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Healthcare practitioner-oriented interventions have the potential to reduce the occurrence of anticholinergic prescribing errors in older people. Interventions were primarily effective in reducing the burden of anticholinergic medications and assisting with deprescribing anticholinergic medications in older adults.
Author, Year, Country | Study Design | Intervention | Description of Intervention(s) | Effect on Outcome/Key Findings |
---|---|---|---|---|
Riordan et al., 2019, Ireland [42] | Convergent parallel mixed-methods design (before and after) | Academic Detailing (pharmacist-led) | Pharmacist conducted face-to-face education sessions and small focus group academic detailing sessions of 19–48 min with physicians. |
Pharmacist-led academic detailing intervention was acceptable to GPs. Behavioural Change: awareness of non-pharmacological methods in treating urinary incontinence. Knowledge Gain: intervention served to refresh their knowledge |
Ailabouni et al., 2019, New Zealand [43] | A single group (pre-and post-comparison) feasibility study | Medication review (deprescribing) | A collaborative pharmacist-led medication review with GPs was employed. New Zealand registered pharmacists used peer-reviewed deprescribing guidelines. The cumulative use of anticholinergic and sedative medicines for each participant was quantified using the DBI. |
Deprescribing resulted in a significant reduction in falls, depression and frailty scores, and adverse drug reactions. No improvement in cognition and quality of life. Total regular medicines use reduced statistically, by a mean difference of 2.13 medicines per patient, among patients where deprescribing was initiated. |
Toivo et al., 2019, Belgium [44] | Cluster RCT | Care coordination intervention (coordinated medication risk management) | Practical nurses were trained to make the preliminary medication risk assessment during home visits and report findings to the coordinating pharmacist. The coordinating pharmacist prepared the cases for the triage meeting with the physician and home care nurse to decide further actions. | No significant impact on the medication risks between the intervention and the control group. The per-protocol analysis indicated a tendency for effectiveness, particularly in optimising central nervous system medication use. |
Hernandez et al., 2020, Spain [45] | Prospective pre-and post- interventional study | Medication review | Pharmacists reviewed the medications and detected drug-related problems using the Drug Burden Index (DBI) tool. Their recommendations were communicated to the physician via telephone, weekly meetings, and email. Further review was conducted at the weekly meeting between physician and pharmacist. | Statistically significant differences were found between pre- and post-intervention in NPI at admission, drug-related problems, MAI criteria (interactions, dosage and duplication), and mean (SD) DBI score. |
Lenander et al., 2018, Sweden [46] | Cross-sectional | Medication Review | Clinical Pharmacist led medication review to assess the prevalence of DRPs and recommendations to discontinue, followed by team-based discussions with general practitioners (GPs) and nurses | It shows that the medication reviews decreased the use of potentially inappropriate medication. |
Weichert et al., 2018, Finland [39] | Multicentre observational study | Medication Review | Medication review was conducted for ACB in patients at the time of admission and discharge | 21.1% of patients had their ACB reduced. There is considerable scope for improvement of prescribing practices in older people. |
Lenander et al., 2017, Sweden [30] | Interventional pilot study | SÄKLÄK project, a developed intervention model | Multi-professional intervention model created to improve medication safety for elderly | Significant decrease in the prescription of anticholinergic drugs indicated the SÄKLÄK intervention is effective in reducing potential DRPs |
Moga et al., 2017, USA [29] |
Parallel arm Randomised Interventional study | Targeted medication therapy management intervention | Targeted patient-centred pharmacist–physician team medication therapy management intervention was used to reduce the use of inappropriate anticholinergic medications in older patients. | The targeted medication therapy management intervention resulted in improvement in anticholinergic medication appropriateness and reduced the use of inappropriate anticholinergic medications in older patients. |
Lagrange et al., 2017, France [47] | Retrospective study | A context-aware pharmaceutical analysis tool | A context-aware computerised decision-support system designed to automatically compare prescriptions recorded in computerised patient files against the main consensual guidelines for medical management in older adults. | Prescription of anticholinergics was significantly decreased (28%). |
Carnahan et al., 2017, USA [34] | Quasi-experimental study design | Educational program on medication use | IA-ADAPT/CMS Partnership is an evidence-based training program to improve dispensing drugs for elderly | Suggests that the IA-ADAPT and the CMS Partnership improved medication use with no adverse impact on BPSD. |
Hanus et al., 2016, USA [35] | Observational Pilot study | Pharmacist-led EHR-based population health initiative and ARS Service | Physicians in the primary care settings could communicate with pharmacists employing a shared EHR. As part of a quality improvement project, a pharmacist-led EHR-based medication therapy recommendation service was implemented at 2 DHS medical clinics to reduce the anticholinergic burden |
High recommendation acceptance rates were achieved using objective anticholinergic risk assessment and algorithm-driven medication therapy recommendations. |
McLarin et al., 2016, Australia [38] | Retrospective study | RMMR | Impact of RMMRs on anticholinergic burden quantified by seven anticholinergic risk scales | Demonstrated that RMMRs are effective in reducing ACM prescribing in elderly |
Kersten et al., 2015, Norway [41] | Retrospective study | Medication review | Investigated the clinical impact of PIMs in acutely hospitalised older adults. | Anticholinergic prescriptions were reduced from 39.2% to 37.9% |
Juola et al., 2015, Finland [40] | Cluster RCT | Educational intervention | Nursing staff working in the intervention wards received two 4-h interactive training sessions based on constructive learning theory to recognise harmful medications and adverse drug events. | No significant differences in the change in prevalence of anticholinergic drugs. |
Kersten et al., 2013, Norway [21] | RCT | Multidisciplinary drug review | Single Blind MDRD was conducted that recruited long-term nursing home residents with a total ADS score of greater than or equal to 3 | After 8 weeks, the median ADS score was significantly reduced from 4 to 2 in the intervention group. The largest improvement in immediate recall after 8 weeks was observed in the five patients in the intervention group who had their ADS score reduced to 0 |
Ghibelli et al., 2013, Italy [48] | Pre, post-intervention study | INTERcheck CPSS | INTERcheck is a CPSS developed to optimise drug prescription for older people with multimorbidity and minimise the occurrence of adverse drug reactions. | The use of INTERCheck was associated with a significant reduction in PIMs and new-onset potentially severe DDIs. |
Yeh et al., 2013, Taiwan [49] | Prospective case-control study | Educational program for primary care physicians | Educational program for primary care physicians serving in Veterans’ Homes, focusing on anticholinergic adverse reactions in geriatrics and the CR-ACHS | CR-ACHS was significantly reduced in the intervention group at 12-week follow-up. |
Boustani et al., 2012, USA [36] | RCT | CDSS Alert (anticholinergic discontinuation) | CDSS alert system sends an interruptive alert if any of the 18 anticholinergics were prescribed, recommending stopping the drug, suggesting an alternative, or recommending dose modification. | Physicians receiving the CDSS issued more discontinuation orders of definite anticholinergics, but the results were not statistically significant. Results suggest that human interaction may play an important role in accepting recommendations aimed at improving the care of hospitalised older adults with CI. |
Gnjidic et al., 2010, Australia [23] | Cluster RCT | Medication review | The study intervention included a letter and phone call to GPs, using DBI to prompt them to consider dose reduction or cessation of anticholinergic and sedative medications. | At follow-up, a DBI change was observed in 16 participants. DBI decreased in 12 participants, 6 (19%) in the control group, and 6 (32%) in the intervention group. |
Castelino et al., 2010, Australia [22] | Retrospective study | Medication reviews by pharmacist | HMR by pharmacists for leads to an improvement in the use of medications | DBI and PIMs identified in 60.5% and 39.8% of the patients. Significant reduction in the cumulative DBI scores for all patients was observed following pharmacists’ recommendations |
Starner et al., 2009, USA [33] | Retrospective study | Educational Intervention | Intervention letters were mailed to the physicians for patients having ≥1 DAE claim | Noticeable decrease was observed after a 6-month follow-up of the intervention in the reduction of DAE claims (48.8%) specifically reduction of anticholinergics (66.7%) was highest |
Nishtala et al., 2009, Australia [37] | Retrospective study | RMMR | Clinical Pharmacist-led medication review decreased the DBI in older people | GP’s uptake of recommendations made by pharmacists resulted in a decrease in DBI score. Clinical pharmacist-conducted medication reviews can reduce prescribing of anticholinergic drugs and significantly decrease the DBI score of the study population. |
van Eijk et al., 2001, Netherlands [50] | RCT | Educational visits as an individual and a group for general practitioners and pharmacists |
Educational visits used academic detailing to discuss prescribing of highly anticholinergic antidepressants in elderly people. | The rate of starting anticholinergic antidepressants in the elderly reduced 26% (in the individual intervention) and 45% (in the group intervention) The use of less anticholinergic antidepressants increased by 40% and 29%, respectively |
Author, Year, Country |
Study Design | Setting | Sample Size | Mean Age (Years) | Gender (Female %) | Study Duration | Follow-Up | Relevant Outcome(s) |
Outcome Measure | Significant Association (±) |
Statistical Tests | |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Control/Pre | Intervention/Post | |||||||||||
Riordan et al., 2019, Ireland [42] | Convergent parallel mixed-methods design (before and after) | General Practice | 154 | 75.0 | 72.1 | 5 months | 6 months | Effects on DBI and ACB scores | Patients having an ACB score of 0 (34%) | Patients having an ACB score of 0 (31%) 65% of patients did not show any change in DBI over time |
− | SD, Range, IQR, Frequency, Percentages |
Ailabouni et al., 2019, New Zealand [43] | A single group (pre- and post-comparison) feasibility study | Residential care facilities | 46 | 65.0 | 74.0 | 6 months | 2 weeks | Reduction in DBI score | ≥0.5 (median DBI) | 0.34 (median DBI) | + | Wilcox-signed Rank test (WSR) t-test Fisher’s exact test |
Toivo et al., 2019, Belgium [44] | Cluster RCT | Primary care | 129 | 82.8 | 69.8 | 1 year | 1 year | Anticholinergic use | 18.8% (Anticholinergic use at baseline) 18.8% (Anticholinergic use at 12 months) |
29.6% (Anticholinergic use at baseline) 18.5% (Anticholinergic use at 12 months) |
− | Binary logistic regression, two-sided statistical tests |
Hernandez et al., 2020, Spain [45] | Prospective pre- and post-interventional study | Intermediate care hospital | 55 | 84.6 | 60.0 | 12 months | NA | Anticholinergic burden per Drug Burden Index (DBI) | 1.38 ± 0.7 (Mean DBI) |
1.08 ± 0.7 (Mean DBI) |
+ | Kolmogorov–Smirnov test Student’s t-test |
Lenander et al., 2018, Sweden [46] | Cross-sectional | Primary care | 1720 | 87.5 | 74.5 | 1 year | 8 weeks | Discontinuation of DRPs | Pts with anticholinergics = 9.2% | Pts with anticholinergics = 4.2% | + | Student’s t-test, Chi-square |
Weichert et al., 2018, Finland [39] | Observational study | Hospital | 549 | 79.6 | 58.3 | 1 year, 5 months | 30 days | Reduction in ACB Score during the hospital stay | Patients on DAPs on admission = 60.8% | Patients on DAPs on discharge = 57.7 | − | Shapiro–Wilk test, Wilcoxon signed-rank test,2 sample t-test, Yates and Pearson’s chi-square test multivariate binary logistic regression |
Lenander et al., 2017 Sweden [30] | Interventional pilot study | Primary care | 2400 to 13,700 patients (estimated) | 65–79 (range) | 63 | 9 months | 6 months | Reduction in anticholinergic PIMs (before/after) | Anticholinergic prescriptions before intervention (4513) | Anticholinergic prescriptions after intervention (3824) | + | Chi-square test |
Moga et al., 2017, USA [29] | Parallel arm Randomised Interventional study | Alzheimer’s Disease Center | 49 | 77.7 ± 6.6 | 70.0 | 1 year | 8 weeks | Significant reduction in anticholinergic drug scale (ADS) Score | 1.0 (0.3) | 0.2 (0.3) | + | Student’s t-tests (or Wilcoxon rank-sum tests for non-normally distributed variables), Chi-square or Fisher’s exact tests |
Lagrange et al., 2017, France [47] | Retrospective study | Hospital | 187 | 73.9 | 63.1 | 10.5 months | 33 and 37 days | Change in number of prescriptions | 6538 doses (Anticholinergics) |
4696 doses (Anticholinergics) |
+ | Descriptive statistics |
Carnahan et al., 2017, USA [34] | Quasi-experimental study design | Nursing home | 411 | 86.7 | 77.0 | 1 year 9 months | 276 days | Anticholinergic use | Mean (SD) 35.9% (12.0%) |
Mean (SD) 36.1% (10.9%) |
− | Generalised linear mixed logistic regression |
Antipsychotic use | Mean (SD) 17.7% (10.4%) |
Mean (SD) 20.7% (10.6%) |
+ | |||||||||
Hanus et al., 2016, USA [35] | Observational Pilot study | Medical clinics | 59 | 77 ± 9.3 | 51.0 | 2 months | 2 weeks | Reduction in ACB Score, Increased medication acceptance rate |
1.08 50% |
0.89 95% |
+ | Generalised linear mixed-effects model, paired t-test |
McLarin et al., 2016, Australia [38] | Retrospective study. | Aged care facilities | 814 | 85.6 | 69.6 | NA | NA | Reduction in anticholinergic medications after a medication review | Mean (SD) 3.73 (1.46) |
Mean (SD) 3.32 (1.7) |
+ | Wilcoxon signed-rank test, ANOVA |
Kersten et al., 2015, Norway [41] | Retrospective study | Hospital | 232 | 86.1 | 59.1 | 8 months | 1 year | Reduction in anticholinergic prescriptions | Prevalence of anticholinergic drugs was significantly reduced (p < 0.02) | + | Paired samples Student’s t-test, McNamar’s test, Mann–Whitney U tests, ANOVA, linear regression | |
Juola et al., 2015, Finland [40] | Cluster RCT | Assisted living facilities | 227 | 83.0 | 70.9 | 1 year | 1 year | Mean Anticholinergic drugs | 1.0 (Mean Anticholinergic drugs) |
1.2 (Mean Anticholinergic drugs) |
− | t-tests, Mann–Whitney U tests, or Chi-square tests, GEE models, Poisson regression models |
Kersten et al., 2013, Norway [21] | RCT | Nursing home | 87 | 85.0 | 39.0 | 8 weeks | 8 weeks | Marked reduction in ADS score | Median = 4 | Median = 2 | + | ANCOVA, Poisson regression analysis |
Ghibelli et al., 2013, Italy [48] | Pre- and post-intervention study | Hospital | 75 for Pre 75 for Post |
81 | 58.3 | 4 months | NA | Reduction in ACB score | 1.3 | 1.1 | − | Pearson Chi-square test, Student’s t-test |
Yeh et al., 2013, Taiwan [49] | Prospective case-control | Veteran Home | 67 | 83.4 | NA | 12 weeks | 12 weeks | Anticholinergic Burden (CR-ACHS) | 1.0 ± 1.1 (Mean CR-ACHS) |
−0.5 ± 1.1 (Mean CR-ACHS) |
+ | Wilcoxon signed ranks test |
Boustani et al.,2012, USA [36] | RCT | Hospital | 424 | 74.8 | 68.0 | 21 months | At the time of discharge | Discontinuation of AC prescriptions | anticholinergic discontinued = 31.2% | anticholinergic discontinued = 48.9% | _ | Fisher’s exact test, t-test, logistic regression, multiple regression |
Gnjidic et al., 2010, Australia [23] | Cluster RCT | Self-care retirement village | 115 | 84.3 | 73.0 | 13 months | 3 months | Drug Burden Index (DBI) | 0.26 ± 0.34 (mean DBI) | 0.22 ± 0.42 (mean DBI) | − | Kolmogorov–Smirnov test Mann–Whitney nonparametric test X2 test |
Castelino et al., 2010, Australia [22] | A retrospective analysis of medication reviews | Community-dwelling | 372 | 76.1 | 55.0 | NA | NA | Impact of pharmacist’s on DBI scores | Sum of DBI scores = 206.86 | Sum of DBI scores = 157.26 | + | Wilcoxon signed-rank test |
Starner et al., 2009, USA [33] | Retrospective study | Pharmacy claims data | 10,364 | 65.0 | NA | 8 months | 6 months | Rate of discontinued anticholinergics | NA | 66.7% | + | NA |
Nishtala et al., 2009, Australia [37] | Retrospective study | Aged care homes | 500 | 84.0 | 75.0 | 6 months | 2 months | Significant decrease in DBI score | NA | 12% decrease in DBI | + | 2-tailed Wilcoxon signed-rank test |
van Eijk et al., 2001, Netherlands [50] | RCT | Primary care | 46,078 | 71 | 58.0 | 1 year | NA | Reduction in the prescribing of anticholinergics | 30% reduction in the rate of starting highly anticholinergic antidepressant in the individual intervention arms compared with the control arm | 40% reduction in the rate of starting highly anticholinergic antidepressants in the group intervention arms compared with the control arm | + | Poisson regression model |