Prescribing and medication management

Drugs that have anti-cholinergic affects are known to have side effects such as urinary retention and constipation. In older people these drugs can also contribute to cognitive decline and loss of functional capacity leading to older patients being at risk of increased falls. Taking multiple medications with anti-cholinergic affects create a higher anti-cholinergic burden. Hilmer and Gnjidic (2022). Drugs that have anti-cholinergic affects block acetylcholine receptors (muscles do not receive neurotransmitter and therefore not functioning properly), Brown (2019). Some of these drugs are prescribed to have this effect but, in some patients’, this is an adverse effect. Although there are some drugs that are classed as anti-cholinergic drugs there are also drugs that have this effect which are not classed as anti-cholinergic such as anti-histamines, anti-depressants and anti-psychotics, Hilmer and Gnjidic (2022). This service improvement project will aim to introduce the anti-cholinergic burden scoring tool to a frailty unit for patients admitted with a fall with the aim of reducing the risk for patients who score highly being re admitted to hospital due to falls. Method This project will deliberate the development of change management using ADKAR (Awareness, Desire, Knowledge, Ability then Reinforce), Hiatt (2021) model of change management. By using this model, the author can prepare people for change, help people change and re-enforce the change allowing a successful service improvement. Results on completion of this project, the anti-cholinergic burden scoring tool will be successfully implemented onto the frailty unit and used by the medical team for patients admitted following a fall. By using ADKAR, Hiatt (2021) the author will be able to raise awareness, desire, build on knowledge and ability then reinforce the importance of reducing the risk of falls in older patients.

Introduction and Background- Bowel obstruction poses a considerable medical dilemma, demanding swift identification and intervention due to its propensity for severe complications. This challenge is exacerbated in elderly individuals who may be frail and less amenable to surgical interventions. Alvimopan, a peripherally acting μ-opioid receptor antagonist renowned for its pro-kinetic effects on the bowel, has shown promise in clinical trials. Nevertheless, despite its efficacy, it remains underutilised in many clinical hospital settings. Thus, our systemic review aims to underscore the potential benefits of Alvimopan, reintroducing its significance in managing bowel obstruction, particularly in elderly patients.

Methods- Four databases were searched to identify relevant studies investigating the use of Alvimopan for treating ileus. Included studies measured time for first bowel motion, and was compared with controls. Animal and non-original research articles were excluded.

Results- Ten randomised controlled trials (RCTs) were incorporated, each showcasing the significant reduction in both time to initial bowel movement and hospital stay attributed to Alvimopan. Findings indicated that Alvimopan can decrease the duration until the first bowel movement by an average of 14 hours compared to placebo, as well as abbreviate the time until discharge by an average of six hours.

Conclusion- Consistently, Alvimopan has demonstrated favourable results for patients experiencing bowel obstruction. Its utilisation could potentially circumvent the necessity for laparotomy in frail patients. Moreover, employing this medication contributes to shorter hospital stays, thus potentially mitigating associated complications. Consequently, we strongly advocate for its use and advocate for additional research to incorporate it into clinical guidelines.

Introduction: On behalf of National Falls Prevention Coordination Group, we were tasked with creating a user friendly guide on Medicines and Falls. We delivered two sessions on this topic one at British Geriatric Society Conference in November 2023 and another to Specialist Pharmacy Service audience in January 2024.

Method: Audience participation was used in both sessions as part of the discussion on “What do you consider important when completing a medication review in a person who is at risk of falls?” and “Which group of medicines do you prioritise for deprescribing discussion in patients at risk of falls?”. The results from slido contribution were analysed for trends and future learning needs.

Results: In the SPS audience, greater level of importance was imparted on individual drug classes when considering question of “what is important when reviewing a person at risk of falls” with anticholinergic burden being quoted most frequently and patient goals being second. Reducing risk and patient goals were the two items which the BGS audience prioritised. In terms of groups of medication to prioritise for deprescribing discussion, SPS audience once again chose anticholinergic medication followed by sedatives while BGS categorised antihypertensives and diuretics most commonly.

Conclusion(s): When completing falls medication reviews, medication groups were most commonly thought as important by pharmacy-focused audience, with patient goals the second most important aspect whilst the BGS audience prioritised reducing risk and patient goals. There should be greater emphasis on managing risk as part of teaching offerings to teams where therapeutics is the core focus. In terms of groups of medications to deprescribe, better guidance around reviewing antihypertensives and diuretics would facilitate more effective falls medication reviews. The difference observed between prioritising anticholinergic burden reduction indicates that general geriatric audience would benefit from further awareness raising of their contribution to falls risk.

 Background: Patients who experience a hip fracture have a high re-fracture risk. Prompt initiation of anti-osteoporosis treatment is therefore vital. Oral bisphosphonates are less well tolerated in some older people resulting in poor adherence. A single dose of IV zoledronate however, can be effective for up to 3 years and is shown to reduce fracture rate by 35% (Gregson, Age and Ageing, Vol 51, 2022).

Aim: To increase use of IV zoledronate post hip fracture in Salford Royal Hospital

Local barriers: a trust guideline advising a 7 week vitamin D loading regime means inpatient IV zoledronate post hip fracture is limited. Waiting time for outpatient parental therapy is > 6 months.

Intervention: • A new trust wide guideline was written, approving rapid vitamin D loading over 10 days post fragility fracture to promote IV zoledronate use.

Methods: Retrospective analysis of case notes for 100 patients admitted with hip fracture at baseline (August 2021). Repeat data collection performed post intervention in August 2023 (100 patients) and March 2024 (30 patients). We recorded FRAX recommendation, adherence to new vitamin D regime, bone health plan on discharge, and osteoporosis treatment implemented.

Results: There was an increase in inpatient zoledronate use to 30 % (5% at baseline). Oral bisphosphonate use reduced to 10% (28%). There was 98% adherence to the new rapid vitamin D loading regime.

In cycle 2, 6% of patients did not receive planned IV zoledronate as discharged before vitamin D loading completion. 2% did not receive planned IV zoledronate despite vitamin D loading complete

Conclusions: Rapid vitamin D loading allowed more patients to receive inpatient IV zoledronate post hip fracture. There is scope to increase this further. Future plans include adding ‘date for IV zoledronate’ to the electronic notes template and including bone health in the pre-weekend check list to avoid delay in IV zoledronate administration. 

Background and Objectives: Polypharmacy is common in frail older adults who often live with multiple co-morbidities. This polypharmacy can carry a significant anticholinergic burden. Frail older adults are particularly sensitive to the anticholinergic side effects of medications which can include constipation, urinary retention and dry mouth. Medications with a high anticholinergic burden scores have also been evidenced to contribute to an increased frequency of falls, cognitive decline and increased mortality. For frail older adults, a medication review, considering anticholinergic burden, is therefore an essential part of Comprehensive Geriatric Assessment. A local frailty census was completed for all medical inpatients over the age of 65 years old and as part of this anticholinergic burden scores were collated.

Materials and Methods: As part of this whole hospital frailty census, an anticholinergic burden score (ACB) was calculated for 77 inpatients. This was calculated using the Anticholinergic Cognitive Burden Scales and Anticholinergic Burden scores.

Results: The average age of the patients was 80.19 (± 9.35). 80.01% of patients were taking one or more medications with an anticholinergic burden. Of those, 40.25% had a significant ACB score of 3 or more (3-8). The patients with the highest ACB scores were those with multi-morbidity, an already established diagnosis of dementia and patients with recurrent falls.

Conclusions: The ACB score for patients included within this frailty census appeared to correlate with certain co-morbidities as would be expected from the known complications associated with these medications in frail older adults. The proportion of our inpatients with a significant ACB score informs us that we need to develop a more robust approach to delivering polypharmacy reviews as part of Comprehensive Geriatric Assessment within our hospital and will help us to inform future service planning and delivery.

Introduction Medication-related harm (MRH) is defined as any negative outcome, harm or injury caused by taking a medication (Falconer et al. Eur J Clin Pharmacol, 2018;75(2):137-145). People living with dementia (PLWD) take more medications than those without dementia, increasing their risk of MRH (Mueller et al. Exp Gerontol 2018;106:240-245). There is urgent need to explore the scale of MRH affecting PLWD. This systematic review aimed to determine the prevalence of MRH in PLWD and evaluate various outcomes to assess its impact.

Methods Twelve databases were systematically searched for articles published in English from date of inception to April 2023. Papers of any study design reporting on the prevalence and/or outcomes of MRH in PLWD were eligible for inclusion. Quality was assessed using the Cochrane Risk Of Bias tool for randomised trials (ROB-2) or the Risk Of Bias In Non-randomised Studies of Exposures (ROBINS-E). Due to lack of consensus on the definition of MRH and the heterogeneity of included studies, a narrative synthesis will be undertaken.

Results In total, 5,951 articles were identified, and 4,946 remained following removal of duplicates. After title/abstract screening, 419 full-text articles were assessed for eligibility. Ninety-eight studies were included in the review. Quality assessment is ongoing. Overall, 29 studies investigated adverse drug events, affecting 5-83% of participants, and 22 studies assessed mortality associated with drug use, with most reporting an increase in mortality. Antipsychotics were the most commonly implicated medication class, studied in 24 papers.

Conclusion This systematic review is the first to report on the prevalence of MRH in PLWD. However, it will not be possible to conduct a meta-analysis to fully analyse the scale of this issue. This review will identify gaps in the current evidence base and inform future research aiming to explore factors contributing to, and ways to reduce, PLWD experiencing MRH.

Introduction:

One of the key action areas of the World Health Organization third Global Patient Safety Challenge¹ ‘Medication Without Harm’ (WHO, 2017) is to reduce severe avoidable medication-related harm and address polypharmacy. NICE guidance on falls risk assessment and prevention² also includes medication review as part of its recommended multifactorial risk assessment (NICE, 2013). Use of Falls Risk Increasing Drugs³ (FRIDs) along with polypharmacy and anticholinergic burden are known to increase the risk of falls, particularly in older people². In 2021, Belfast HSC Trust appointed a pharmacist to work with the community falls multidisciplinary team and optimise medicines in older people at risk of falls, and we aim to explore the impact of this role on medicines optimisation in older people.

Method:

This research quantitatively evaluates the impact of the intervention of a novel community falls pharmacist role on medicines optimisation, in relation to FRIDs in older people who have had a fall. We will present data on admission and discharge from the service in relation to:

• Number and type of FRIDs prescribed
• Calculation of Anticholinergic Burden score using the ACBcalc® (King and Rabino, 2022)
• Polypharmacy- number of medications prescribed
• The appropriateness of medicines prescribed
• Undertake measurement of lying/ standing manual blood pressure to identify potential postural drop in blood pressure, and hypertension.
• Undertake a Bone health review using an approved tool (FRAX)
• Outcome of pharmacist referral of appropriate patients for DEXA scan using a new direct referral system
• Measure the significance of clinical interventions (Eadon graded)
• Calculate the cost avoidance of pharmacist interventions (ScHARR Tool) Results

Results:

92 patients were reviewed by phone (35%) or during home visit (65%), by the community falls pharmacist June 2022- August 2023.

• FRIDs³ prescribed, were identified and reviewed, and Anticholinergic Burden score (ACB) was measured using the anticholinergic burden calculator⁴ (ACBcalc®)
• The number of medications prescribed and the appropriateness of these was measured using Medicines Appropriateness Index⁵ (MAI)
• Significance of clinical interventions by the community falls pharmacist was measured using Eadon⁶ scale and cost avoidance of these measured using an adapted version of the ScHARR tool⁷. Potential cost savings⁸ from deprescribing, and  environmental impact were calculated (every £1 spent on pharmaceuticals generates greenhouse gas emissions 0.1558kg C0₂⁹)
• Lying/ standing manual BP measurement was undertaken
• Bone health review was undertaken using a fracture risk assessment tool¹⁰ (FRAX^®) & appropriate patients referred for a DEXA scan, using a new direct pharmacist referral pathway

Results indicate a medicines review by the community falls pharmacist leads to a statistically significant reduction in polypharmacy (¯8%; p<0.05) and ACB (¯33%; p<0.05), an increased appropriateness of prescribing (MAI ¯56%; p<0.05), 317 clinically significant interventions, identification of blood pressure issues (22%) eg orthostatic hypotension, and identification of osteopenia (n=14) or osteoporosis (n=3) using a new pharmacist DEXA referral pathway. Amitriptyline was the most common FRID deprescribed (22%). Annual cost avoidance due to pharmacist interventions were in the range of £28160 – £62358 along with drug cost savings of £6041, amounting to total savings of £34201-£68400, and invest to save return of one to two pounds for every £1 invested. Benefit to the environment of reduced inappropriate prescribing amounted to almost 1 tonne of avoidable CO₂ emissions per year.

Discussion:

The pharmacist review had a statistically significant impact on reducing the ACB score by an average of 33% . The MAI pre- and post-review reduced  by an average of 56% indicating an improvement in appropriateness of prescribing.  101 FRIDs were deprescribed & amitriptyline was deprescribed in 22% patients. 94% of clinical interventions were significant resulting in improvement in care and an additional 19 preventing potentially serious outcomes.

Conclusion:

Introduction of a community falls pharmacist role is an effective and cost efficient means to optimise medicines in older people who experience falls, as well as having a positive impact on the environment. The community falls pharmacist ­ prescribing appropriateness, generates a return of £1-£2 per £1 invested, & ¯CO₂ emissions by 1 tonne

1 World Health Organisation (WHO) Third Global Patient Safety Challenge: Medication Without Harm 2017 www.who.int

2 NICE Falls In Older People: Assessing risk and prevention Guidance 2013 www.nice.org.uk

3 Falls Risk Increasing Drugs (FRIDs): NI Medicines Optimisation Older People (MOOP) 2022

4 ACBcalc® ACB Calculator web app created by Dr Rebecca King and Steve Rabino

5 Hanlon, J. et al. A method for assessing drug therapy appropriateness, J Clin Epidemiol. 1992 45(10):1045-51

6 Eadon, H. Assessing the quality of ward pharmacists’ interventions. Int J Pharm Pract. 1992 1:3; 145-147

7 Miller, R. et al. Consultant pharmacist case management of older people in intermediate care. EJPCH 2016 4:1; 46-52

8 Health & Personal Social Services NI September 2023 Drug Tariff (hscni.net)

9 Gompertz, D. ‘Show me your meds, please’: the impact of home-based medicines assessments. The Pharmaceutical Journal 2023 vol 310. no. 7971;310

10 Fracture Risk Assessment Tool (FRAX®) University of Sheffield www.frax.shef.ac.uk

Introduction

A quarter of people with hip fractures sustain another fragility fracture within 5 years, but most receive no osteoporosis medication as secondary prevention. To coincide with the publication of ‘A call to action: a five nations consensus on the use of intravenous zoledronate after hip fracture" Age and Ageing, September 2023, we set out to explore clinicians’ reasons for not previously using zoledronate (IV Zol).

Methods

Prior to first presentation of the ‘Call to Action’ at the Global Fragility Fracture Network (FFN) and British Geriatrics Society conferences in autumn 2023, we used conference apps to run an online survey of 156 attendees (99 from UK, and 57 working in other countries).

Results

Licensing of IV Zol excludes people with creatinine clearance (CrCl) <35ml/min. Our surveys found that 27% of UK clinicians (9% of non-UK) already use a 30ml/min CrCl threshold. In addition, 13% (vs. 26%) use eGFR 30ml/min, and 23% (vs. 51%) eGFR 35ml/min as their threshold. This suggests that 63% of UK (87% of non-UK) clinicians already administer IV Zol if CrCl <35ml/min. UK clinicians indicated fewer concerns over reduced effectiveness if IV Zol was given within 14 days of fracture (56% vs. 86%), and greater preparedness to consider 4mg, rather than more expensive 5mg, doses (42% vs. 18%) and single infusions without a subsequent dose (91% vs. 68%).

Conclusions

It is important to understand why people feel reluctant to use IV Zol, despite this being the first-line recommendation of the National Osteoporosis Guideline Group (NOGG).

In particular, our demonstration that many clinicians in the UK and around the world are already using IV Zol, off license, in people with CrCl of 30-35 ml/min will support the ‘Call to Action’ paper, helping many more hip fracture patients with renal function in this category to receive a medication of proven effectiveness.

Background Alzheimer’s disease-modifying drugs (DMDs) are in routine use in other countries. They will likely be available in the UK within the next year. It is not yet clear how many patients will be eligible for them or what resources are required to establish this eligibility. Methods Patients attending the out-patient memory clinic of a single geriatrician between 01/02/2022 and 12/01/2023 were identified. Information required to judge eligibility according to the lecanemab appropriate use recommendations (Cummings et al 2023) was extracted between 08/08/23 – 13/09/2023. Relevant data included: diagnosis, that is dementia or mild cognitive impairment (MCI), cognitive symptoms due to a non-dementia causing disease pathology or diagnosis unclear; Addenbrooke’s Cognitive Examination III (ACE-III) and Mini-Mental State Examination (MMSE) scores; brain MRI reports; CSF analysis results; anticoagulant/antiplatelet drug history. Results In total, 328 records for n=214 patients were identified during the audit period. Of these 214 patients, 4 were <50 years and 9 were >90 years. Of the remaining 201 patients, 122 were diagnosed with dementia, 31 with MCI due to an underlying dementia-causing disease, 45 with symptoms due to non-dementia-causing pathology and 3 had an unclear diagnosis. Of the 153 patients with dementia/MCI, 105 had an ACE ≥60 or an MMSE ≥22. Of these, 32 were on anticoagulants. Of the 73 patients therefore potentially eligible for DMDs, 26 had MRI imaging and 2 CSF analysis. With the information available at the time of audit, one patient would have fulfilled the lecanemab appropriate use recommendations. Conclusion A large proportion of patients attending a geriatrician-led memory clinic during this audit period were ineligible for DMDs at first pass assessment, mostly on the basis of diagnosis and cognitive scores. Adequate investigation of potentially eligible patients will require significant increases in MRI and CSF analysis capabilities. Of note, this audit did not consider likely aetiological diagnosis.

Introduction: Reducing inappropriate polypharmacy is a major public health goal and deprescribing is considered one potential solution. Although patient attitudes towards deprescribing have been well studied, little consideration has been given to the informal caregiver perspective, how this differs from the views of patients and how that might influence care.

Method: A survey including demographic questions and the revised Patients’ Attitude Towards Deprescribing (rPATD) questionnaire was undertaken. The primary outcome was to identify the willingness of respondents to deprescribe. This survey was distributed as online, telephone or paper versions, via social media, community centres, day care centres, local organisations, and personal networks. It had two sections composed of equivalent questions: one for the ‘patient’ (age 65+, based in England, taking one or more prescription medication) and one for their ‘informal caregiver’ (age 18+). Data were analysed using descriptive statistics and binomial logistic regression.

Results: After exclusion of ineligible respondents, a total of 1,307 survey responses were received (861 patients and 446 caregivers). The average patient was 76±9 years, female (526; 61.6%), white (831; 97%), and educated to degree level (482; 56.9%). The average informal caregiver was 73±14 years, female (278; 62.9%), white (426; 96.4%) and educated to degree level (258; 58.2%). A total of 77.1% patients agreed that they were willing to deprescribe medications if their doctor said it was possible. In contrast, significantly fewer informal caregivers were happy for their patient to have medications deprescribed (59.7%; p-value for difference <0.001). Trust in physician, concerns about stopping medication and belief in the appropriateness of withdrawal were all associated with respondent willingness to deprescribe.

Conclusion: This large study suggests patients are more willing to deprescribe than their informal caregivers. Better understanding these attitudes and how they differ between patients and caregivers, will help inform interventions to improve involvement in medication-related decisions.