FRAILTY 360- Holistic review of medications and anticholinergic burden in frail older people in the community

Polypharmacy is highly prevalent among frail older adults due to multi-morbidity and is a major contributor to medication-related harm. Of particular concern is anticholinergic burden, resulting from the cumulative use of drugs with anticholinergic properties. In frail older patients, high anticholinergic burden is associated with cognitive impairment, delirium, falls, functional decline, increased hospitalisation and mortality. Careful medication review and reduction of anticholinergic burden are therefore important components of comprehensive geriatric care.

Methods:

A retrospective review of case notes was carried out to assess the current practice. It was followed by implementation of quality improvement project using PDSA cycles by introducing comprehensive medication reviews, prioritising reduction of high risk and anticholinergic medications. Anticholinergic cognitive burden (ACB) scores and medication counts were recorded pre- and post-review. Patients were later followed up at 3 months to assess improvement in cognition, memory, number of falls, sleep quality, urinary symptoms and constipation after reduction in anticholinergic burden.

Results:

Over a period of 6 weeks after implementation of comprehensive medication review, the number of patients with reduced number of medications in the first cycle increased from 7 to 8 (21%) and in the second cycle it further increased to 9 (29%), the average number of medications reduced per patient were between 1-4, and the number of patients with reduced anticholinergic burden during first cycle increased from 3 (9%) to 4 (10%) and during the second cycle it further improved to 5 (16%), compared to existing practice. Patients were followed up at 3 months after reduction in anticholinergic burden regarding improvement in cognition, memory, reduced number of falls, quality of sleep, urinary symptoms, bowel habit and 83% reported marked improvement in all symptoms.

Conclusion:

There has been an improvement in all aspects including reducing polypharmacy along with achieving reduced anticholinergic burden after introducing comprehensive medication review.