Abstract
Introduction
The impact of taking medications with anticholinergic activity is called anticholinergic burden (ACB). A high ACB can cause physical and cognitive impairment, especially in the elderly, and is associated with increased falls, incidence of dementia and mortality. Therefore, we audited our admissions with delirium to see if we deprescribed to reduce medication number and ACB and if this impacted sedation use.
Method
A list of 146 admissions over two months were analysed; 46 had a delirium diagnosis. The number of medications and ACB scores were calculated at arrival to ED, admission to and discharge from our ward. We excluded six patients: one due to death, one due to incorrect delirium diagnosis and four due to anticipatory medication use. Total lorazepam and haloperidol expenditure across complex care was calculated and compared for the same period.
Results
On arrival to ED, the mean medication number and ACB scores were 9.85 and 1.88, respectively. On arrival to the ward, these were 11.03 and 1.73 but then decreased to 9.20 and 1.28 at discharge. Our ward's combined expenditure for lorazepam and haloperidol was lowest at £199.12, compared to £318.81 and £433.63 on similar wards.
Conclusions
These data show that there was a statistically significant reduction in medication number (16.6%) and ACB score (31.9%) comparing ED arrival vs discharge from the ward, and ACB score on ward arrival vs at discharge (26%). We also spent least on sedation (59.9-117.8%), suggesting this reduction may reduce the need for sedation and costs for drug budgets.
Comments
Thanks, Robert, for your poster and talk that accompanied it.
You allude to the fact that there is reduced ACB on your ward throughout the stay. Is it a formalised ward round structure that the team used on the ward, or is it something that is spearheaded by particular senior consultants and done more informally as part of their ward round plans? Have you spoken about your findings locally and discussed ways to see if highlighting ACB has similar outcomes in other wards?
Hi Dr Bunn
Thank you for your question and for watching my presentation.
I would say it is a mixture of these two methods. We currently have two permanent consultants based on our ward, and they both very much highlight ACB within our formal daily ward round structure.
We then look at formulating plans to wean or stop offending drugs in our patients, which is documented within our thorough problem lists.
These problem lists are automatically pulled through to new subsequent ward round notes created in our electronic patient record so that the following doctor is aware and can act appropriately in future ward rounds.
We then highlight these changes in our discharge summaries so that their GP knows 1) the continuing weaning regimen we have recommended (if applicable) and 2) why specific medications have been stopped.
In regards to sharing our findings locally, we hope to do so with our senior department members.
Then to gauge broader current practice in complex care, we hope to extend this project to include the other wards, either with myself involved or with other colleagues.
Then depending on our results, we can make changes as necessary to our formalised ward-round structures across the department with specific inclusion of ACB score within delirium or more widely in our elderly patients (if this is not current practice in the department). We could then also look at the correlation with sedation spending, which would hopefully decrease.
But to clarify, this, unfortunately, has not happened yet and is in the planning stages.
I hope this answers your question, but please do let me know if I can expand on anything further.
Kind Regards
Rob
Thanks Rob for your poster and presentation. Which ACB score did you use?
It would be really interesting to compare your falls, lengths of stay and readmission rates compared to other wards to see whether the deprescribing you describe also impacts on these outcomes.
Hi Dr Richardson, thank you for watching my presentation and your question.
Initially, we looked at several online to see which appeared to be the most comprehensive regarding the array of medications included to help calculate an accurate ACB score.
Therefore, we decided to use "acbcalc.com", an online calculator created by Dr King, which appears to be relatively comprehensive, reviewed regularly and has an easy-to-use interface.
I agree; it would be good to take this work further to see if this has a beneficial impact on those outcomes mentioned above on our ward and then, results depending, roll this out across the department if needed.