Episode 34: Important but not always front of mind – anticholinergic burden

Dr Caroline West:

Hello and welcome, I'm Dr. Caroline West, I'm a GP and an NPS MedicineWise medical advisor. Now, it's timely that we are turning the spotlight today on the issues around some of our most commonly prescribed medications, the so-called anticholinergics, that include medications as diverse as allergy medications, opiates, and antidepressants. Now, these can have unintended consequences, especially, for older people. Dr. Kate Annear joins us today, she's also a GP and an NPS MedicineWise advisor and she's going to take us through this often-overlooked area. Can you give us a brief overview of why this area of anticholinergics and the unintended consequences is just so important?

Dr Kate Annear:

Sure, so in this program, we're taking a close look at anticholinergic medications and the problems that arise when taking multiple medications with anticholinergic effects, particularly for older people. Now there's several reasons why we're targeting anticholinergics, firstly, because they include commonly prescribed medications, so it's a relevant issue for a lot of people. And secondly, and more importantly, because the research tells us that the outcomes for older people with a high anticholinergic burden are actually very poor, studies tell us that the use of one or more anticholinergic medications has been associated with an increased risk of cognitive decline, delirium, dementia, falls, fractures, and mortality for older people. So, you can see it's a really relevant and important issue.

Dr Caroline West:

I guess that as a GP, when I think of anticholinergics, I think of side effects, like dry mouth, dry eyes, urinary retention for example. But what you are saying is that there's also the whole area of falls and impacts on your cognition.

Dr Kate Annear:

Yep, that's exactly right. It's not just benign side effects with these medications, there are a lot of very serious complications and potential outcomes for people that are taking a lot of these medications.

Dr Caroline West:

Because if you have a fall, especially, as you get older and you have something like a fracture, that can totally derail your independence and indeed your longevity.

Dr Kate Annear:

That's absolutely right, I don't know about you, Caroline, but when I was an intern at Orthopaedics, our wards were full of patients with fractured neck or femurs and the major complication rate was really high for those patients. For many of them, those that survived, they often had a prolonged hospital stay and became quite deconditioned and often that resulted in a need for higher level of care and loss of independence and a poor quality of life. So the trajectory of their lives changed quite dramatically from that point, so falls can be very serious.

Dr Caroline West:

Yeah, falls can be absolutely terrible, and I know that as we get older, often we really prize highly having independence and if you have a fall that leads to a fracture, which leads to hospitalization or being placed into care, that's a completely different pathway that you might be going down. I think too, that it's interesting that we are looking at anticholinergic drugs and the burden associated with these medications because I guess that for many GPs and health professionals, it's great to have a bit of a refresher because quite frankly, a lot of us have been very distracted with COVID for the last 18 months and this is an opportunity to get our focus back on management of chronic conditions, updating medication lists what's your take on that?

Dr Kate Annear:

Oh, that's exactly right, so GPs are incredibly busy and COVIDs made everything a lot harder. And I think now is real the time to rethink that big picture again and update our skill set on medications and we are perfect opportunity to look at anticholinergic burden.

Dr Caroline West:

When you talk about anticholinergic side effects, I know we've talked about some really serious ones there, around falls and the impact on mobility and cognition, but also the other things we mentioned, which was dry mouth, dry eyes, I know dry mouth can actually be one of those things that's really awful.

Dr Kate Annear:

Yeah, so there's actually been a recent Australian Prescriber article on the topic of the dry mouth, which highlights that it can be actually very debilitating. Dry mouth can lead to tooth decay and oral infections as well as aspiration pneumonias, nutritional problems, psychosocial problems and depression. So dry mouth can potentially have a lot of implications as well.

Dr Caroline West:

And halitosis, which makes people less socially confident, yeah, horrible, not being able to swallow well or speak clearly because you've got such a dry mouth. So it's often those little things that actually impact on how you feel about your quality of life and it's all about quality of life and the other thing that I find is a big one, is bowels and constipation.

Dr Kate Annear:

Yes, definitely.

Dr Caroline West:

Yeah, when, people have chronic Constipation off the back of their medications, that can make them feel pretty miserable.

Dr Kate Annear:

Yeah, and it can be an issue where it just requires that they take more medications on top of everything else, to help manage their constipation, so yeah, constipation can be terrible.

Dr Caroline West:

There's irony there, isn't it? When we have side effects and then we have to take more medications to deal with the side effects and

Dr Kate Annear:

The prescribing cascade.

Dr Caroline West:

... And on and on it goes. Can we go back a couple of steps? We've talked about some of these side effects, can you remind us, those listening will be a diverse audience, there'll be GPs, specialists, health professionals, and consumers, what is an anticholinergic, how would you take us through that?

Dr Kate Annear:

Well, if we go back to the basic pharmacology, anticholinergics block the action of the neurotransmitter, acetylcholine, in the central and peripheral nervous system. So blocking the action of acetylcholine, affects signal transfer between certain cells in order to affect how your body functions, so that's the basic pharmacology. And we know that anticholinergic medications can be really useful and they can be used specifically for that effect and that's for example, antiparkinsonian agents and drugs used to treat urinary incontinence like Oxybutynin.

Dr Caroline West:

Yeah, so as you say, they've got a really important clinical place. And I guess in this program around anticholinergic burden, we're not sort of saying that anticholinergics in themselves are problem drugs, it's more the unintended consequences of the side effects, am I right in that?

Dr Kate Annear:

That's Correct, Yes, Yeah, so particularly for some medications, it's really not well known that they have anticholinergic side effects. So that's when the problem really arises, it's when we are taking lots of medications, which are not typically thought of as anticholinergic.

Dr Caroline West:

So, what are some of the most commonly prescribed medications? What are some of the meds on that list?

Dr Kate Annear:

So, the antidepressants, so SSRIs are really common. The antipsychotics, opioids as well, antihistamines and urinary anticholinergics.

Dr Caroline West:

When you are thinking about these medications, I mean I have to be honest here, I don't know whether I've always considered anticholinergic burden. I think that those GPs, who have expertise in older populations, are probably thinking about it very clearly, but I know that for a lot of my time, I've spent in an area with a very young population and so I guess that all GPs have different areas of strengths and weaknesses, but it's a good reminder for GPs like me, who may not have it on the top of our list, in terms of thinking about it with our older patients.

Dr Kate Annear:

That's exactly right, and I'm the same, my population was generally quite a younger group, so it wasn't something that I was facing on a daily basis, but it's really great to have a refresher, particularly for my older patients.

Dr Caroline West:

Yeah, to sort of remind ourselves that actually we need to think about medications and because what you sort of said loud and clear, is that what we're talking about here is really maintaining a quality of life. So, it's making sure that you are appropriately managed, but the medications that you're taking are, I guess, considered at every opportunity and adjustments are made, if there's a burden that's resulting in unnecessary side effects.

The other thing that I think is curious here is that as we all get older, it's very easy to put down side effects as being a natural part of aging, like even if we think about dry mouth and bowel changes, a lot of people think, oh, I'm just getting older, my diet's adjusting as I get older, my activity levels are adjusting, so that's a consequence of aging and indeed people who are wobbling on their feet or having falls might just think, oh, I'm just getting older.

Dr Kate Annear:

Yeah, look, it's very common that people put these symptoms down to aging. And unfortunately, that can lead to patients failing to report their symptoms and to doctors missing an opportunity to have a conversation with the patient about dose reduction or deprescribing, which could potentially have a huge impact on the quality of life, that individual. So really the message here for patients is have an open conversation with your doctor about any symptoms you might be experiencing because it could be your medications.

Dr Caroline West:

And when we think about the burden of anticholinergics, how on earth do we actually assess that? Wwhat do we need to think about there?

Dr Kate Annear:

Well, when we talk about anticholinergic burden, we're referring to the cumulative effect of taking multiple medications with anticholinergic effects and that burden can be quantified using various different scales. So there's quite sophisticated ways of measuring anticholinergic burden. Now, the scale we're using for this program is the Drug Burden Index or the DBI, which looks at both sedative and anticholinergic effect and that's mainly because there's a lot of overlap between the two, both impair the cognitive and physical function in older adults and both contribute to poor health outcomes. So essentially, they're both really relevant, so the DBI is great because it incorporates both.

Dr Caroline West:

And a GP is able to access that? Is that going to be something that, down the track they'll be able to do so?

Dr Kate Annear:

Yeah, look, we're going to go into that in the program in detail, and we are hoping that at some point down the track, the DBI will be able to be integrated into clinical software because I think that would be a game changer and that would really make it a lot easier for GPs to evaluate anticholinergic burden themselves.

Dr Caroline West:

And when you're also thinking about medications and thinking about lists of medications that people are on, we've also got to think about that whole area of what's needed and what is a legacy prescription. Because I guess that some of these commonly prescribed medications are actually, leftovers, from a prescription that was initiated many years prior that's perhaps well passed, it's used by date.

Dr Kate Annear:

That's exactly right, yeah, and look a common scenario, one that I've come across a few times before, is when a patient's prescribed an antidepressant that might have been started at a time of an adverse life experience, like a death in the family, and then this medication's continued indefinitely, even when it's no longer needed. And I think that's something that we've all seen many times, so it's important that we are really closely looking at medications and saying, does this still need to be taken?

Dr Caroline West:

When I think about some of those legacy prescriptions, SSRIs comes to mind. And I remember I had one person who'd been on an SSRI for 20 years and the reason they'd started on it was that they'd gone through a very difficult relationship breakup, which had derailed their life for a period of time and they'd had a medication started, counselling, got some life skills. It was 20 years later and their life had actually turned around. They were in a new relationship, had lots of life skills, wisdom, and experience to be able to be more resilient and yet when we looked at the SSRI, they were sort of reluctant to give it up because they felt as though that was the cornerstone of their long term success, which it probably wasn't, they'd acquired a whole lot of other buffers around them and skills to have a different take on their mental health. But there can be some reluctance on both sides to move on from a medication or try deprescribing.

Dr Kate Annear:

Yeah, definitely, it's often both factors for both the doctor and the patient, patients can definitely be really resistant to stopping medications because they think that continuing it might make them remain feeling well, particularly for antidepressants. People are concerned about stopping them because they're worried about returning or experiencing depression again. And also doctors, I think, are also often concerned that there'll be poor health outcomes if they adjust or deprescribe medications.

Dr Caroline West:

I guess it's a reminder though, that we need to constantly have a look at the list because there may be things that creep onto the list, SSRI's one, something like Temazepam's another, where something starts short term use and then it rolls on long term inappropriately, the other one, which I think is a key one, which is anticholinergic, is the opioid class.

Dr Kate Annear:

Yeah, definitely, so paracetamol and codeine combinations are really common things that are started in hospital and then they continue on sometimes. So they might be used for an acute pain episode and then they end up becoming a long term medication, so that's not a situation that we want to see happening.

Dr Caroline West:

Yeah, I guess we have to stop this, just in case, prescribing, don't we? That often happens where people are discharged or any doctor can fall into that trap of, I'll give you a script, just in case, and the next thing it becomes included in their medication chart and then it just rolls on and on.

Dr Kate Annear:

That's right.

Dr Caroline West:

Nobody's really quite clear as to why on earth it was initiated and what the intended timeframe was, so it's important that we have a look at this list because as many people get older, the list just keeps growing.

Dr Kate Annear:

It does yes.

Dr Caroline West:

And teasing out, what's what becomes difficult. I guess, I also keeping track of it, I've had many of my older patients arrive with lots of information on the back of envelopes, so they've often transcribed their medication list roughly on the back of an envelope, which is one way of doing it, but it's not a very fail-safe way of recording your medications and the envelope can get lost. And also people add a lot of stuff over-the-counter, so it's not just prescription meds here. You talked, I think earlier about allergy drugs, for example.

Dr Kate Annear:

Oral antihistamines are big one, very commonly used over-the-counter medication, that actually has quite a lot of anticholinergic effect.

Dr Caroline West:

And do you have a suggested tool that helps people actually track what they're on?

Dr Kate Annear:

Look, there are various different apps out there, NPS actually has amedication tracking app that is really helpful for patients, who have trouble remembering a dose and it really reminds you when the dose is due, it can help you manage more complex medication dosing and you can download that by the app store.

Dr Caroline West:

Yeah, so it's good to sort of have that NPS MedicineWise app on your device and keep track of it that way and I guess if we looked at from a provider point of view, from the health professional point of view, I know that Home Medication Reviews are one area that are probably underused to be honest, but they probably play a pretty big role here.

Dr Kate Annear:

We talk a lot about Home Medicine Reviews in the program, and it's a really great tool that a GP's disposal to assist them in optimizing patient's medications, but some GPs really don't like HMRs because they've had a bad experience with them. They might have had a generic or poor quality report in the past and they feel that they don't getting any new insights or recommendations from the HMRs. So look, we are really emphasizing the importance of quality Home Medicine Reviews. And we really want GPs to try to develop relationships with pharmacists that provide quality reports, and there's lots of different ways that GPs can build on that relationship because really a quality Home Medication Review is great, it can help you identify anticholinergic burden and lots of other issues particularly with the polypharmacy that we see in the older population.

Dr Caroline West:

When it comes to Home Medication Reviews, if I look at it through the lens of the pharmacy side of things, they often get requests for reviews with scant information, it must be so hard from their end of things to actually work out, what it is that you want to zone in on, when there's very little information provided or when you've just clicked in your software and it's just generated a list without much extra information and then when you get back in return, a similarly, as you say, generic report, that's kind of not very satisfactory either, but when you do actually find that sweet spot with a good pharmacist with a good Home Medication Review, gosh, it makes such a big difference.

I've been working rurally and remotely, and I've had the joy of working with an excellent community pharmacist, who has done my medication reviews. And it's made such a big difference because his expertise is really thinking about the evidence base and what's perhaps changed, and to be honest, I haven't always kept up with all of those changes and he's been able to provide guidance on deprescribing and initiating a different medication altogether and was able to follow that to actually get a much better result for the patient and so, I think that there's something that I need to remind myself to do them more frequently because I think you get so much value from them.

Dr Kate Annear:

Oh, absolutely, did you have any trouble with access in regional remote areas to a pharmacist cause I know that's a common problem as well.

Dr Caroline West:

Luckily the services I was with actually, had a pharmacist too, as part of our team who used to work in the practice and also at the Aboriginal Health Services out there, is very much part of the setup and was very involved with the COVID role at every aspect of patient care. But I know that interestingly enough, often in the city, if your local pharmacists has reached their limit and they're very good at doing them, but they can't fit anymore in, in that month, you're often a bit stretched to find somebody good. So I think it is worth putting in a little bit of effort to establish that relationship so that you get a really good report back.

Dr Kate Annear:

I agree.

Dr Caroline West:

Is there somewhere else that's a resource that people can tap into to get recommendations?

Dr Kate Annear:

I think it's always important that you consider patient preference as well for you, they might prefer a particular community pharmacy that they might have already have a relationship with a pharmacist. So yeah, I think it's always important to check with the patient first. I've always found, like you said, word of mouth really helpful, I always like to see who my colleagues are using and the Australian Association of Consultant Pharmacy, you can also go to their website to search for an accredited pharmacist in your area.

Dr Caroline West:

And can you remind us in terms of the anticholinergic burden and side effects, that we're interested in, what sort of information should we put into the Home Medication Reviews?

Dr Kate Annear:

Yeah, so it's really important that you put comprehensive information just to provide the context for the pharmacist. So make sure you've got relevant demographic, social history, the patient medical and surgical history, any relevant pathology results, renal functions, always a really important one to include and a complete list of medications with the indications. I also find it's helpful to include any other relevant issues. For example, if the person has any cognitive impairment or vision or hearing problems and always the specific clinical question that you would like answered, that's helpful too.

Dr Caroline West:

And I suppose that for a lot of COVID, people weren't actually able to go into people's home and check out what was in the cupboard which was often done with these reviews.

Dr Kate Annear:

Yeah, I think for a period of time, I could be wrong here, but some pharmacists were doing the HMRs via telehealth. But my understanding is now that it's back on track at taking place at people's homes is great.

Dr Caroline West:

You do get a lot more information, when you're able to see the environment in which medications are stored and what they've got in the cupboard and what they've kept in the cupboard, just in case, because they might also have stuff that's not even on their medication list, that they've stored from an old script or half a box of something that you have no idea about.

Dr Kate Annear:

Exactly, you learn a lot from going to someone's home.

Dr Caroline West:

From a consumer point of view, it's interesting to see that younger people, I think, in general are becoming far more health literate, and far more confident around speaking up and asking questions. I'd like to think that older people are also following in that same path, but I guess that some of them may have grown up in a time when they were given a medication and it was expected that they would just trust their health provider, that was the right thing to do without asking many questions. For the consumers listening out there, what are some of the things that they need to think about in terms of asking the right questions of their doctors and health providers?

Dr Kate Annear:

NPS has an initiative called Choosing Wisely, which is actually part of a global push to put consumers at the centre of their care. And you can actually access the Choosing Wisely questions, which are five questions that you can ask your doctor. So, they are conversation starters in order to make sure that you're having a conversation about what care is truly needed and that's based on the best available evidence, based on a conversation with consumers to decide what's right for them. So things that you might want to ask your doctor are things like, why am I taking this medicine? What are the potential side effects? What can I do about the side effects? What happens if I don't do anything? And are there any other things I can do to manage my condition?

Dr Caroline West:

I find that those five questions are quite good conversations starters as a doctor, to use as a template for having a discussion with a patient.

Dr Kate Annear:

Yeah, that's exactly right.

Dr Caroline West:

And getting that collaborative sense of, well, this is a shared decision we are making here around whether you continue a medication or not, and really exploring some of those barriers and perhaps finding some of those enablers to actually change things around, if that's appropriate.

Dr Kate Annear:

That's right, and I think both doctors and patients benefit from that conversation, it really builds the therapeutic relationship. So yeah, it's really helpful, I think, to try to incorporate those for both for the patients and doctors.

Dr Caroline West:

And when we think about older people in particular, because the NPS MedicineWise program around anticholinergics and the unintended consequences, you're really focusing in on those older people, who are over 65, there's a framework, isn't there? The way we can think about the areas that are important to consider in somebody's overall management.

Dr Kate Annear:

I think what you're referring to is the 4M model, which ought to explain to you what the 4Ms are, so they Mentation, Mobility, Medication and What Matters. And it's essentially, it's identifies the core issues that should drive all decision making and the care of older adults. So we need to be really having the patient at the centre of the care, what are their specific outcome goals and care preferences, so for that individual, it might be, they want to remain in their own home.

They might want to keep looking after their grandchildren as long as they can. So it's focusing in on what's really essential for that individual. And then it's making sure that we are keeping an eye out for issues around mobility, making sure that older adults are moving safely every day and that we are looking at their mentation, that we are preventing, identifying and treating dementia, depression, and delirium. And if we do put a patient on medications, if it is necessary, make sure that it as much as possible doesn't interfere with the other Ms. Its a great framework. It focuses on the older person's wellness and strengths rather than solely on the disease.

Dr Caroline West:

Fantastic model, that 4M model because we're all living longer and really if life is to be enjoyable, it's all around maintaining the best quality of life we can possibly have and avoiding some of the pitfalls, some of those side effects that might lead us down a path that's really devastating. I think the program's going to really be very timely because I think that, as we mentioned earlier, a lot of us in the community have been very focused on COVID as we should have been, because that's been just such a devastating global pandemic.

But now it's time, I think to shift our focus to not just COVID, but to the burden of chronic disease. Because as we live longer, we are all going to be living with usually at least one chronic disease, if not many, and so really sorting out our medications to make sure that we are not putting ourselves at risk of more problems.

NPS MedicineWise also provides educational visits, can you take us through what they are? There maybe people listening, who are not entirely clear what an educational visit is. Can you remind us what it is Kate?

Dr Kate Annear:

Sure, So it's NPS will send an Educational Visitor out to many general practices, and they'll actually talk through the program in detail and provide GPs with supporting consumer resources and resources that can be used by the GP as well, just to basically help in assisting or fleshing out this program.

Dr Caroline West:

I've always found them incredibly useful because they always give me a refresher on whatever the topic is and I think in this particular area, it's of interest to me because I must admit that I think that my skillset probably has a little bit of a gap there, in terms of understanding more clearly what the issues are here. From your end of things, Kate, you've obviously got across the project in depth because you've been advising on it, what are some of the take home messages that you think need to be reinforced?

Dr Kate Annear:

We're hoping that the program will increase awareness of anticholinergic medications and the adverse effects and poor outcomes that can result from a high anticholinergic burden. And we really want GPs to take the opportunity to consciously and objectively consider anticholinergic burden and to support better outcomes for their patients by using some of these resources and pathways, such as medication management reviews, and really the overarching messages about the importance of deprescribing these medications where possible and utilizing more non-pharmacological alternatives where they're feasible. It's really important to keep in mind that if we fail to take action on this issue, we face not only increase morbidity and mortality rates, but also loss of opportunity to maximize quality of life for older Australians and this really affects us all.

Dr Caroline West:

And how precious that quality of life is, so thanks so much for that, there's so much more that we could continue to chat about, but that's all we have time for. So thank you so much, Dr. Kate Annear for joining us today and sharing your wisdom.

Dr Kate Annear:

My pleasure.

Dr Caroline West:

And for all those listing, you can get more information on our website, nps.org.au, or if you'd like to follow up on those five questions, [email protected]. And you can also go to our website for information on CPD activities on this topic. Thank you for joining us and we look forward to being with you next time, I'm Dr. Caroline West, bye for now.