Abstract
Introduction: Polypharmacy is a major risk for older patients aged 65 and above. Commonly prescribed medications may have anticholinergic properties causing dry mouth, constipation, and urinary retention which can exacerbate delirium in older adults1. ACB scores help quantify the cumulative effect of these medications. ACB scores of three or more are associated with confusion, falls and death2.
Aim: To evaluate whether automated alerts of ACB scores help reduce scores and encourage medication reviews in older patients.
Method: Over two weeks, automated alerts were set up within the hospital’s online noting system, which is simulated to flag high ACB scores based on inpatient drug charts. The alert identified the total ACB score and highlighted offending medications. Data was collected from 40 patients across four elderly care wards over two weeks, on alternate days. ACB scores were calculated using an online ACB calculator. ACB scores collected before and after two simulated alerts were analysed and compared.
Results: Out of 40 patients, 12 had an ACB score of 3 or more before the simulated alerts. Following two automated alerts, this reduced to 9 patients, which equates to a 25% reduction. However, in 31 patients, the ACB score remained unchanged. The ACB scores increased in 8 of the 40 patients. Furthermore, lansoprazole was the most common offending drug [ insert number here], followed by tricyclic antidepressants [insert number here].
Conclusion: Our study demonstrated that automated reminders could facilitate regular medical reviews and reduce anticholinergic burden in elderly patients. However, this would work better in combination with regular teaching sessions to increase awareness. Importantly, proton pump inhibitors (PPIs) were prescribed to over a quarter of patients. This raises questions about the necessity of these medications in this age group and a potential QIP looking at deprescribing PPIs as per the deprescribing algorithm.
Comments
Good work. I think use of…
Good work. I think use of technology like this is very important - but I do worry there is a 'alert fatigue' with the ieMR notifications. And I do wonder how, over time, whether they remain as impactful as we hope they should be. Interesting re: PPI use, an often underappreciated/overlooked culprit.
Alert fatigue and technology
Agreed - we are currently living in an age where technology should be used to promote efficiency and safety within our patient cohort! Not sure if AI has been used to facilitate professionals within the spheres of polypharmacy or deprescribing yet but I think its definitely something worth looking into. Re: Alert fatigue - I can confirm it does happen on the shop floor with routine things such as borderline electrolyte abnormalities etc but it is useful when there is a new radiological report for example. So just need to be strategic on what triggers a notification.
Really interesting and important ACB research for older adults
Really interesting and important research as ACB is a really important but easily missed factor when it comes to managing the care of unwell older adults. However, I do agree with the above comment regarding alert fatigue as healthcare becomes increasingly digitalised. As a nurse, I would empathise with wards staff being burdened with numerous alerts that may risk not all being addressed in a timely manner. Teaching and awareness of ACB would be important for all ward staff, do you think the ACBs could be more adequately addressed in MDT meetings?
Teaching
Yes, our first project (poster submitted to Belfast BGS) was on providing teaching sessions in local HCOP meetings which demonstrated an impact, posters - not so much. So definitely needs to be taught widely amongst HCOP/ Pharmacy colleagues. I also think there is an element of confidence with deprescribing medications with anticholinergics properties at a junior level and also it takes time on a busy working day to calculate medications using the ACB calculator - so perhaps technology could be used in a way to help calculate it for us; and we can make changes based on that. If we can do this, then all we would need to do is signpost clinicians to look at the automated scoring system.