Polypharmacy and potentially inappropriate medications (PIMs) in older adults referred to a memory clinic

AimsThe older adult is more likely to be prescribed a lot of medications (polypharmacy) on account of multi-morbidity and consequently being under the care of several specialists. Adverse drug events and reactions account for significant morbidity and mortality in this population group. Common sequelae include confusional episodes, dementia syndromes, falls, and higher rates of acute hospital admissions.Medications are not routinely reviewed in elderly care. We sought to estimate the prevalence of polypharmacy, and potentially inappropriate medications (e.g. anticholinergics or medications with central anticholinergic effects) in those referred to the Cognitive Impairment and Dementia Service (Elm Lodge), Older Persons Mental Health, West London NHS Trust.MethodAll referrals between 01/10/2020 and 30/11/2020 were screened for medications prescribed. Polypharmacy was defined as prescription of 5 or more medications. Medications with anticholinergic properties were considered examples of Potentially Inappropriate Medications (PIMs). The Anticholinergic Effect on Cognition (AEC) Tool, ‘Medichec’, was used to identify and rate anticholinergic burden. Anticholinergic load was also compared using the Anticholinergic Burden Scale (ABS).ResultTotal number of patients referred – 19311 patients excluded due to unavailable/incomplete medication records.Study number: 182Polypharmacy: 79.67% (n = 145) were prescribed 5 or more medications.44.51% (n = 81) prescribed 5–9 medications.23.08% (n = 42) prescribed 10–14 medications.8.79% (n = 16) prescribed 15–19 medications.1.67% (n = 3) prescribed more than 20 medications.Anticholinergics prescribed (AEC Tool): 37.36% (n = 68) prescribed an anticholinergic.6.59% (n = 12) prescribed more than 1 anticholinergic.Anticholinergics (ABS): 29.67% (n = 54) prescribed an anticholinergic.7.699% (n = 14) prescribed more than 1 anticholinergic.ConclusionPolypharmacy and potentially inappropriate prescribing (e.g. anticholinergics) remain widespread within the older adult population. Anticholinergic load was broadly similar with the Anticholinergic Effect on Cognition tool and the Anticholinergic Burden Scale. Increased anticholinergic burden further compounds risks of cognitive impairment, delirium and death.Other categories of Potentially Inappropriate Medications, including those no longer needed, ought to be identified and reviewed. Over-the-counter medications also need to be screened for.Elimination or reduction of anticholinergic burden may improve quality of life for patients, as well as cost burden on services.Pharmacovigilance, collaborative working, and regular training are needed across services providing care for the older adult.

CUMULATIVE CHOLINOLYTIC EFFECT IN CLINICAL PRACTICE (LITERATURE REVIEW)

Anticholinergic agents are widely used in clinical practice. However, they can cause various cumulative side effects (dry mouth, drowsiness, confusion, residual urine accumulation, etc.). The purpose of the study is to perform an analytical review of the literature dedicated to causes, complications and rehabilitation of patients with cumulative anticholinergic effect. The analytical review of the literature highlights the risks and benefits of using anticholinergic drugs. Anticholinergic agents make up to one third of all medicines for the aged people. Recent data have proved the relationship between the long-term use of anticholinergics and dementia. New results relating to the cholinergic system in the regulation of cerebral vascularisation and in neuritis indicate that anticholinergics may contribute to the absolute risk and progression of neurodegenerative diseases. It has been proven that more than 600 drugs taken by aged patients carry the so-called "anticholinergic load". The number of drugs with anticholinergic properties is constantly increasing, they include: antidepressants, antihistamines, antiparkinsonian, antipsychotic, antispasmodic, mydriatic drugs, drugs for the treatment of overactive bladder and many others. Conclusions. The number of drugs that have anticholinergic activity and can cause complications associated with anticholinergic load is increasing. To assess the anticholinergic action of drugs, several methods have been proposed, taking into account the amount of dose and the intensity of anticholinergic activity of drugs. The research of the general medical community about the anticholinergic load problem and high alertness when prescribing drugs with anticholinergic properties can prevent the cumulative anticholinergic effect development and severe complications, and, thus, save the life and health of patients.

Safe prescribing in cognitively vulnerable patients: the use of the anticholinergic effect on cognition (AEC) tool in older adult mental health services

Aims and methodMedication with anticholinergic action is associated with potentially serious adverse effects in older people. We present an evaluation of a novel anticholinergic burden scale introduced into routine practice in older adult services in the South London and Maudsley (SLaM) NHS Foundation Trust. Our aim was to assess whether this tool improved the accurate identification of anticholinergic medication and guided safer prescribing in cognitively vulnerable older people.ResultsThe introduction of the anticholinergic effect on cognition (AEC) tool into clinical practice led to an increase in the identification and reporting to general practitioners of anticholinergic medication from 11 to 85% of cases (P = 0.0015).Clinical implicationsApplication of the AEC tool led to improved detection of anticholinergic medication and advice to primary care on when a medication review is necessary. This is an important step towards improving the safety of prescribing in this patient group.