Abstract
Introduction
Anticholinergic medications remain widely prescribed to older adults despite evidence linking cumulative anticholinergic burden (ACB) with delirium, accelerated cognitive decline, falls, longer admissions, and excess mortality. ACB score ≥3 signals heightened risk, yet systematic review is rarely embedded in ward routines. We designed a quality improvement (QI) project using sequential Plan–Do–Study–Act (PDSA) cycles, aiming to show that pragmatic ward-level interventions can deliver measurable clinical benefit by reducing ACB among geriatric inpatients.
Method
Conducted on a geriatric ward in a District General Hospital, the project included 100 inpatients aged ≥65 in 3 cohorts (baseline n=40; PDSA 1 n=30; PDSA 2 n=30). Admission and discharge ACB scores were calculated using online calculators. PDSA 1 introduced multidisciplinary team (MDT) education and visual prompts to reduce ACB. PDSA 2 embedded routine calculation and documentation of ACB, active flagging of high scores to prescribers, and protocol-driven substitutions with safer alternatives (e.g., famotidine for omeprazole). The primary outcome was the proportion of patients with reduced ACB at discharge.
Results
With usual prescribing practice (baseline), only 7/40 patients (17.5%) had lower ACB at discharge than admission. This rose to 12/30 (40.0%) following intervention in PDSA 1 and further to 20/30 (66.7%) in PDSA 2 (χ²=17.44, p=0.00016). Among patients admitted with high-risk ACB ≥3, reductions improved dramatically from 3/9 (33.3%) at baseline to 6/7 (85.7%) in PDSA 1, and were sustained at 6/7 (85.7%) in PDSA 2 (χ²=6.63, p=0.036). Increases in ACB declined from 15.0% baseline to 3.3% and 10.0% post-intervention.
Conclusions
This project demonstrates that simple, scalable interventions can rapidly and sustainably transform prescribing practice and reduce ACB in frail older adults. Education alone improved outcomes, but embedding ACB calculation, flagging, and substitution protocols delivered the largest impact. This model represents a future-focused, low-cost pathway to safer inpatient prescribing and improved geriatric outcomes.
Comments
ACB prescribing
Interesting project. Did you have a system embedded into your electronic prescribing to help flag ACB and then suggest alternatives? If so was this a difficult tool to produce or was it something already built into electronic prescribing but not utilised before?
How much education was given to patients about medication substitutions? Did any patients complain about medications being stopped or substituted as im guessing some patients could be intolerant of substitutions and may want an ACB med restarting.
Thank you for your comments…
Thank you for your comments. We didn’t have an automated electronic prescribing alert – the ACB score was calculated and documented as part of the ward workflow, supported by visual prompts and pharmacist input rather than a built-in electronic tool. This made it easy to implement quickly during the project.
Patient education took place during routine medication reviews, but we didn’t formally collect data on patient reactions to substitutions. In practice, most changes were accepted when the rationale was explained, but this is an area we’d like to explore further in future cycles.
Great project
Really great presentation with great use of graphs to clearly demonstrate your findings. The utilisation of embedded tools is a fantastic improvement to implement within your trust to help enable safer prescribing for elderly patients.
Thank you for your comments …
Thank you for your comments — we really appreciate that. Embedding the ACB calculation and flagging into the routine workflow made a big difference, and it was great to see the impact reflected so clearly in the data. We’re hoping to build on this further to make safer prescribing even more consistent across the ward.