Name: Caroline McKenna
[email protected] Background/Purpose:Anticholinergic medications block the effects of the neurotransmitter acetylcholine. These medications treat a variety of conditions, including seasonal allergies, Parkinson’s disease, chronic obstructive pulmonary disease, urinary incontinence, and more. Side effects of anticholinergic medications include urinary retention, blurred vision, confusion, altered mental status, dry eyes and mouth, flushing of skin, and tachycardia.1 Persistent use of anticholinergic medications are associated with cognitive dysfunction in older adults, including Alzheimer’s, Lewy body dementia, and delirium.2 Various scoring scales are able to quantify the risk of anticholinergic burden in a quick and reproducible way. The Anticholinergic Cognitive Burden (ACB) Scale compares a medication’s ability to bind to muscarinic receptors and the degree of serum anticholinergic activity, and is the most common scoring system used in clinical research.2 Medications are scaled from 0-3, with zero implying no anticholinergic activity and 3 implying high anticholinergic cognitive effect. Summative burden can be categorized into low (0), medium (1,2), or high (3+) risk. The purpose of this study was to reduce anticholinergic burden in older adults and lower the risk of cognitive impairment, by implementing pharmacist-led ACB scoring and medication review during Medicare Annual Wellness Visits (AWVs).
Methodology:This prospective, quality improvement study included patients with Medicare Part B coverage scheduled with a clinical pharmacist for their AWV across two outpatient family medicine clinics. Scheduling was handled by office support staff and based on primary care provider availability and pharmacist schedule openings. Patients were excluded if younger than 65. Guidance from the American Academy of Family Physicians in combination with clinical judgement by pharmacists were incorporated to determine appropriate intervention. During the AWV, medication reconciliations were completed. Patients received paper handouts for applicable anticholinergic medications, including but not limited to medications for pain, sleep, anxiety, allergies, and reflux. Handouts reviewed both risk and benefit of the offending agent, which were discussed with the pharmacist. Additional appointments were scheduled for deprescribing on a case-by-case basis. Data of age, ACB score, risk category, offending agents, and intervention offered was collected and analyzed by hand on a spreadsheet.
Results:A total of 76 patients were evaluated, with 6 patients excluded given age <65. Of those included, 28 (40%) had a low ACB score, 28 (40%) had a medium ACB score, and 14 (20%) had a high ACB score. The most common offending agents were omeprazole/pantoprazole/lansoprazole (n=14), metformin (n=11), cetirizine/loratadine (n=6), and chlorthalidone (n=4). In terms of interventions, 28 patients (40%) had no intervention given low ACB score, 3 (4%) patients were no longer taking an anticholinergic medication, 14 (20%) patients declined pharmacist intervention, 18 (26%) patients medication benefit outweighed anticholinergic risk, and 7 (10%) patients were open to pharmacist intervention and scheduled follow-up for deprescribing. For patients open to pharmacist follow-up, 4 patients were on omeprazole/pantoprazole, 2 patients were on cetirizine, and 1 patient was on both omeprazole and cetirizine. For patients on proton-pump inhibitors, 2 patients were successful in stopping the agent with minimal reflux symptoms, 1 patient found that famotidine alone relieved symptoms, 1 patient agreed to esomeprazole switch (ACB score = 0), and 1 patient continued on omeprazole after trial off. For patients on anticholinergic allergy medications, 1 patient self-stopped use prior to AWV, one agreed to as needed use, and one agreed to switch to fexofenadine (ACB score = 0).
Conclusions:Incorporating anticholinergic burden discussions during Medicare Annual Wellness Visits by pharmacists provided a seamless and meaningful impact. Of those reviewed, 60% had a medium or high ACB score. Through patient education and deprescribing efforts, a pharmacist was able to identify inappropriate anticholinergic use and support individualized deprescribing plans, promoting medication safety for older adults. Although only a subset of patients elected to pursue pharmacist follow-up, the majority saw success in either discontinuing the anticholinergic medication or switching to a safer medication alternative. Continued focus on anticholinergic deprescribing by pharmacists during AWVs may further enhance medication optimization, promote shared decision-making, and reduce long‑term risks associated with anticholinergic medications.
