HPE 101 – July 2022 | Page 28

in the ACB scores in 59.2 % of patients . The European study also observed that the same medications , while stopped in some patients , were started in others , and that more than one in five patients who were not taking anticholinergics when admitted were prescribed them by discharge . ¹⁸ Compared with this European-based study ¹⁸ and the New Zealand study , ¹⁷ we found 9 % had a reduced ACB , 37 % had an increased ACB , and 53 % had no change by the final day on the ward .

A specialist multidisciplinary team based in a UK Emergency Department was able to perform targeted medication reviews and significantly reduced anticholinergic drug exposure in frail older patients as measured by the ACB scale . ¹⁹ Interestingly , only 2.3 % ( n = 3 / 129 ) of ACB-naive patients were started on an anticholinergic drug ( that is , ACB score 0 pre- to 1 post-review ) and there were no other examples of patients experiencing an increase in ACB score during admission .

The importance of this topic of ACB is highlighted in the national Getting It Right First Time report , which recommends that older patients should have an initial review of medicines management when they are admitted to hospital . This report notes that the admission might be triggered by adverse drug reactions and the risks and benefits of drugs need to be reviewed . This can be done using a structured approach such as the STOPP-START tool , or the anticholinergic burden score to assess the risk of drugs that contribute to falls and delirium . ²⁰

It is recognised that the provision of guidelines and education alone do not seem to be sufficient to ensure the best medicines review and optimisation in older people . Whereas evidence shows an improvement in the quality of prescribing and deprescribing via the use of multidisciplinary teams , geriatric case conferences , medication review by pharmacists and the use of information technology to support medication decisions . ²¹ In the context of reviewing and possibly reducing ACB score , we have in place in our Trust an electronic tool that identifies possible opportunities for review . However , we know this RADAR report is not utilised .

A strength of our study was the use of an e-prescribing system , which facilitated the accurate extraction of prescribed medication . We recognise the limitations of this retrospective study of patients admitted to a single acute trust during a relatively short follow-up period . During the pandemic , these five wards may have held outlier patients not under the care of the elderly team and so any review of ACM may not have been a priority . It is important to note that what was prescribed on the e-prescribing system at admission may be different to medicines identified at the reconciliation ( clerking in ) process , that is , some ACM might have been ceased / withheld at admission to the ward and we did not record this . Also , we looked only at prescribed medication , and we recognise that , especially for ‘ as required ’ medication , these might not have actually been administered to patients . In particular , those patients on Trauma would have had analgesic requirements ( weak or strong opioids ) accruing an ACB score typically of one per different opioid prescribed and this continued throughout the hospital stay with little opportunity to reduce the score , although these opioids might not then have continued into discharge medication . Finally , we did not record patient comorbidities .

Conclusion In this study , the overall ACB did not change significantly during an inpatient stay on five wards typically caring for older people . It might be appropriate to raise prescribers ’ and pharmacy team awareness of these practices such that there is more of a focus on ACB and the potential for corresponding iatrogenic effects .

KEY POINTS

• Anticholinergic medication is associated with adverse clinical outcomes , including delirium and cognitive decline .

• Various anticholinergic burden ( ACB ) or risk scales have been devised to aid medication reviews .

• Anticholinergic medication use in a hospital setting has been less extensively reported than in primary care , although some studies have tracked changes in ACB during hospital admission .

• In this retrospective study , there was an increase in the total ACB score between admission and the final day on the ward for the 212 patient spells from 322 ( mean 1.52 per spell ) to 456 ( mean 2.15 per spell ).

• It might be appropriate to raise prescribers ’ awareness of these practices such that there is more of a focus on ACB , and the potential for corresponding iatrogenic effects .

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