The Health Innovation 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, Re-establishing autonomy in elderly frail patients, can be viewed here. For more information about the polypharmacy programme, please visit https://thehealthinnovationnetwork.co.uk/programmes/medicines/polypharmacy/

1. Re-establishing Autonomy in Elderly Frail Patients
Dr Rute Rosa-Marsh (PharmD)
Dr Rute Rosa-Marsh, PharmD ruterosa.marsh@dorsetgp.nhs.uk
PDSA PLAN DO STUDY ACT
#1 Elderly frail patients’
selection
Select patients taking ≥1 drugs with ACB=3:
Run a S1 report to populate >60yo patients
taking any Ach drug with ACB=3 using the
following ACB scale. 6 All eligible patients or
respective carers to be contacted asking
permission to participate in the study.
Assess, classify and record individual
patient frailty level using Rockwood Frailty
Scale Questionnaire and Classification
Tree. 7,8,9 Performed by the Frailty Clinical
Pharmacist.
Reduce the cohort population by
selecting those with Clinical Frailty Score
(CFS) ≥ 4 ≤7. Reassess as per PDSA #4 to
assess progress.
#2
Determine cognitive
decline baseline
Ask each eligible patient carer or family
member to answer the Informant
Questionnaire on Cognitive Decline in the
Elderly (IQCODE)9: The same carer/family
member must be used all time this
questionnaire is answered to keep
consistency.
Establish each patient cognitive decline
baseline score: Collect and record each
patient IQCODE score and alert patient
carer/family member to pay attention and
record any changes in each of the
questionnaire elements along the study, in
order to keep accurate measurements of
changes along the study.
Reassess as per PDSA #4 to assess
progress.
#3 Reduce total AEC
score to ≤2
Using PDSA#1 final cohort, invite patients
(and/or carers) for a SMR. Obtain consent
and discuss: patient concerns about their
current medication; if they are coping with
current regime; what are the patient
preferences, and if there are any drugs they
feel that are no longer needed and why.
Investigate if patient takes all currently
prescribed medication as indicated and if
any medication is not taken, why is that so.
Discuss the meaning of AEC and its effect in
the individual quality of life, explaining the
importance of reducing the AEC score and
its relation to quality of life and
independence improvement.
Quantify each patient current total AEC:
All eligible patients are to have each of
their taken medications scored for AEC
and total AEC score calculated using the
following classification tool. 10
Switch current Ach drugs to another
appropriate drug with the lowest AEC
score possible. Always follow local
formulary indications as much as
possible, and respect NICE guidelines
regarding initiation and monitoring all
times. Aim to achieve a total AEC of 2 or
less when possible. When planning
multiple Ach drugs switches, switch one
at each step of the process: start by
switching the drug with the highest AEC
first, when possible, safe and appropriate.
Repeat this PDSA in conjunction with
PDSA #4 according to results.
#4 Determine
outcomes
Using PDSA #1 and PDSA #2 assessment
tools, reassess patients CFS and IQCODE at
weeks 4, 12, 24 post each PDSA #3
medication optimisation cycle.
Collect CFS, IQCODE scores and AEC
changes and analyse patients progress and
correlation of CFS/IQCODE and AEC
reductions.
Run a patient satisfaction survey, and
possibly publish the QI study outcomes.
Develop a policy in anticholinergic de-
prescribing for our PCN.
BACKGROUND
It has been established that a high ACB/AEC scores are intimately related to frailty and cognitive decline levels, and that drugs
with a high AEC score are those with the highest impact. This issue is most found in polypharmacy patients and has a worse
outcome in frail elderly patients due their complex clinical nature. Tackling polypharmacy demands a careful and thorough
clinical judgement and a well-planned strategy to implement the necessary changes to avoid or slow down frailty and cognitive
decline levels and re-establish patient independence where possible. This type of process is quite time consuming but still less
expensive on a long run when compared with the daily cost of risks related hospital admissions and care plans. 1–6
AIMS
To demonstrate that focused and comprehensively planned SMR’s in complex multimorbidity elderly patients can contribute to
reducing frailty and cognitive impairment levels by tackling polypharmacy related risks using relevant available tools. Achieve an
AEC of ≤2 in the subject population of our GP practice to improve patient care quality, patient QoL and reduce polypharmacy
related hospitalisations and NHS costs overall. To show that investing time in quality SMR’s has lower economical burden to NHS
when compared to related hospitalisations and care plans.
People
Communication
Process
Equipment
Culture
Environment
No ACB/AEC check: Hospital
Discharge/Consultant Letters
Patient is seen by
several medical
professionals due to
multimorbidity
Clinical Professionals workload:
Lack of time, funding, support,
trained staff/experts
Lack of awareness and knowledge
about ACB/AEC polypharmacy
consequences
Communication challenges: Inter-
professionals;
Clinician-patient
S1/EMIS/Ardens no automatic
alert for ACB/AEC score ≥2
Local/National
formularies/Guidelines
Cognitive Impairment development
Increased Frailty and Cognitive
Impairment Levels
REFLEXIONS AND SUGGESTIONS
Always make my SMR’s patient wellbeing focused and not
strictly budget focused;
Improve self-confidence of sharing my knowledge with more
senior clinicians than me and challenge their clinical
therapeutical choices appropriately.
Contact The Phoenix Partnership (TTP) and Ardens to suggest
total ACB/AEC alert algorithm;
Use Clinical Meetings to spread awareness of ACB/AEC
consequences importance;
Propose local CCG to fund a campaign to train other clinical
professionals and increase awareness regarding ACB/AEC.
RESULTS
RESULTS INTERPRETATION/CONCLUSION
A reduction of AEC score can contribute to a decrease in
Rockwood Frailty Scale and IQCODE scores. This revealed some
autonomy re-establishment in the 2 patients of this study so
far. It also contributes to increase patient safety by reducing
polypharmacy related risks such as dizziness and drowsiness,
which are frequently associated with fractures in elderly frail
patients. Therefore, increased patient care quality, patient
QoL, NHS costs savings overall, patient satisfaction and
possibly lifespan extension.
Investing time in carefully planned SMR’s can lead to higher
quality care and lower burden to the NHS in general.
GP
Nurse
Rheumo
Memory Clinic
Urologist
Pain Clinic
Polypharmacy Champion
ACB
LEARNINGS AND CHANGES
• ePACT2: Polypharmacy prescribing comparators. ACB score is incorporated into
indicators available through ePACT2, which identifies numbers of patients with
ACB scores ≥6, ≥9 or ≥ 12 in a month.
• Performing AEC/ACB score screens at any Ad-Hoc opportunity: discharges,
letters, SMR’s, repeat prescriptions authorisations.
• Influencing colleagues about ACB/AEC importance.
• Importance of always putting patient health best interest first, regardless time
constraints.
6
2
Patient X AEC reduction AEC 6 AEC 2
Time (wks) FCS IQCODE
0 6 3.38
4 6 3.12
8 6 3.01
12 5 2.89
Figure 2. Rockwood Frailty Scale 10
REFERENCES
1. Bell B, Avery A, Bishara D, Coupland C, Ashcroft D, Orrell M. Anticholinergic drugs and risk of dementia: Time for action? Pharmacol Res Perspect. 2021;9(3). doi:10.1002/PRP2.793
2. Scottish Government Polypharmacy Model of Care Group. Polypharmacy Guidance, Realistic Prescribing 3 rd Edition, 2018. Scottish Government. Published 2018. Accessed September 19, 2022. https://www.therapeutics.scot.nhs.uk/wp-content/uploads/2018/04/Polypharmacy-Guidance-2018.pdf
3. Gorup E, Rifel J, Petek Šter M. Anticholinergic Burden and Most Common Anticholinergic-acting Medicines in Older General Practice Patients. Slovenian Journal of Public Health. 2018;57(3):140. doi:10.2478/SJPH-2018-0018
4. Cardwell K, Hughes CM, Ryan C. The Association Between Anticholinergic Medication Burden and Health Related Outcomes in the ‘Oldest Old’: A Systematic Review of the Literature. Drugs Aging. 2015;32(10):835-848. doi:10.1007/S40266-015-0310-9
5. Bulletin 253: Anticholinergic burden | PrescQIPP C.I.C. Accessed September 19, 2022. https://prescqipp.info/our-resources/bulletins/bulletin-253-anticholinergic-burden/
6. PrescQIPP. B140. Anticholinergic drugs 2.1. Accessed September 19, 2022. www.prescqipp.info
7. Aging Brain Program of the Indiana University Center for Aging Research. ANTICHOLINERGIC COGNITIVE BURDEN SCALE. Published 2012. Accessed September 19, 2022. https://gwep.med.ucla.edu/files/view/docs/initiative2/conferences/Anticholinergic-Burden-Scale.pdf
8. Clinical Frailty Scale Health Questionnaire. Accessed September 19, 2022. https://cdn.dal.ca/content/dam/dalhousie/pdf/sites/gmr/2021-08-03_CFS%20Questionnaire%20Online%20Version.pdf
9. CFS Classification Tree - Geriatric Medicine Research - Dalhousie University. Accessed September 19, 2022. https://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale/cfs-classification-tree.html
10. Clinical Frailty Scale (Rockwood) : Frailty Toolkit. Accessed September 19, 2022. https://www.frailtytoolkit.org/rockwood/
11. Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) | Doctor | Patient. Accessed September 19, 2022. https://patient.info/doctor/informant-questionnaire-on-cognitive-decline-in-the-elderly-iqcode
12. Medichec. Accessed September 19, 2022. https://medichec.com/
Table 1. Patient X IQCODE results along time 11
Figure 1. Patient X MEDICHEC AEC score comparison 1
Oxybutynin
Solifenacin
Promethazine
Hydroxyzine
3
3
1
1