Baseline Anticholinergic Medication Burden in Patients with Overactive Bladder

Objectives: Anticholinergic medications are associated with increased risk of dementia, and in patients 65 and older, increased risk of fall and all-cause mortality. The objective of this study is to explore the distribution and factors associated with baseline medication Anticholinergic Cognitive Burden (ACB) score for women presenting for evaluation and treatment of overactive bladder (OAB).

Methods: We performed a retrospective chart review of new patients with a chief complaint of OAB in an academic urogynecology practice from January to December 2022. Patients were excluded if they had a diagnosis of recurrent urinary tract infection (rUTI) or had a culture-proven UTI upon presentation. ACB score at presentation, a measure of risk of harm in patients taking anticholinergic medications, was explored as a continuous measure and as a binary indicator of high-risk, defined as ACB>=3. This score is a widely accepted threshold of greater side effects to be avoided in older individuals. Associations between baseline ACB score and demographic and clinical characteristics were examined using Pearson’s Chi-square or Fisher’s exact test for categorical comparisons, and unadjusted linear regression models were fitted to examine individual factors associated with continuous ACB score.

Results: 134 patients were included, with an average age at presentation of 65 years (SD=13). 76% identified as White, 9.7% as Black, 9.6% as another race. The median baseline ACB score was 2.0 and ranged from 0 to 18. 46% of patients had a high-risk baseline ACB score. At the index visit, 12% of patients were taking an anticholinergic medication for OAB, and 3.7% were taking a beta-3 agonist. Only 3.7% of patients were prescribed an anticholinergic medication at their index visit, while 24% were prescribed a beta-3 agonist. Of those prescribed a beta-agonist, 14 (43%) did not initiate therapy due to cost. In unadjusted linear regression, estimated average ACB scores were 2.6 units higher in patients with Medicaid (n=11) compared to Medicare (n=45) insurance (95% confidence interval: 0.75-4.4). A higher proportion of patients with a high-risk baseline ACB score were managed with sacral neuromodulation compared to patients with a low-risk baseline ACB score (13% [n=8] vs 2.8% [n=2], p=0.044).

Conclusions: Baseline anticholinergic medication burden was high among patients presenting for treatment of OAB, with nearly one-half of patients having a high-risk ACB score of 3 or greater. Overall new prescription rates for anticholinergic medications were low. Medicaid insurance status was associated with a higher baseline ACB score. A significant number of patients were managed with advanced therapies, particularly if their baseline ACB score was high.