GETTY between admission and the last day on the ward for patients on those specific wards that are the subject of this RADAR report . The objectives were to report on changes to ACB score over the hospital stay and to ascertain if , in general , any particular ACM was stopped to reduce the ACB score .
Method This was a retrospective study utilising the electronically available RADAR ACB score report that was run for November 2021 for those patients admitted to the five target wards . Data were extracted such that the report displayed any ACM that contributed to the patient ’ s ACB score both at admission and the final day on the ward . This extraction did not include medication listed on any discharge prescription . Patients on the same medication , for example , morphine prescribed as a standard-release oral formulation and an injectable formulation ‘ as required ’ accrued a score of only one . Likewise , the presence of both cyclizine lactate and cyclizine hydrochloride on the same patient ’ s electronic prescribing chart accrued a score of only one . Data were entered into Excel for analysis . Data for two wards that were more typical of care of the elderly patients were also analysed separately .
Ethics Health Research Authority criteria for research and service evaluation were considered . This was a retrospective assessment involving no changes to the service delivered to patients , and we used the NHS Health research authority tool ( www . hra-decisiontools . org . uk / research / index . html ) which helped confirm that no ethical approval was required for this project .
Results Over an approximate three-week period in November 2021 , there were 262 episodes of patients admitted to the five wards . Sixty-two of these episodes were on the two wards grouped together for further analysis as they were considered to be more representative of care of the elderly patients . Excluding those whose admission was apparently less than one day , this left a total of 212 patient episodes ( mean age 70 years , range 21 – 99 , 100 male ), of which 59 ( mean age 74 years , range 23 – 97 years , 27 male ) were on the two subset wards . Overall , the duration of stay ranged from one day ( 29 %) to 5 days and longer ( 27 %).
Overall , there was an increase in the total ACB score between admission and final day on the ward for the 212 patient spells from 322 ( mean 1.52 per spell ) to 456 ( mean 2.15 per spell ), and also across the subgroup of 59 spells from 105 ( mean 1.78 per spell ) to 120 ( mean 2.03 per spell ). This overall increase in ACB score was also seen when considering only those patient spells that were for 5 days or longer . The number of patients with an ACB score of 2 or ≥3 was greater on the final day on the ward than at admission when considering all 212 spells ( Table 1 ). For the subgroup of 59 patient spells , it was only the number of patients with an ACB score of ≥3 that increased during the acute stay .
However , 9 % ( 20 / 212 ) and 15 % ( 9 / 59 ) of patient spells did show a decrease in their ACB score ( Table 2 ). Across all patient spells , the most frequent medicines that were ceased were fentanyl , morphine , furosemide and co-dydramol .
Discussion We examined the ACB of medication for patients admitted to a select group of wards caring for , in the main , older people . This analysis has shown an overall increase in ACB score during the acute inpatient stay for 212 patient spells from a mean of 1.52 per spell to 2.15 per spell . There were some instances where a reduction did occur – 9 % of 212 patient spells and 15 % of the subgroup of 59 spells .
Several studies with varying results have tracked changes to ACB during the hospital stay of older people . A study , utilising the Anticholinergic Risk Scale ( ARS ), 14 described the burden of prescribed ACM in all older adults admitted as an emergency to any specialty in a large hospital in the UK . These authors looked at how ARS scores changed from admission to discharge and evaluated associations between both admission ARS and change in ARS score and hospital outcomes , primarily inpatient and post-discharge mortality . 15 They found that from 33,360 patients included , just under one-third were prescribed an anticholinergic on admission , with 3266 ( 9.8 %), 2479 ( 7.4 %) and 4438 ( 13.3 %) patients scoring 1 , 2 or > 3 respectively on the ARS . In our much smaller study , we found 46 / 212 ( 22 %), 34 / 212 ( 16 %) and 51 / 212 ( 24 %) patients scoring 1 , 2 or > 3 respectively on the scale we used . These UK authors 15 did find a statistically significant reduction in mean ARS from admission to discharge in all specialties . Interestingly , the largest absolute and relative reductions in mean ARS scores were seen in patients discharged by Geriatric Medicine and Trauma and Orthopaedics , although they report that patients experiencing either an increase or a decrease in ARS score from admission to discharge were more likely to have a prolonged (> 10 days ) hospital stay . Our five wards would be similarly classified as Geriatrics and Trauma and Orthopaedics , although we found an overall increase in mean ACB score . However , we only had
ten patients with a prolonged stay and two of these had a decrease in ACB score
A similar study in New Zealand measured the ACB using the total Anticholinergic Drug Scale ( ADS ) score for 224 patients on presentation to and at discharge from a geriatric unit . 17 Despite medication changes occurring during the hospital stay , there was no significant change in ADS score between admission and discharge . Compared with admission , 35 % patients had a reduced ACB ; 28 % patients had an increased ACB , whereas 37 % had no change on discharge .
A study based in the UK and Europe , 18 described changes in the ACB in 549 patients admitted to hospital with a diagnosis of delirium , chronic cognitive impairment , or falls . They utilised an adapted 2012 revision of the original ACB scale . 13 Key findings were that 21.1 % of patients had their ACB score reduced , 19.7 % had their ACB increased , 22.8 % of ACM-naïve patients were discharged on ACM , and there was no change
hospitalpharmacyeurope . com | Issue 101 | 27