Carrie Stewart

Older people are at the greatest risk of harm from medicines.1 Rising life expectancy and greater multi-morbidities, has resulted in increased usage of medicines amongst older people.2 Age related ...

Background: Anticholinergic burden refers to the cumulative anticholinergic effect of all medications taken by an individual. Anticholinergic burden scales help identify patients at risk of anticholinergic adverse effects and guide prescribing. However, substantial variation exists between scales, with no gold standard identified. This variability may contribute to inconsistent risk assessment, suboptimal prescribing, and adverse outcomes. Aim: To systematically review available anticholinergic burden scales and their variability in medication lists, development strategies and scoring methods. As a secondary objective, the clinical outcomes associated with each scale were summarized. Methods: A systematic search was conducted up to January 2025. Studies proposing novel or updated anticholinergic burden scales were included. Two reviewers independently performed study selection, data extraction, and quality assessment, using a custom tool based on expert consensus and principles of scale development. Findings were narratively synthesized. Results: From 10,969 identified records, 21 studies met inclusion criteria. Medications included per scale ranged from 27 to 217, with 74% of high‐potency drugs scored inconsistently. Variability was influenced by geographical origin and methodology, with literature review followed by expert opinion the most common method of development. Dosage consideration, among others, was inconsistent across scales, affecting clinical relevance. Clinical outcome studies reflected such inconsistencies. Conclusion: No gold standard anticholinergic burden scale was identified. Scales with broader drug coverage and accounting for individual variability appeared more clinically relevant. This review highlights the need for a clinically accessible, universal scoring system to better address the risks associated with anticholinergic polypharmacy.

Introduction: Older patients are often exposed to medications with anticholinergic activity. Anticholinergic burden (ACB) from medicines is linked to adverse health outcomes. However, healthcare professionals’ familiarity with ACB remains poor, and there is a lack of research on knowledge, attitudes, or practices (KAPs) of ACB among Emergency department (ED) clinicians. Methods: A nationwide survey of ACB based on a pilot survey was developed using the KAP framework and assessed for face and content validity by ACB experts. It was distributed to ED physicians across the UK using REDCap through social media and professional networks. Results: Among the 108 ED physicians who responded, 54.6% (n = 59) were aware of the term ACB, but 54.2% (n = 32/59) of them were unable to describe it. Their mean scores for quantifying the ACB score and identifying side effects in older patients were 2.9 and 4.1 out of 10, respectively. 88.9% (n = 96) believed that ACB is an important consideration in older patients. 67.6% (n = 73) agreed that awareness of the consequences of prescribing anticholinergic medications to older patients is important. 50% (n = 54) emphasized the importance of being able to assess and quantify the ACB score. Of the 75 physicians who prescribed these medications, 40% (n = 30/75) were unaware of ACB. 38.7% (n = 29/75) rarely considered ACB, 30.7% (n = 23/75) never considered it, and only 1.3% (n = 1/75) always considered it. The majority of respondents (88.9%, n = 96) agreed that more education on ACB is needed in the ED. Conclusions: ED physicians in the UK have limited knowledge and awareness of ACB management and prescribing practices for older patients. However, they show positive attitudes towards their role in ACB management and a willingness to receive further education. The low response rate suggests that findings may reflect a motivated subset of clinicians. These results highlight the need for targeted education and further investigation into curricular coverage of prescribing safety and anticholinergic burden.

Introduction Older patients are often exposed to medications with anticholinergic activity. Anticholinergic burden (ACB) from medicines is linked to adverse health outcomes. However, healthcare professionals’ familiarity with ACB remains poor, and there is a lack of literature in knowledge, attitudes, or practices (KAP) of ACB among Emergency department (ED) clinicians. Methods A nationwide survey of ACB (using https://www.acbcalc.com) based on a pilot survey was developed using the KAP framework and assessed for face and content validity by ACB experts. It was distributed to ED physicians across the UK using REDCap through social media and professional networks. Results Among the 108 ED physicians who responded, 54.6% (n=59) were aware of the term ACB, but 54.2% (n=32/59) of them were unable to describe it. Their mean scores for quantifying the ACB score and identifying side effects in older patients were 2.9 and 4.1 out of 10, respectively. 88.9% (n=96) believed that ACB is an important consideration in older patients. 67.6% (n=73) agreed that awareness of the consequences of prescribing anticholinergic medications to older patients is important. 50% (n=54) emphasized the importance of being able to assess and quantify the ACB score. Of the 75 physicians who prescribed these medications, 40% (n=30/75) were unaware of ACB. 38.7% (n=29/75) rarely considered ACB, 30.7% (n=23/75) never considered it, and only 1.3% (n=1/75) always considered it. The majority of respondents (88.9%, n=96) agreed that more education on ACB is needed in the ED. Conclusion ED physicians in the UK have limited knowledge and awareness of ACB management and prescribing practices for older patients. However, they show positive attitudes towards their role in ACB management and a willingness to receive further education.

Background: Experiences of dental pain among older people living with dementia, particularly those residing in care homes, have been identified as an under-researched area. There is an urgent need for initiatives, co-developed with experts according to their experience, to address key challenges for oral health improvement among older people living with dementia. This paper reports the findings from a participatory activity which informed the development of an intervention. Methods: Informed by discussions with a prominent PPI representative in the field of caring for persons with dementia and a prior multi-disciplinary stakeholder event, a discussion involving ten caregivers of individuals with dementia was conducted. Caregivers were invited from different regions of the UK, with seven joining an online group discussion and three engaging in one-on-one conversations. Transcripts of the conversations based on three topics of discussion (dental experiences, dental challenges and thoughts on a dental pain risk assessment tool) were analysed using thematic analysis to inform a proposed co-developed model of an intervention which can improve dental care for those living with dementia. Results: Areas which informed the next phase of discussions and intervention development were access to dental services, lack of alignment between dental care services and health and social care, and low support for carers in how to carry out mouthcare, specific to the type of dementia lived with. Carers felt that preventing, monitoring and managing dental pain should form part of the care package and that it should not be the responsibility of the carer to conduct a dental pain risk assessment. The key recommendation made by carers was the need for a multi-component intervention. This should be flexible according to individual needs and provide education and support to carers to assist with mouthcare, with responsibility for assessing dental pain risk sitting firmly with a nominated professional. Conclusions: Our findings from this discussion group with carers of persons living with dementia identified which areas of mouthcare responsibility should be part of the unpaid caring role and which should form part of a healthcare professional role. This shaped a final stakeholder event and facilitated the development of a grant proposal (which includes one of the caregivers as a co-investigator) to test a co-developed intervention for the prevention of dental pain in persons living with dementia.

Background: Parkinson′s disease (PD) is an age‐related neurodegenerative condition with a range of motor and nonmotor symptoms. Nonmotor symptoms such as constipation and orthostatic hypotension can occur at any stage, while dysphagia is common in later stages of the disease. Previous work by our group showed that people with PD who lose weight within a year of diagnosis had a poorer prognosis. In this study, we explored whether fluid intake was also reduced in people with newly diagnosed PD. Materials and Methods: We invited people with newly diagnosed PD (within 6 months of a diagnosis or longer if not requiring treatment) to join the study. Controls were household members of the participants with PD. Participants all underwent the same assessments, including a 24‐h dietary recall, a video‐recorded swallowing assessment, and grading of stool sample consistency using the Bristol Stool Chart. Results: We recruited 30 participants, 19 with PD and 11 household controls. People living with PD reported significantly lower fluid intake from drinks (control median = 1799 mL, PD median = 1124 mL, p = 0.005 for difference in medians). People with PD drank fluid slightly slower than the controls, 6.0 mL/second vs 7.5 mL/second, but this did not reach statistical significance. Participants with PD had significantly harder stools than controls, with a mean Bristol Stool Chart number of 3.2 vs 4.6 for controls ( p = 0.01). Conclusion: PD is associated with significantly reduced intake of fluids from beverages around the time of diagnosis, which may contribute to constipation and orthostatic hypotension.

Objectives To identify suitable patients for glaucoma home monitoring and explore clinicians’ perceptions of the possible benefits and risks of home monitoring within the National Health Service. Design An online survey composed of open-ended and closed-ended questions. Setting Secondary care. Participants Glaucoma specialists registered with the UK and Eire Glaucoma Society. Outcome measures Agreement with clinical scenarios. Results The estimated response rate was 68% (n=49). Of 49 participants, 92% (n=45) were consultant ophthalmologists and 71% (n=35) had over 10-year experience. There was a poor agreement regarding an ideal glaucoma patient for home monitoring, with only one scenario achieving over 60% agreement. Most participants believed that home monitoring would be most suitable for low-risk scenarios, rather than high-risk, due to fear of missing progression. In relation to acceptability, key facilitators included the potential to increase healthcare capacity and promote patient safety. However, low clinician trust in equipment reliability and fear of patient harm were reported as concerns. Conclusions There was no clear consensus on which patients would benefit most from glaucoma home monitoring. While many clinicians believe home monitoring may enhance healthcare, there were also many concerns about the technologies themselves. Further work to address clinician concerns is warranted. Research Registry registration number 6213.

Background: Glaucoma is a chronic disease of the optic nerve and a leading cause of severe visual loss in the UK. Once patients have been diagnosed, they need regular monitoring at hospital eye services. Recent advances in technology mean patients with glaucoma can now monitor their disease at home. This could be more convenient for patients and potentially reduce costs and increase capacity for the NHS. However, it is uncertain whether self-monitoring would be acceptable or possible for patients with glaucoma.Objectives: The objectives were to: identify which patients are most appropriate for home monitoring; understand views of key stakeholders (patients, clinicians, researchers) on whether home glaucoma monitoring is feasible and acceptable; develop a conceptual framework for the economic evaluation of home glaucoma monitoring; and explore the need for and provide evidence on the design of a future study to evaluate the clinical and cost-effectiveness of digital technologies for home monitoring of glaucoma.Design: In-home Tracking of glaucoma: Reliability, Acceptability, and Cost (I-TRAC) was a multiphase mixed-methods feasibility study with key components informed by theoretical and conceptual frameworks.Setting: Expert glaucoma specialists in the UK recruited through professional glaucoma societies; study site staff and patient participants recruited through three UK hospital eye services (England, Scotland, Northern Ireland); and UK research teams recruited though existing networks.Intervention: Home tonometer that measures intraocular pressure and a tablet computer with a visual function application. Patients were asked to use the technology weekly for 12 weeks.Results: Forty-two patients were recruited. Retention and completion of follow-up procedures was successful, with 95% (n= 40) completing the 3-month follow-up clinic visits. Adherence to the interventions was generally high [adherence to both devices (i.e. ≥ 80% adherence) was 55%]. Overall, patients and healthcare professionals were cautiously optimistic about the acceptability of digital technologies for home monitoring of patients with glaucoma. While most clinicians were supportive of the potential advantages glaucoma home monitoring could offer, concerns about the technologies (e.g. reliability and potential to miss disease progression) and how they would fit into routine care need to be addressed. Additionally, clarity is required on defining the ideal population for this intervention. Plans for how to evaluate value for money in a future study were also identified. However, the study also highlighted several unknowns relating to core components of a future evaluative study that require addressing before progression to a definitive effectiveness trial.Limitations: The main limitation relates to our sample and its generalisability, for example, the over-representation of educated persons of white ethnicity who were generally experienced with technology and research motivated.Conclusions: The In-home Tracking of glaucoma: Reliability, Acceptability, and Cost study has demonstrated ‘cautious optimism’ when considering patients’ and healthcare professionals’ views on the acceptability of digital technologies for home monitoring of patients with glaucoma. However, the study also highlighted several unknowns relating to the research question and design of a future evaluative study that require addressing before progression to a randomised controlled trial.Future work: Further research is required to determine the appropriate population (i.e. low vs. high risk of progression) and further refine the intervention components and delivery for planning of future evaluation studies.Study registration: This study is registered as Research Registry #6213.Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR129248) and is published in full inHealth Technology Assessment; Vol. 28, No. 44. See the NIHR Funding and Awards website for further award information.

Introduction: To promote optimal healthcare delivery, safeguarding older adults from the risks associated with inappropriate medication use is paramount. Objective: This study aims to evaluate the effectiveness of implementing the Qatar Tool for Reducing Inappropriate Medication (QTRIM) in ambulatory older adults to enhance medication safety. Method: The QTRIM was developed by an expert consensus panel using the Beers Criteria and contained a list of potentially inappropriate medications (PIMs) based on the local formulary. Using quality improvement methodology, it was piloted and implemented in two outpatient pharmacy settings serving geriatric medicine and dermatology clinics at Rumailah Hospital, Qatar. Key performance indicators (KPIs) using implementation documentation as a process measure and the percentage reduction in PIM prescriptions as an outcome measure were assessed before and after QTRIM implementation. This study was conducted between July 2022 and September 2023. Results: In the outpatient department (OPD) geriatric pharmacy, the prescription rate of PIMs was reduced from an average of 1.2 ± 0.7 PIMs per 1000 orders in 2022 to an average of 0.8 ± 0.2 PIMs per 1000 orders in 2023. In the OPD geriatric pharmacy, the results showed a 66.6% reduction in tricyclic antidepressants (TCAs) (from 30 to 10), a reduction in first-generation antihistamines by 51.7% (29 to 14), and muscle relaxants by 33.3% (36 to 24). While in dermatology, the older adult prescription rate of PIMs was reduced from an average of 8 ± 3 PIMs per 1000 orders in 2022 to a rate of 5 ± 3 PIMs per 1000 orders in 2023; the most PIM reductions were (49.4%) in antihistamines (from 89 to 45), while muscle relaxants and TCAs showed a minimal reduction. Conclusions: Implementing QTRIM with pharmacy documentation monitoring markedly reduced the PIMs dispensed from two specialized outpatient pharmacies serving older adults. It may be a promising effective strategy to enhance medication safety in outpatient pharmacy settings.