Prescribing and medication management

A lighter load: Tackling ACB (Anticholinergic burden) in geriatric wards:

Background: Exposure to high levels of anticholinergic and sedative medications significantly increases the risk of fall-related hospitalizations, delirium, and mortality in the elderly. While the dangers of traditional anticholinergic medications are well-documented, the cumulative effects of drugs with mild to moderate anticholinergic properties often go unrecognized in everyday clinical practice.

Objectives: To identify the primary contributors to anticholinergic burden (ACB) in geriatric wards and propose practical strategies to reduce ACB by at least 20% over the next three months through sustainable alternatives.

Methods: A comprehensive audit of sixty inpatient medication charts in geriatric wards was conducted in September 2024, based on revised STOPP START criteria, focusing on identifying medications contributing to ACB using an ACB calculator.

Results: 16.17% of medication charts had a high ACB of 3 or greater. Preliminary findings highlighted the necessity of re-evaluating ongoing drug needs, considering non-pharmacological alternatives, emphasizing patient education on ACB risks, tapering or discontinuing anticholinergic medications, and substituting them with safer, evidence-based alternatives with lower ACB. A weekly “medication review” day has been proposed, engaging ward pharmacists, nursing staff, and other members of the multidisciplinary team. We aim to conduct periodic re-audits to identify and address the project's pitfalls for ongoing improvement.

Conclusion: By ensuring the continued training of healthcare professionals and displaying visual learning aids in clinical areas, this initiative is expected to enhance patient well-being by prioritizing ACB reduction and improving adherence to deprescribing strategies.

The elderly population ( cut off 65 and over, for this audit) are being increasingly prescribed direct oral anticoagulants(DOAC) for prevention of stroke in atrial fibrillation/ prevention and treatment of DVT/PE.This poses significant difficulties when stopping/ restarting these medications in the peri-operative period , due to the ever changing clinical circumstances in this period. Therefore , we performed an audit( in Glangwili Hospital, Jan-July 2024)  , using the Welsh Frailty Fracture Network guidelines as our standard and found out(during the first cycle) that around 40 percent of patients did not have their DOAC restarted on time post surgery and that poor documentation regarding the circumstances causing delay was prevalent. We intervened by providing teaching , putting up posters and trying to include the guidelines in the trust intranet. In the second cycle, there was significant improvement in the documentation of the circumstance causing delay of restart and higher number of patients with DOACs stopped in correct time in keeping with their renal functions.

Background: Accurate documentation of medication suspension is crucial for patient safety, especially during transitions such as out-of-hours discharges. In early 2023, an audit in our hospital’s elderly care ward revealed a significant number of medications were suspended without proper documentation, raising concerns about continuity of care, medication errors, and patient outcomes. This Quality Improvement Project (QIP) aimed to improve the consistency, clarity, and quality of documentation in the ward to enhance patient safety and reduce risks associated with incomplete information.

Methods: The project consisted of three cycles. In the first cycle, retrospective data from 29 patients showed 33 medications were suspended, with only 18% having a documented rationale. Following this, interventions were implemented, including raising staff awareness through handovers and posters displayed throughout the ward. These interventions aimed to highlight the importance of proper documentation in clinical practice. In the second cycle, data from 23 patients revealed 42 suspensions, but 24% still lacked documentation. Further steps included assigning responsibility to each clinical team member for ensuring proper documentation during their shifts. In the third cycle, data from 30 patients showed 82% of 31 suspended medications were documented appropriately. To address remaining gaps, a proposal was made to introduce a mandatory rationale field in the Electronic Prescribing and Medicines Administration (EPMA) system to ensure consistent and comprehensive documentation.

Results: The project led to progressive improvements in documentation, increasing from 18% to 82%. The proposed enhancement to the EPMA system aims to achieve near-total compliance and further streamline documentation practices, ultimately improving patient safety.

Conclusion: This QIP significantly improved documentation of medication suspensions, enhancing patient safety and care continuity. Ongoing education, monitoring, and system improvements will be essential to sustaining these advancements and ensuring thorough documentation in clinical practice. Regular audits, feedback mechanisms, and increased engagement with clinical staff can further reinforce the importance of maintaining high standards of documentation to prevent medication errors and optimize patient care.

In 2022 we had a unique opportunity to develop a Geriatric service in Totnes Community Hospital after a long-standing GP led service provision ended. Given the fact that the majority of patients in the Community Hospitals were over the age of 65 and many had multiple co-morbidities or presented with a frailty syndrome, it was felt that the Geriatric department was the most suitable specialty to take over the service provision. Method Over a period of 12 months, we have gradually introduced key aspects from the Comprehensive Geriatric Assessment (CGA) to the care of our patients. Every new patient had a CGA on admission, completed by the clerking doctor with support from the MDT. We have concentrated on identifying and managing falls risk, bowel and bladder care, bone protection assessment and reviewing inappropriate polypharmacy. Through collaboration with our community pharmacist and nursing staff we have introduced additional medication administration services to include intravenous bisphosphonates, monofer infusions, medical hyperkalaemia management and intravenous electrolyte replacements. For our frailer patients we looked at prioritising care in the community, and closer to their home and family. Where appropriate and safe, we kept the patients in the community hospital for both acute illness and end-of-life care, instead of re-admitting them back to the acute hospital. Conclusion Over the year we have trained, upskilled and supported our nursing staff in managing and treating more acutely unwell and complex patients, so that we can provide more comprehensive and holistic care to our frailer patients in a community setting. We have prevented numerous re-admissions back to the acute hospital by being able to provide increased level of medical care. This was particularly important for the many patients with advanced dementia and delirium. The current model of care is still ongoing and continuing to develop.

Introduction

It is estimated that by 2030, 1 in 5 people undergoing surgery will be over the age of 75. These patients are often frail with a higher risk of post-operative complications including delirium. They are also more likely to have multiple co-morbidities and an increased anticholinergic burden due to polypharmacy. Anticholinergics are often linked with an increased risk of dementia, delirium, and falls.

Methods

This retrospective cohort study analysed anonymised data from 50 emergency general surgery patients the POPS team reviewed between December 2023 and February 2024 at the University Hospital of Wales. Objectives included measuring ACB (anticholinergic burden) scores on admission and discharge and evaluating subgroup analysis such as the relationship between CFS (clinical frailty score), known or new cognitive impairment and ACB score.

Results

66% of patients were female, the median age was 82 and median CFS was 6. 32% had delirium on admission, 40% had a Charlson comorbidity score of 5 or 6 and the median length of stay was 17 days. 74% of patients had no known cognitive impairment while 8% had dementia on admission. Small bowel obstruction (34%) was the commonest diagnosis and emergency laparotomy was the most common surgery type (56%). The median number of medications on admission and discharge was 9. Median ACB score on discharge reduced from 1.5 to 1 and 86% showed a stable or reduced ACB score. There was a positive correlation between frailty and delirium as well as frailty and ACB score. The correlation between delirium and ACB score was unclear. 

Conclusion

CGA by the POPS team reduces the anticholinergic burden of this patient cohort. Increasing frailty appears to be associated with an increased risk of delirium and ACB score on admission, however the relationship between anticholinergic burden and delirium is unclear in this small patient cohort. 

INTRODUCTION: Our QIP was conducted in the Geriatric wards at Royal Gwent Hospital by doctors working in Geriatrics. Delirium, falls, confusion and urinary retention are common reasons for hospital admission in the elderly. Anticholinergic burden (ACB) is the cumulative effect of taking multiple medicines with anticholinergic properties contributing to frequent admissions. The aim of our QIP was to increase doctor’s awareness of ACB and encourage the review and deprescribing of regular medications in elderly patients to decrease ACB.

METHODS: ACB was measured on admission and discharge using the AEC tool by doctors and pharmacists. Baseline data was collected. Awareness of ACB among doctors was improved through education email and posters on the ward followed by another data collection. An oral presentation on ACB and stickers on patients drug charts and medical notes prompting medication review was done, followed by final data collection. A questionnaire was distributed to all doctors working in the Geriatric unit before the first cycle and after the third cycle to evaluate their knowledge on ACB.

RESULTS: Baseline data shows the percentage of patients admitted with an AEC ≥ 3 on admission and discharge was 12.7% and 10.9% respectively. In the 3rd data collection, these figures were 17.3% and 11.5% respectively. The questionnaire before and after intervention indicated that clinician confidence in identifying anticholinergic medications improved from 44% to 83.8% and awareness of tools to calculate ACB increased from 8% to 88.9%. Utilization of the AEC tool grew from 4% pre-intervention to 73.7% post-intervention. The percentage of patients with reduced AEC scores due to the interventions rose from 16.4% (baseline) to 30.7% (3rd data).

CONCLUSION: The project demonstrated significant enhancements in clinician awareness and utilization of tools to assess anticholinergic burden (AEC) in elderly patients and reduced ACB significantly, which is vital in reducing admissions in elderly.

Introduction:

Polypharmacy is commonly defined as the concomitant use of five or more medications. This is a common problem in frail elderly patients and more so on the surgical inpatients where it is not regularly reviewed by the surgical team.

Methods:

We reviewed retrospectively the data on vascular inpatients from 2015-2016 and after the set-up of the perioperative services in 2022-23. Patients above 65 years of age with a clinical frailty score of 4 or more or with two or more co-morbidities were selected from both groups. In total 130 patients were selected from each group and their notes were reviewed in terms of polypharmacy review, before and after the introduction of the perioperative service in the trust.

Results:

Average age of the patients in both groups combined was 75 years. Average polypharmacy number per patient before and after the perioperative service were 6.8 and 10.7, respectively. In 2022-23, all the 130 patients had a polypharmacy review by a Consultant Geriatrician. In 2015-16, polypharmacy was reviewed only if there was an adverse effect to the drug, for example bradycardia caused by beta blockers. There was no routine review of polypharmacy. 0.06 Medications were stopped per patient in 2015-16, in contrast to 1.7 per patient in 2022-23. Most common causes of discontinuation of medications were falls, confusion, postural hypotension, drowsiness, electrolyte imbalance or medication no longer needed.

Conclusions:

Polypharmacy optimisation should routinely be practised in frail vascular surgical patients as it leads to avoidance of undesirable side-effects, improves patient compliance to medications, and has a huge financial benefit from deprescribing.

Vitamin D deficiency is common amongst elderly patients resulting in fragility fractures. Following fragility fractures, patients require vitamin D to be checked prior to initiating bone protection, e.g zoledronic acid/ denosumab. Ideally, all patients should have their first dose of bone protection prior to being discharged from hospital to reduce the risks of fragility fracture.

In this project, carried out in Trafford General Hospital (TGH) amongst patients from orthogeriatric wards, we had observed that the time taken for these results varied significantly depending on the hospital location where patients had their samples taken. 

The patient population consisted of patients who suffered a fragility fracture and would be classed as frail. Our analysis suggested significantly prolonged processing times of vitamin D samples in Trafford General Hospital. The median processing time for vitamin D samples at Trafford General Hospital falls behind that of other hospitals in the Manchester Foundation Trust (MFT) network. 

This project proposed a strategy to shorten the treatment time of vitamin D replacement from 4 weeks to 1 week, which is now being actively practiced in Trafford General and Wythenshawe Hospitals

Drugs that have anti-cholinergic affects are known to have side effects such as urinary retention and constipation. In older people these drugs can also contribute to cognitive decline and loss of functional capacity leading to older patients being at risk of increased falls. Taking multiple medications with anti-cholinergic affects create a higher anti-cholinergic burden. Hilmer and Gnjidic (2022). Drugs that have anti-cholinergic affects block acetylcholine receptors (muscles do not receive neurotransmitter and therefore not functioning properly), Brown (2019). Some of these drugs are prescribed to have this effect but, in some patients’, this is an adverse effect. Although there are some drugs that are classed as anti-cholinergic drugs there are also drugs that have this effect which are not classed as anti-cholinergic such as anti-histamines, anti-depressants and anti-psychotics, Hilmer and Gnjidic (2022). This service improvement project will aim to introduce the anti-cholinergic burden scoring tool to a frailty unit for patients admitted with a fall with the aim of reducing the risk for patients who score highly being re admitted to hospital due to falls. Method This project will deliberate the development of change management using ADKAR (Awareness, Desire, Knowledge, Ability then Reinforce), Hiatt (2021) model of change management. By using this model, the author can prepare people for change, help people change and re-enforce the change allowing a successful service improvement. Results on completion of this project, the anti-cholinergic burden scoring tool will be successfully implemented onto the frailty unit and used by the medical team for patients admitted following a fall. By using ADKAR, Hiatt (2021) the author will be able to raise awareness, desire, build on knowledge and ability then reinforce the importance of reducing the risk of falls in older patients.

Introduction With an increasing ageing population, more people are now living with multiple comorbidities and on polypharmacy. Medicines prescribed appropriately provide huge benefits; but inappropriate prescribing without safe optimisation can cause significant harm.

Method We assessed current practices of reviewing and optimising medications in Elderly Care at Maidstone Hospital. 44 Patients were selected randomly from three elderly care wards. We retrospectively evaluated if medications for these patients were reviewed and optimised using the START-STOPP tool at clerking, post take and Geriatrics review.

Results Of the 44 patients screened, 31(70.4%) patients had all their home medications prescribed at the time of clerking but only 23(52%) had their medications reviewed at the time of clerking, based on clear documentation. 11 patients had some of their medications stopped. 23(52%) had their medications reviewed at the time of post take ward round. 19 of the 23(82.06%) had some of their medications stopped. 25(56%) had their medications reviewed at the time of Geriatric review. 15 patients(60%) had their medications stopped. Most medication reviews with clear documentation took place at the time of Geriatrics' review (56%). Least medications were reviewed and stopped at the time of clerking. Most number of patients had their medications stopped at the time of PTWR and geriatrics' review.

Conclusion It is important for admitting teams to ensure all home medications are reviewed and correctly prescribed within 24 hours of acute admission, in keeping with NICE guidelines. This ensures patients do not miss any crucial drugs and also unnecessary medications are stopped, minimising drug related safety-incidents. Least number of drugs were stopped by clerking doctors, which suggests lack of adequate training and low confidence in stopping medications. As such teaching and awareness of junior doctors re: polypharmacy and use of STOPP/START tool is crucial. Electronic clerking proforma prompts will also prove helpful.