Pill burden

Medication Review

1. Conduct a comprehensive medication review – assess the necessity and appropriateness of each medication and identify medications that are no longer beneficial or have minimal impact on the individual’s health
2. Consider
   1. Deprescribing
   2. tapering off medications

 suggest:

• Minimize Polypharmacy
  1. Eliminate unnecessary medications or reduce the number of medications being taken.
• Simplify Medication Schedule
  1. the number of doses per day.
  2. Consider once-daily or long-acting medications to reduce the frequency of administration.
• Combination Medications
  1. reducing the number of pills required.
• Liquid or Dispersible Formulations
  1. easier to administer and swallow
• Medication Administration Aids
  1. pill organizers or medication dispensers
  2. blister packs or pre-packaged dose systems
• Collaboration with Healthcare Providers
  1. Involve pharmacists
  2. caregivers regarding the importance of medication adherence.
• Compliance
  1. reminder systems such as medication alarms, smartphone apps, or electronic pillboxes.
• Alternative Delivery Methods
  1. alternative delivery methods with healthcare providers, such as transdermal patches, inhalers, or injections, which may reduce the need for oral medications.
• Health and Lifestyle Modifications
  1. Encourage healthy lifestyle changes
  2. including regular exercise
  3. balanced diet, and stress management

Anticholinergic burden 

• Anticholinergic medicines (also called antimuscarinic medicines) antagonise the effect of the neurotransmitter acetylcholine on muscarinic (M1–M5) receptors in the central and peripheral nervous system
• Medicines with anticholinergic activity are used to treat a wide range of conditions. 

• The anticholinergic effect may be
  1. intended (eg, hyoscine for gastrointestinal muscle spasm, oxybutynin, benzatropine, procyclidine) 
  2. unintended (eg, tricyclic antidepressants, sedating antihistamines, clozapine, olanzapine, chlorpromazine).
• Many commonly used medicines such as warfarin, metoprolol, furosemide, venlafaxine and loratadine have weak anticholinergic effects, which may be inconsequential when used alone but have an additive effect when used in combination

Undesirable anticholinergic effects

• Peripheral
  1. Constipation
  2. dry mouth
  3. dry eyes
  4. blurred vision (mydriasis)
  5. tachycardia
  6. urinary retention. 
• Central nervous system
  1. Agitation
  2. Confusion
  3. Delirium
  4. Hallucinations
  5. cognitive impairment
  6. Consequential effects include problems such as tooth decay, falls or gastrointestinal obstruction.

Problems with anticholinergics in older patients

• Older patients are more susceptible to adverse reactions associated with anticholinergic medicines. 
• Effects such as cognitive impairment, dizziness and blurred vision increase the risk of falls in older patients and may increase the risk of hospitalisation and limit their ability to perform activities of daily living
• Combined use of sedative and anticholinergic medicines further increases the risk of falls and cognitive impairment in the older patients and should be avoided

Minimising risk

• consider the overall ‘anticholinergic burden’  when prescriping
• Where clinically possible, aim to reduce the anticholinergic burden by
  1. Avoiding
  2. Reducing
  3. deprescribing medicines 
  4. replace with alternatives that do not have anticholinergic properties
     1. look for medications from different drug classes or with different mechanisms of action.
• Consider Non-Pharmacological Approaches:
  1. Explore non-pharmacological interventions to manage symptoms or conditions that may be contributing to the need for anticholinergic medications.
  2. For example
     1. physical therapy
     2. cognitive-behavioral therapy
     3. lifestyle modifications
• Patient and Caregiver Education