OBJECTIVES : Limited national data exists regarding the extent of prescribing cascade of antimuscarinics due to the use of acetylcholinesterase inhibitors (AChEIs) in dementia. This study examined prescribing cascade involving antimuscarinics to treat AChEI-associated urinary incontinence in older dementia patients.

METHODS : A nested case-control study was conducted using 2005-2018 TriNetX Electronic Medical Records (EMR), a federated global electronic network, involving AChEI users. The base cohort included patients aged ≥ 65 years with dementia, no use of AChEI, and no antimuscarinic use between January – June 2005. Cases were dementia patients who initiated antimuscarinic treatment between July 2005 and December 2018. Each case was matched on age (±5 year) and sex to 3 controls using incidence density sampling. The event date for cases was defined as the date of first antimuscarinic prescription. Incident prescription of AChEIs within 6 months before the event date formed the primary exposure. Conditional logistic regression model stratified on matched case-control sets was performed to evaluate the association between incident AChEI use and antimuscarinic prescribing cascade after controlling for several risk factors.

RESULTS : The study identified 5,534 cases and 16,585 controls. Cases were significantly more likely to have incident AChEI exposure within 6 months preceding the event date, compared to controls (5.15% vs 0.30 %; p-value <.0001). After controlling for other risk factors, conditional logistic regression analyses revealed that incident AChEI use was associated with 16 times higher odds of antimuscarinic prescribing cascade, compared to non-use (OR =16.49; 95% CI, 11.97–22.71). Other risk factors significantly associated with antimuscarinic prescribing cascade were history of COPD, depression, obesity, other neurological disorders, solid tumor, valvular diseases and use of antipsychotics.

CONCLUSIONS : Incident AChEI exposure was strongly associated with prescribing cascade of antimuscarinics in older dementia patients. Future studies are needed to evaluate the consequences of prescribing cascade associated with AChEI treatment in this vulnerable population.