Anticholinergic burden - An overlooked problem

By Katherine Burchfield, CEO, NPS MedicineWise and Kate Annear, Medical Advisor at NPS MedicineWise and GP 

Source: APNA Primary Times Winter 2022 (Volume 22, Issue 1)

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Around a third of older people in Australia take medicines with anticholinergic effects. Possible adverse effects from these medicines include forgetfulness and confusion, dizziness and falls as well as dry mouth and constipation. Most people in the general public have not even heard of anticholinergic effects of medicines, and amongst health professionals these effects can be easily overlooked.

The more of these medicines a person takes, the greater the ‘anticholinergic burden’ and the risk of poor health outcomes, including delirium, fractures, fall-related hospitalisation, dementia and even death.  

NPS MedicineWise is running an educational program to help raise awareness of anticholinergic burden and minimise the negative impact on patient health outcomes. Reviewing a person’s medicines and reducing or stopping medicines when they are no longer needed can reduce the risk. 

Many medicines have anticholinergic effects 

A medicine has an anticholinergic effect if it impacts how nerves communicate by blocking the action of acetylcholine – a type of neurotransmitter.  

A lot of these medicines are in the top 200 most-prescribed medicines subsidised under the Pharmaceutical Benefits Scheme, but also include medicines available without a prescription. Some examples include antidepressants (used to treat depression and anxiety), antipsychotics (used for a variety of mental health disorders), benzodiazepines (for insomnia and anxiety disorders), opioid and non-opioid medicines for chronic non-cancer pain, and antihistamines (for allergies). 

The more of these medicines a person takes, the higher the anticholinergic burden and the associated risks. Anticholinergic burden is associated with a 60% increase in fall-related hospitalisations, a 50% increase in risk of dementia compared with non-use and a 30% increase in mortality for older people. 

Medicine reviews  

Reviewing the medicines a person is taking is a good opportunity to check for a high anticholinergic burden and identify medicines that could be reduced or stopped. The medical practitioner may do this as part of a consultation, or they may refer someone for a medicines review by an accredited pharmacist. When this is done in a person’s home, it is called a Home Medicines Review (HMR); when it takes place in a residential aged-care facility it is called a Residential Medication Management Review (RMMR). A patient or their pharmacist can also ask for a referral for a medicines review from a GP. 

A medicines review may identify medicines that are no longer needed or that may be contributing to medicine interactions or other medicine-related problems. Medicine reviews are potentially underused for people taking medicines with anticholinergic effects. A study using MedicineInsight data of over 400,000 older Australians found that only 7% of people with a high anticholinergic exposure had had a medicines review in the last 2 years.  

MedicineInsight is a quality-improvement program developed and managed by NPS MedicineWise with funding from the Australian Government Department of Health. MedicineInsight contains data from participating general practices, covering 10.7% of all Australian GPs and 11.1% of all patients seen by GPs nationally – a sample representative of all people seen by GPs nationally (March 2021 data). For more information about MedicineInsight, visit nps.org.au/medicine-insight. 

Stepping down or stopping medicines 

If it is decided a medicine is no longer needed, the next step is to consider reducing the dose or stopping the medicine. This may be done when the medicine has no clear benefit, may cause harm, is being used to treat a condition that is no longer present, or no longer fits with the health-care goals of the patient.  

Deprescribing guidelines for many different classes of medicines with anticholinergic effects (including antidepressants, opioids, antihistamines and others) can help with this. 

Raising awareness and reducing the anticholinergic burden 

The NPS MedicineWise educational program Anticholinergic Burden: The Unintended Consequences for Older People¹ aims to raise awareness and address the issues around anticholinergic burden, focusing on health professionals and consumers. 

While designing the program, a range of barriers to reducing anticholinergic burden were identified, ranging from a lack of public awareness and health-professional focus, through to communication gaps. 

The program aims to address these barriers through a suite of activities and resources for GPs, nurses, pharmacists and aged-care workers in both general practice and aged-care settings. To support the general public, we have created consumer information and resources,² some available in 12 different languages.³ 

Anticholinergic burden is an example of a medicine-safety and quality-use-of-medicines issue. Medicine safety was recently named a National Health Priority Area, and tackling anticholinergic burden is a key part of delivering on that priority and improving the quality use of medicines in Australia. 

For more information, Reducing Anticholinergic Burden: Framework for Action⁴ provides key insights about anticholinergic burden, including the scale of the issue, clinical practice challenges and barriers to reducing anticholinergic burden. It also lists current programs and activities that are addressing the problem. The aim of the briefing paper is to build momentum for shared action to address anticholinergic burden. 

 

References 

1 NPS MedicineWise, ‘Anticholinergic burden: the unintended consequences for older people’, NPS MedicineWise website, n.d., accessed 12 April 2022. https://www.nps.org.au/professionals/anticholinergic-burden 

2 NPS MedicineWise, ‘Falls, confusion... is it my medicine?’, NPS MedicineWise website, n.d., accessed 12 April 2022. https://www.nps.org.au/professionals/anticholinergic-burden/consumers 

3 NPS MedicineWise, ‘Medicine side effects: resources in community languages’, NPS MedicineWise website, n.d., accessed 12 April 2022. https://www.nps.org.au/professionals/anticholinergic-burden/consumers/resources-in-community-languages 

4 J Kron, R Osman, S Warwar, P Naikpanvelkar, J Dartnell and R Lindner, Reducing anticholinergic burden: framework for action, NPS MedicineWise, Sydney, 2021. https://www.nps.org.au/assets/NPS/pdf/NPSMW2411_Anticholinergics_Briefing_Paper_v4.pdf