Reducing Anticholinergic Burden in Hospital at Home Patients: A Quality Improvement Project

INTRODUCTION
High anticholinergic burden (ACB) is associated with cognitive impairment, delirium, falls, and adverse side effects in older adults. Hospital at Home patients are particularly vulnerable due to frailty and poly-pharmacy. The aim of the project was to improve identification and reduction of high-risk ACB scores (≥3) by using ACB calculator and stopping unnecessary medications carrying side effects.
METHOD
A two-cycle quality improvement project was conducted within an Hospital at home service. At baseline, ACB scores were not routinely calculated. Interventions included awareness within team through education, implementation of routine ACB scoring on admission with recalculation at discharge, and highlighting high ACB scores. Medication reviews were supported through weekly multidisciplinary team ward rounds with pharmacist involvement for medication optimisation and deprescribing.
RESULTS
In Cycle 1, ACB scores were calculated in 68% of patients. Patients with high risk ≥3 decreased from 20 on admission to 18 at discharge (10% reduction). Although identification improved, medication optimisation was limited.
In Cycle 2, ACB score calculation increased to 81.8%. Patients with high Risk score ≥3 reduced from 16 to 12 (25% reduction). Improved MDT reviews and awareness of ACB risk resulted in more frequent medication changes and greater reduction in ACB burden.
CONCLUSION
Introducing routine ACB scoring and  MDT medication review improved identification and reduction of high anticholinergic burden. This led to stopping or reducing inappropriate medicines, lowering associated side effects. This project shows that simple changes in practice can improve medication safety in a older patients . Sustained impact will require ongoing education, integration into routine practice, and better communication with primary care to maintain medication optimisation after hospital at home episode.