Deprescribing with Emphasis on

Anticholinergic Burden

Dr. Lesley Hannah, Portlethen Medical Centre 2014

I am responsible for providing medical care to around 56 patients residing in long term care in Lethen Park Nursing Home in Portlethen, all of whom by most currently accepted models are defined as ‘frail elderly’. I decided to look closely at my prescribing in this group of patients - considering carefully, and most specifically, issues of polypharmacy and drug burden (anti-cholinergic and sedative drugs). Drug prescribing was audited initially retrospectively looking at repeat prescribing for June 2012 and repeated 12 and 23 months later with interim results shared amongst multi-disciplinary clinicians (GPs, pharmacist, community and practice nursing staff) on 25th June 2013. Rationalising prescribing resulted in a net reduction in number of items prescribed and a reduction in Total Drug Burden (TDB) (and incidentally in the monthly cost of prescribing) for the cohort of patients. The work was carried out with close reference to local and national polypharmacy guidelines and these guidelines were discussed and learning points shared at the July meeting . In optimising safe prescribing we hope to reduce hospital admission and adverse drug effects in this group of patients. As a practice we are currently developing systems to identify our community dwelling frail elderly population most at risk. We would aim to carry out polypharmacy reviews in these patients- once identified- having learned from this initial work. Arguably the impact in this second group will be greater- their social circumstances being in general more precarious.

Auditing Repeat Prescribing at Lethen Park Nursing Home  

A retrospective look at the repeat prescribing history of 53 patients resident in Lethen Park Nursing home formed the first cycle of the audit. Patients included were all resident in the home in June 2013. 48 of these patients have a diagnosis of dementia on their clinical summary, 1 has cognitive impairment due to head trauma and 4 have no previously identified cognitive impairment. Their repeat medications as at June 2012 were analysed and where a patient had been admitted to the home between June 2012 and June 2013 their admission medication was taken as their starting point.

 Only oral medications were included in the audit, all topical and inhaled medications were excluded from study with the exception of opiate patches which were considered to be of significant relevance where sedative/anticholinergic burden is concerned and therefore merited inclusion. Medications prescribed on an ‘as required’ or ‘PRN’ basis were excluded from study.

 Nursing staff were briefed on some of the principles of deprescribing and the aims of my audit in March 2013 (see appendix 1). From April 2013 there followed a period of regular rolling weekly medication reviews with prime consideration given to reducing anticholinergic burden (drugs commonly considered for reduction or discontinuation included SSRIs, antipsychotics, opiate analgesics, antihistamines, tricyclics etc). Review of all sedative drugs (benzodiazepines and ‘Z’ drugs) was considered a further priority. Drugs prescribed for primary or secondary prevention (antiplatelets, antihypertensives and statins) were also carefully considered but on scrutiny of current evidence and polypharmacy guidelines it became clear that there is little reassurance regarding medium to longer term outcomes following deprescribing these agents and minimal evidence to support short term safety of doing so.

 The use of anticholinergic risk scales (ARSs) was considered to quantify risk scoring for individual patients and perhaps try to demonstrate reduced burden following comprehensive review of patients repeat medication- the theory being that certain medications impart a greater or lesser anticholinergic burden on patients- however it became quickly apparent that there is little concorrdence between the several ARSs currently circulating and it was decided that simply counting number of meds prescribed was simpler and valid.

 Care was taken at all times during each patient assessment or multidisciplinary discussion to ensure that the overall effects of rationalising a patients medication was at least nil but it was of course hoped and expected that for some patients their quality of life might improve.

 As most of the 53 patients suffer from cognitive impairment there were frequent discussions re medication changes with family members and these discussions often informed decisions re deprescribing.

 In June 2013 following the initial period of rolling reviews the repeat medications of the 53 patients was analysed again. The comparative results are detailed below.

  June 2012 In June 2012 the average number of medications per person (ANMPP) for the 53 patients was 6.77

(most 13 and least 2) In June 2012 the average cost per person per month (ACPPPM) of repeat medications for the 53

patients was £50.93 (most £297.67 and least £4.49)

June 2013 In June 2013 the average number of medications per person (ANMPP) for the 53 patients was

5.98 (most 13 and least 1) In June 2013 the average cost per person per month (ACPPPM) of repeat medications for the 53

patients was £46.56 (most £296.94 and least £4.44)   In 18 cases the medication review process resulted in no changes to number of repeat

medications.In 7 cases the medication review process resulted in an increased number of repeat medication

items.In 28 cases the medication review process resulted in a decreased number of repeat medication

items. In total 12 sedative drugs were discontinued.In total 18 drugs carrying anticholinergic burden were discontinued.In total 10 drugs carrying anticholinergic burden were reduced in dose.3 patients had their antihypertensives stopped and remained normotensive 3 months after

stopping.  

May 2014

Repeating the audit cycle in May 2014 following an ongoing medication review process continuing to apply the principals of safe deprescribing and looking at the same 53 patients the results were as follows.

 6 patients died in the 11 month period from June 2013-May 2014 2 patients moved to different care homes in the 11 month period from June 2013- May 2014 In May 2014 the average number of medications per person (ANMPP) for the surviving 45 patients

was 5.44 (most 11 and least 1) In 32 cases the medication review process resulted in no changes to number of repeat

medications.In 5 cases the medication review process resulted in an increased number of repeat medication

items.In 8 cases the medication review process resulted in a decreased number of repeat medication

items. In total one sedative drug was discontinued.In total 4 drugs carrying anticholinergic burden were discontinued.In total 8 drugs carrying anticholinergic burden were reduced in dose. 

Discussion 

As expected the process of ongoing medication reviews with a view to deprescribing potentially harmful medication yields diminishing returns within a chosen cohort - and indeed during the second audit cycle 3 sedative drugs and 3 second generation antipsychotics were added to repeat medication schedules. The process though continued to result in a net reduction in prescribing and in particular in the prescribing of potentially hazardous medication. I discovered that there are subtle differences between the Grampian, Highland and Scottish polypharmacy guidelines and found the Grampian guideline to be the most practical and GP friendly. In choosing to undertake polypharmacy reviews with a view to deprescribing the clinician must be prepared to make difficult decisions on a case by case basis as there is often no clear risk/benefit bias and the guidelines are not prescriptive. Regular nursing and care staff provided invaluable assistance with monitoring of outcomes of medication changes to ensure my changes were at least ‘effect neutral’. The process was rewarding not least due to the need for this close working and engaging staff in the project from the early stages.

Participating in the Dementia Scholarship has improved my understanding of the diagnostic pathway and of local service provision for patients with a diagnosis of dementia. The telemed demonstration was quite frankly a revelation and the imaging session was fascinating. It has been pleasing and useful to have forged closer relations with my sectoral consultant and CPN.