USA. 10. Department of Psychiatry, Beth Israel Deaconess Medical Center and Harvard Medical School, 401 Park Drive, Boston, MA 02215, USA. 11. Department of Psychiatry, Duke University School of Medicine, 4080 Hosp South, Durham, NC 27710, USA. 12. Department of Psychiatry, University of Cincinnati, 3235 Eden Ave., Cincinnati, OH 45267, USA. 13. Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, 308 Harvard St. S.E., Minneapolis, MN 55455, USA; Department of Psychiatry, College of Medicine, University of Minnesota, 2450 Riverside Ave. S., Minneapolis, MN 55454, USA. Electronic address: jrbishop@umn.edu.
Abstract
BACKGROUND: Patients with psychotic disorders are often treated with numerous medications, many of which have anticholinergic activity. We assessed cognition in relation to the cumulative anticholinergic burden of multiple drugs included in treatment regimens of participants from the Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP) study. METHOD: Clinically stable participants with schizophrenia (n=206), schizoaffective disorder (n=131), and psychotic bipolar disorder (n=146) were examined. Anticholinergic properties of all scheduled drugs were quantified using the Anticholinergic Drug Scale (ADS). ADS scores were summed across individual drugs to create a total ADS burden score for each participant and examined in relation to the Brief Assessment of Cognition in Schizophrenia (BACS). RESULTS: Anticholinergic burden aggregated across all medications was inversely related to cognitive performance starting at ADS scores of 4 in participants with schizophrenia. Those with ADS scores ≥4 had lower composite BACS scores compared to those with ADS<4 (p=0.004). Among BACS subtests, Verbal Memory was the most adversely affected by high anticholinergic burden. Despite similar anticholinergic burden scores across groups, a significant threshold effect of anticholinergic burden was not detected in schizoaffective or psychotic bipolar disorder. CONCLUSION: We identified an adverse effect threshold of anticholinergic burden on cognition in clinically stable participants with schizophrenia. This relationship was not identified in affective psychoses. Examination of other medications, doses, and clinical measures did not account for these findings. Patients with schizophrenia may have increased cognitive susceptibility to anticholinergic medications and the aggregate effects of one's medication regimen may be important to consider in clinical practice.
BACKGROUND:Patients with psychotic disorders are often treated with numerous medications, many of which have anticholinergic activity. We assessed cognition in relation to the cumulative anticholinergic burden of multiple drugs included in treatment regimens of participants from the Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP) study. METHOD: Clinically stable participants with schizophrenia (n=206), schizoaffective disorder (n=131), and psychotic bipolar disorder (n=146) were examined. Anticholinergic properties of all scheduled drugs were quantified using the Anticholinergic Drug Scale (ADS). ADS scores were summed across individual drugs to create a total ADS burden score for each participant and examined in relation to the Brief Assessment of Cognition in Schizophrenia (BACS). RESULTS: Anticholinergic burden aggregated across all medications was inversely related to cognitive performance starting at ADS scores of 4 in participants with schizophrenia. Those with ADS scores ≥4 had lower composite BACS scores compared to those with ADS<4 (p=0.004). Among BACS subtests, Verbal Memory was the most adversely affected by high anticholinergic burden. Despite similar anticholinergic burden scores across groups, a significant threshold effect of anticholinergic burden was not detected in schizoaffective or psychotic bipolar disorder. CONCLUSION: We identified an adverse effect threshold of anticholinergic burden on cognition in clinically stable participants with schizophrenia. This relationship was not identified in affective psychoses. Examination of other medications, doses, and clinical measures did not account for these findings. Patients with schizophrenia may have increased cognitive susceptibility to anticholinergic medications and the aggregate effects of one's medication regimen may be important to consider in clinical practice.
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