Anticholinergic burden in older adults
Publication Date
July 17, 2024
Creator
Abstract
Introduction
The world’s older population, often defined as people aged ≥65, is growing rapidly. With advancing age, there is an increased likelihood of adverse effects from medicines. Medications possessing anticholinergic properties are commonly used for a variety of medical conditions. The accumulation of these anticholinergic effects (the anticholinergic burden) has been reported to increase the risk of adverse outcomes such as cognitive impairment, falls, physical impairment and mortality. About 25% of the overall population and 50% of the older population could be at risk of these adverse outcomes. To reduce the risk of adverse outcomes in this population, pharmacists need to identify and make recommendations to deprescribe inappropriate medicines. Existing guidelines on deprescribing are limited. They are often bulky, not tailored to pharmacists’ workflow, do not address barriers to deprescribing, and do not guide pharmacists through what to do after identifying problem areas. Consequently, they are often ignored, resulting in lost opportunities to deprescribe or switch to safer alternatives, and frail older adults continue to be prescribed numerous medications that increase their anticholinergic burden. Therefore, this thesis aimed to develop an intervention to reduce anticholinergic burden in older adults.
Method
A study design involving both qualitative and quantitative methods was used. The thesis initially examines the evidence linking anticholinergic burden to adverse outcomes, including a systematic review of the literature on the strength of the association between anticholinergic burden, cognitive impairment, and mortality (Chapter 2). Then, a service evaluation was conducted to evaluate current practice regarding anticholinergic burden in a UK hospital (Chapter 3). Afterwards, a qualitative interview study with pharmacists was aimed to identify barriers and facilitators to deprescribing and decision-making among pharmacists (Chapter 4). Finally, the Behaviour Change Wheel (BCW), incorporating the Capability Opportunity Motivation Behaviour model (COM-B) and Theory Domains Framework (TDF), was used as the theoretical basis for developing a decision support tool for pharmacist users. The tool was refined iteratively to improve its usability (Chapter 4).
Results
The systematic review and meta-analysis included 19 studies and established the evidence linking anticholinergic burden and adverse outcomes. The results from the meta-analysis of 6 studies on mortality showed that patients with low, and moderate to high, anticholinergic burden had a statistically significant 29% and 94% increase in the risk of mortality, respectively, compared to those with no anticholinergic burden (Chapter 2). The evaluation of a hospital frailty service including a pharmacist included 110 hospitalised patients showed that there was no significant difference between anticholinergic burden on admission and at discharge. Some drugs with anticholinergic properties were stopped during hospitalisation, but there was considerable scope for further reduction in anticholinergic burden. There were also missed opportunities to avoid increasing anticholinergic burden in patients who were started on new drugs, where alternatives with lower burden were available (Chapter 3).
Given the importance of reducing anticholinergic burden, the potential to do so, and the failure to do so, eight pharmacists' interviews provided insight into the barriers and facilitators to deprescribing. These barriers and facilitators fit within three target behaviour domains from the COM-B model. They included physiological capability, reflective motivation, and physical opportunity. These were mapped to 5 behavioural change techniques; action planning (e.g. through providing guidance on what to say to prescribers and patients to facilitate planned communication), information on health consequences (e.g. through providing information on the consequence of increased anticholinergic burden in older adults), credible source (e.g. through providing evidence-based guidance), prompts/clues (e.g. through providing a checklist of things to consider with the purpose of cueing deprescribing) and restructuring the physical environment(e.g. introducing the tool). From insights gained from the interviews, a 3-step anticholinergic burden decision support tool was designed. The tool comprised a checklist to identify patients at more risk of anticholinergic burden, an ACB score table, instructions on calculating anticholinergic burden and a medication review section.
Conclusion
In summary, this thesis describes a multifaceted approach, including an exploration of current practice and an evaluation of theoretical determinants of behaviour resulting in the design of a decision support tool to improve consideration of anticholinergic burden among pharmacists. This study has important implications for patients, health care professionals, research, and the healthcare system. Reducing anticholinergic burden could improve the quality of life for patients and reduce the financial burden on the NHS. This thesis also highlights the need for decision support to aid pharmacists in participating more in the deprescribing process. Further research is needed to pilot this tool before testing in a big trial.
Item Type
ethesis
Thesis Type
PhD
Subjects (LC)
Associated Schools / Departments
School of Medicine
eprints ID
76509
UoN Repository URI
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Examined. Anticholinergic burden in older adults
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