Title: Evaluating the Impact of Targeted Medication Review on Anticholinergic Medication Prescribing in Patients with Psychosis
Authors: Eva Shkreta, PharmD; Rebecca Bourgery, PharmD, BCPP, BCPS; Caralyn Granato, PharmD, BCPP, BCPS
Presentation objective (for CE credit): At the conclusion of my presentation, audience members will be able to describe the impact of anticholinergic burden in patients with psychosis.
Self-assessment question: What is the clinical significance of anticholinergic burden in patients with psychosis?
- Blocks absorption of atypical antipsychotics
- Significantly increases risk of cognitive impairment
- Main cause of tardive dyskinesia
- Primary driver of metabolic syndrome
Background:
This project aims to reduce anticholinergic burden (ACB) in patients with psychosis followed by the Health Integration Program (HIP), a specialty team serving patients with psychotic disorders, through targeted medication reviews (TMR).
Methods:
Behavioral health ambulatory care pharmacists completed a TMR for all patients 18 years and older who are served by the HIP team at Cambridge Health Alliance (CHA). TMRs included a review of all anticholinergic medications the patient was prescribed, ACB score, and recommendations for potential deprescribing. A retrospective chart review was conducted at least three months after TMRs were completed. Patients not engaged with a HIP team prescriber or who were hospitalized at the time of chart review were excluded. Primary outcomes included the change in average number of anticholinergic medications and average ACB score after the TMR. Secondary outcomes included anticholinergic prescribing patterns to identify opportunities for intervention, subgroup analyses, and the number of referrals to behavioral health ambulatory care pharmacists. Subgroup analyses to include patients aged 65 years and older, prescribed clozapine, and the use of two or more high-risk anticholinergic medications.
Results:
A total of 215 TMRs were completed and 206 met the inclusion criteria at the time of data collection. The average ACB score increased by 0.14 from 4.21 three months after the TMRs, with a decrease observed in 8.7% of patients. The average number of medications with ACB increased by 0.06 from 2.52 per patient, and 7.8% of patients had fewer anticholinergic medications.
TMRs led to 42 medication changes, including 20 discontinuations and 22 dose reductions. Additionally, TMRs resulted in 7 new referrals to ambulatory behavioral health pharmacists. Among this patient group, the anticholinergic medications most frequently prescribed were clozapine, followed by olanzapine, benztropine and quetiapine.
Conclusion:
Following TMR completion, both average ACB score and number of ACB medications increased. Based on these results, TMRs may not be the most effective tool to reduce anticholinergic burden. Finding alternative interventions to reduce anticholinergic burden is especially critical for patients with psychosis.
