Improving recognition & reduction of anti-cholinergic burden in older patients admitted with falls and/or confusion: a quality improvement project across two NHS trusts

Anticholinergic medications are associated with increased risk of falls and cognitive impairment in older adults, yet anticholinergic burden is not routinely considered during medication review. Through a two-cycle quality improvement project, we aimed to improve recognition of anticholinergic burden among patients aged ≥65 years admitted with falls and/or confusion and evaluate whether a simple educational intervention could reduce the proportion of these at-risk patients with anticholinergic burden. 

This quality improvement project was undertaken across a total of seven Care of the Elderly wards between Walsall Manor Hospital and Birmingham Heartlands Hospital. Patients aged ≥65 years admitted with falls and/or confusion or developed falls/confusion during admission were included. Medication charts were reviewed using the Medichec Anticholinergic Effect on Cognition (AEC) tool to quantify anticholinergic burden. Baseline data collection identified 46 patients at Walsall and 53 patients at Heartlands fulfilling the criteria. Interactive educational posters were then displayed on all seven wards. Following a period of healthcare professional engagement, repeat data collection was conducted with identical inclusion criteria, with 46 patients at Walsall and 66 patients at Heartlands being included. 

At baseline, 41% of the 46 patients at Walsall and 60% of the 53 patients at Heartlands had moderate to significant anticholinergic burden. Post intervention posters, this reduced to 30% at Walsall and 45% at Heartlands, representing absolute reductions of 11% and 15% respectively. Improvement was observed across patients admitted with falls and/or confusion at both NHS trusts. The intervention posters provided easy access to the Medichec AEC tool to review both paper-based and electronic prescribing systems.

Thus, a simple educational intervention increased awareness of anticholinergic burden and was associated with clinically meaningful reduction of burden for at risk patients, across two NHS trusts. This project highlighted the importance of incorporating anticholinergic burden assessment into routine medication reviews.