The AHSN Network Polypharmacy Programme is working with healthcare professionals to address problematic polypharmacy by supporting easier identification of patients at potential risk from harm from multiple medications. Our evidence-based polypharmacy Action Learning Sets (ALS) are being rolled out across England to support GPs, pharmacists and other healthcare professionals who undertake prescribing or medication reviews to understand the complex issues around stopping inappropriate medicines safely. To drive and accelerate changes in practice, delegates complete a quality improvement project to address problematic polypharmacy in their workplace. This poster summary, Mind over bladder - Prevent harm associated with excessive or inappropriate anticholinergic burden, can be viewed here. For more information about the polypharmacy programme, please visit https://www.ahsnnetwork.com/programmes/medicines/polypharmacy/

1. Evaluation of the Deprescribing of Anticholinergic Medications
in Dementia patients
Rachael Thornton BPharm(Hons) PGClinDip MRPharmS MAPCPharm IP MFRPSII
Polypharmacy and anticholinergic medicines are associated with an increased risk of Adverse Drug Reactions (ADR’s) and hospital
admissions¹. Anticholinergic drugs in particular are known to increase cognitive impairment and where the Anticholinergic Burden (ACB)
score is ≥ 3, patients have a higher incidence of mortality². This evaluation explores the value of Specialist Pharmacists in supporting the
safe use of medicines in older people living in care homes with inappropriate polypharmacy through Structured Medication Reviews
Objective: The objective is to evaluate the number of anticholinergic medicines prescribed in one residential home caring for people with
dementia with the aim of reducing inappropriate polypharmacy and potential adverse effects from medications with an ACBs score
Method: Every resident had a structured medication review (SMR) where a holistic review was undertaken with the resident and/or the
carers in the residential care home. Medication was scored against a standardised ACB score²
Results and Discussion:
23 residents with dementia received a SMR, there was an average of 9.91 repeat
medicines being prescribed monthly for each resident (range 1 – 26 medicines). The
average age in the care home was 85 years (range 75 – 100 years). The largest
number of medicines discontinued were in the Cardiovascular, Gastrointestinal and
Nervous System BNF groupings. These are also the three main groups known to
contribute to Anticholinergic Burden³.
Of the 23 dementia residents reviewed, 57 of the 228 (25%)
medicines prescribed had an Anticholinergic Burden. 16 /23 of
the residents had an ACB score ≥ 3. After all the SMR’s were
completed the average ACB score for all 23 residents reduced
from 3.95 to 1.82 p = 0.0006 (95% CI -3.2966 to -0.9634). Only 1
resident had an ACB score remaining ≥ 3. Fourteen residents
had a reduction in their ACB and five residents had their ACB
score reduced to zero.
60 medicines were stopped, 27 of these had an ACB, the
reduction in ACB score was statistically significant, p = 0.5613
(95% CI –11.5960 to 6.3760).
Total number of repeat
medications after review = 228
Total number of repeat
medications before review = 288
References:
1. Woodford, H.J. and Fisher, J., 2019. New horizons in deprescribing for older people. Age and ageing, 48(6), pp.768-775.
2. Fox, C., Richardson, K., Maidment, I.D., Savva, G.M., Matthews, F.E., Smithard, D., Coulton, S., Katona, C., Boustani, M.A. and Brayne, C., 2011. Anticholinergic medication use and
cognitive impairment in the older population: the medical research council cognitive function and ageing study. Journal of the American Geriatrics Society, 59(8), pp.1477-148
3. ACB Calculator <accessed 24.04.23>
4. eepru-overprescribing-revised-report-final-clean.pdf <accessed 18.05.23>
5. Anticholinergic medication use and cognitive impairment in the older population: the medical research council cognitive function and ageing study - PubMed (nih.gov) <accessed
11.05.23>
Polypharmacy: For the 23 residents in this care homes 288 repeat medications were prescribed (average: 9.91 medications per resident)
BNF Group
Anti-
infective Blood Cardiovascular Endocrine Eye
Gastro-
intestinal
Genito-
urinary Malignant
Musculo-
skeletal
Nervous
System Nutrition Respiratory Skin
Number of
medicines
prescribed 2 4 55 12 7 31 8 4 14 50 17 5 17
Conclusion
Inappropriate polypharmacy is an increasing problem particularly in older people⁴, from the completion of Structured Medication Reviews by an Older
Persons Specialist Pharmacist it can be seen that the average tablet burden was statistically significantly reduced from 12.5 to 9.91 repeat medications,
p = 0.5643 (95% CI –11.5760 to 6.3960).
In one study it was found that 20% of patients over 65 years taking medicines with an ACB score ≥4 died within 2 years compared to 7% of those with a score
of 0, and that every additional ACB point can increase the risk of dying by 26%⁵. In the case of this home the 9 residents with a previous ACB score of ≥4, now
reduced, can expect to have a 68% reduced odds of dying within the next two years as consequence of adverse drug effects and a further 6 residents can
expect to have a better quality of life with improved cognition and reduction in ADRs from anticholinergic effects. In can be concluded that these residents
will experience a better quality of life and a reduced risk of hospital admission related to medication.