Abstract
Introduction
The cumulative effect of medications with anticholinergic properties is known as anticholinergic burden (ACB). Adverse effects of anticholinergic drugs include increased risk of cognitive impairment, dementia, falls, and mortality among older people. Despite its serious implications for quality of life of older people, deprescribing to reduce anticholinergic burden is not guided by a single standardised guideline. Hence, practice remains variable. The aim of this service evaluation was to assess how effectively deprescribing is undertaken on Healthcare of Older People (HCOP) wards, to reduce ACB and the quality of documentation supporting it. The goal was to identify strengths and gaps in the current practice to suggest practical improvements.
Method
50 recent consecutive HCOP discharge summaries were evaluated retrospectively. Cases with significant ACB (≥3) were included. ACB at admission and discharge was calculated using the ACB calculator toolkit. Documentation quality was assessed across five domains-rationale, alternatives, patient/carer involvement, multidisciplinary team input, and follow-up planning- scored 0-2 per domain (total 0-10), with overall documentation categorised as poor (0-3), moderate (4-6), or good (7-10).
Results
16 (32%) cases met the inclusion criteria. ACB was successfully reduced in 7 (44%) patients. Missed opportunities to deprescribe significant ACB occurred in 6 (37%) patients. Surprisingly, new ACB was introduced in 3 (19%) patients. Documentation quality was poor in all (100%) of 6 missed opportunities , moderate in 2 (29%) and good in 5 (71%) of the 7 deprescribing cases. For new ACB 1 poor, 1 moderate, and 1 good documentation was recorded.
Conclusion
Findings indicate high quality documentation was associated with successful deprescribing. Consistently poor documentation of missed opportunities reflects limited clinical attention to ACB. Current practice can benefit from practical measures to ensure that high ACB is identified, deprescribed, and well documented for optimisation of patient safety.
Comments
This is an insightful and…
This is an insightful and interesting QIP which shows how the quality and care of our work in documentation is so important in improving patient safety and outcomes! I wonder if there was any correlation noted between the level of clinicians completing discharge and the documentation completeness? There could be scope for training for more junior clinicians perhaps at their induction, on ACB and how to safely deprescribe. This is such an important area but perhaps not one that all resident doctors are really confident in. Thanks for your hard work in this area!
Valubale feedback
Thank you for the comment Isabel! Where as in this project we did not co-relate the level of the clinician to the quality of the documentation, this could definitely be an area to explore in the next cycle.
Also a briefing on ACB burden and importance of deprescribing to reduce it during the junior doctor induction is a great idea. I know it would have helped me! Hopefully upon suggestion the next batch of geriatrics juniors can benefit. This is the most gratifying part of doing these projects, as areas of improvement come to light!