Perspectives of health professionals and patients on reducing ACB
Research type
Research Study
Full title
Perspectives of health professionals and patients on reducing anticholinergic burden by stopping or switching medications: A qualitative study
IRAS ID
251186
Contact name
Phyo Myint
Contact email
Duration of Study in the UK
1 years, 2 months, 30 days
Research summary
Research Summary
Multimorbidity and associated polypharmacy are increasingly prevalent in ageing populations (i.e. those aged 65 years and over). Medications with anticholinergic properties are frequently prescribed for example cardiovascular drugs, urologicals and anti-parkinsonism drugs. It has been shown that increasing anticholinergic burden has a positive and linear relationship on negative health-related outcomes, but there are still uncertainties around whether reducing this burden by stopping medication and/or switching to another medication with no or low anticholinergic burden influences health-related outcomes.
In a recent review seven deprescribing guides were identified, with varying content and applicable to any medicine. Some offered broad principles to adopt while others contained detailed sequential steps to follow while deprescribing. Efficacy in reducing the number of inappropriate medicines was reported in studies implementing deprescribing guides. Additionally, other outcomes measured reductions in mortality, hospitalisation and falls. However, the acceptability of deprescribing to patients has not been explored.
Current practice appears to be inconsistent across prescribers, and this is likely to be multifactorial. For example, variation in the risk of adverse effects between medications and a lack of evidence of the impact of anticholinergic deprescribing on health-related outcomes may result in prescribers feeling uncertain about how best to proceed.
This research is part of an overall programme of work to develop and test an intervention to reduce the anticholinergic burden for patients aged 65 years and over. The programme is following the stages of the MRC Framework for developing and evaluating a complex intervention. A systematic review has already been undertaken to identify previous intervention studies designed to reduce anticholinergic burden. This aim of this study is to conduct interviews with patients and focus groups with professional stakeholders to explore their knowledge and views of anticholinergic burden and the facilitators and barriers to implementing any future interventions to reduce anticholinergic burden.Summary of Results
Perspective of health care professionals on reducing anticholinergic burden.
Health care professionals in general perceived they have good background knowledge on anticholinergic medications and their side effects and potential long-term impacts. They understand that over-prescribing of medications with anticholinergic properties is problematic and needs to be addressed. Other studies have demonstrated that deprescribing of general medications in frail older people is feasible and may improve health. Based on the findings, it is clear that the ACB intervention should be developed and implemented in older patients to promote quality of life.
Some health care professionals believed patients were prescribed ACB drugs for long periods of time without any assessment of continued benefit and need. Therefore, formal medication review with a focus on ACB drugs, especially in older patients, may be an important process for medication optimisation.
This study was conducted in two health board areas, and hence, the results are more robust than a study carried out in one locality. A variety of health professionals were involved including pharmacists from both primary and secondary care, GPs and consultants who have experience in dealing with older people where ACB is an issue and thus they were able to express their views on ACB reduction in older population. This research used both one-to-one interviews and focus groups to explore in-depth participants’ voice from interviews and polished and consensus voice from focus group discussion. Using both interviews and focus group discussion on this study had some advantages. As per example, people often do not express their views openly in a group setting which would introduce some bias in findings. However, interview process might have resolved this issue by providing some flexibilities and privacy during our data collection. We explored people’s views from different HCPs and therefore data saturation was not considered in this part of the research.
The participants in focus groups in Aberdeen involved only pharmacists and in Glasgow only GPs so the mix of professional in one focus group might better than having homogenous participants. GPs and pharmacists could discuss and share their idea in ACB if the focus group were conducted in both professionals at the same time. Another limitation is that year of experience among GPs in Glasgow was not collected so we were unable to foresee whether work experience had an influence on their perspectives.
Perspective of patients on reducing anticholinergic burden.
The patient participants in the interviews and focus group had experience with both anticholinergic and non- anticholinergic medications. Some of them accepted the side effects and did not take any actions because they believed those were consequences of treatment and could not be avoided. Some participants applied their own strategies for self-managing the side-effects. However, some sought advice and support from health care professionals as well as lay resources. Participants mentioned that the side effects of drugs could be prevented at the early prescribing stage by receiving information from prescribers.
The barriers of participants willingness to change medication were mainly around their knowledge and risks and benefits of the new medications. Facilitators were mainly about informed process of changing medication such as receiving information about alternative drugs and related benefits of proposed changes. Therefore, participants suggested that there is a need of the benefits of changing medication and ongoing monitoring being explained by the prescriber for the purpose of reassurance. The majority of participants would like to take part in future trial. Their preferred recruitment methods suggested were via Internet or a face-to-face approach or telephone call. Some expressed concerns about a blind trial and placebo drugs.
The strength of this study included using interviews and focus groups to explore in-depth participants’ voice. Researchers in Glasgow offered the participants a gift voucher which might have influenced their participation in the study. There are advantages to conducting interviews on the telephone, such as being quicker and more convenient for the researcher and patients as compared to a face-to-face meeting. Nevertheless, phone interviews can be difficult due to the parties not being able to see each other and the resultant absence of visual clues. A limitation of this study was that no participants were recruited in Aberdeen due to lack of response from community pharmacists and COVID-19 restrictions. The author was not present during the focus groups but analysed transcripts from the Glasgow team; therefore, some information were missing such as patient characteristics (age of some patients and medication use details) and nonverbal expression that can be observed from participants in the interviews and focus group discussions.REC name
East of Scotland Research Ethics Service REC 2
REC reference
18/ES/0144
Date of REC Opinion
7 Dec 2018
REC opinion
Further Information Favourable Opinion