Deprescribing Polypharmacy: Precision over Pills

Introduction

Polypharmacy is the use of multiple medications by an individual to manage various medical conditions Although sometimes necessary, this practice can lead to serious health complications This state is prevalent among older adults as the incidence and cooccurrence of chronic diseases tend to rise, resulting in increased medication usage1 Polypharmacy carries several potential risks such as adverse drug reactions, drug interactions, and significantly increases incidence of fall1

Anticholinergic Burden

Anticholinergic drugs block action of neurotransmitter acetylcholine in central and peripheral nervous systems2 The long-term use of these medications can have a cumulative effect, leading to cognitive and physical impairment that contributes to a person's overall ‘burden’ Several types of medications, including antihistamines, antidepressants, and antipsychotics, can have varying levels of anticholinergic activity2 Each medication that displays such activity is assigned an Anticholinergic Burden Score (ACB), with a higher score indicating greater burden Clinicians should regularly review these medicines to optimise therapies and promote healthy ageing2.

Ø Failure to address this issue can result in frequent hospitalisations and higher mortality approach to medication

Ø This achieve better health polypharmacy

Summary

Ø Prolonged use of anticholinergics can impair cognitive and physical function Using drugs with ACB scores of 3 or more for over 6 years increases dementia risk by 46%3

Ø Targeted medication reviews have demonstrated the ability of clinical pharmacists in general practice settings to effectively reduce the potential for iatrogenic harm

Ø A significant decrease in the total ACB score by 57 points within cohort, results in a substantial reduction of the risk of falls and dementia in these patients

0 3 6 9 12 15 18 21 24 27 Reduced Medication Dose Stopped Medication No Change in Medication Reduced Medication Dose Stopped Medication No Change in Medication Number of patients ACB score in patients on initial intervention relative to final outcome ACB Score 0 ACB Score 1 ACB Score 2 ACB Score 3 ACB Score 4 ACB Score 5 Final Outcome Initial Intervention ACB Score 6 ACB Score 7 ACB Score 8 ACB Score 9 3 5 4 4 4 7 5 4 1 1 1 1 1 1 6 5 3 4 2 1 1 1 1 2 5 8 4 4 1 1 1 16 22 8 20 20 6

Figure 3: A targeted medication review was conducted for suitable patients with high ACB scores, followed by one-month assessment of tolerance The review resulted in a significant proportion of patients reducing or stopping targeted medication, while some interventions were not well-tolerated, resulting in higher overall ACB scores The final result was positive, with an increase in total number of patients with ACB scores of 0 Some patients who reduced their dosage were able to stop taking medication altogether, resulting in lower ACB scores However, patients who were unable to tolerate the reduction continued with their regular treatment, leading to higher ACB scores within cohort

Figure 1:

Methodology

Ø A patients' medication lists with highest ACB therapy Ø A deprescribing Findings

Influential Factors for Non-Intervention within Cohort

5%

10%

25% 20%

Justifications for non-intervention within cohort n = 20

-5 -4 -3 -2 -1 0 +1 +2 +3 0 3 6 9 12 15 18 21 24 27 30 0 1 16 2 1 26 0 0 0 Change in ACB Score Number of patients Change in ACB Score from before and after medication review

Figure 4: The impact of targeted medication reviews on preventing polypharmacy and reducing associated risks was evident Out of 46 reviews, 16 patients reduced their ACB score by 3 points, resulting in a 48-point reduction within cohort Two patients reduced their score by 2 points, leading to a 4-point reduction within cohort One patient reduced their score by 4 points, and another by 1 point, leading to a total point reduction of 57 points Although most patients had no change in ACB score, reducing dosage by 50-75% significantly minimises patients' exposure to treatment and thereby, reducing associated risks Above all, the final outcome showed either a reduction or no change in ACB scores indicating a positive result in maintaining or significantly reducing patients’ overall risk

Background

Midwives’ experiences of participation in a national quality