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Researchers developed the Anticholinergic Medication Index to estimate older patients’ risk of delirium or falls associated with medicines with anticholinergic effects. Its electronic decision-support version is live in two NHS trusts, but wider rollout and its effect on patient outcomes have not yet been established.
Researchers have developed an electronic medication risk tool that helps clinicians identify older patients whose combination of medicines may raise their risk of delirium or falls. The Anticholinergic Medication Index was developed and tested using health records for nearly 750,000 adults aged over 65; its clinical decision-support version is now in use at two NHS trusts, although wider rollout and any reduction in falls or delirium have not yet been demonstrated.
The index, called the Anticholinergic Medication Index (ACMI), scores a patient’s anticholinergic medication burden according to risks associated with delirium and falls. Anticholinergic effects can occur in medicines prescribed for different conditions, even when those effects are not the drugs’ primary purpose. The concern is that effects from several medicines can accumulate, particularly in older people.
Researchers from the University of Leeds, University of Liverpool and Bradford Institute for Health Research report the index’s development and external validation in BMJ Medicine. They used de-identified linked records from Connected West Yorkshire to develop it and tested it against a national dataset of patients in Wales held by the SAIL Databank.
In a Bradford primary-care pilot, the tool generated lists of patients aged 65 and older, showing their ACMI score, the medicines contributing to it and their predicted one-year risk of a fall or delirium. The researchers say this automates work that would otherwise need to be done patient by patient before pharmacists could prioritize structured medication reviews.
A related clinical decision-support system, called ACMICS, has been integrated into electronic patient records and is live in two NHS trusts. It recalculates when an anticholinergic medicine is started or stopped. The team also produced a technical specification intended to help other health organizations build an equivalent system in their own records.
How the Tool Could Guide Reviews
The tool is designed to help clinicians find patients who may warrant a closer look at their medicines, rather than to automatically stop or change a prescription. That distinction matters because a medicine with anticholinergic effects may still be the best treatment for an individual patient; the score is intended to support a structured medication review, not replace clinical judgment.
Researchers say routine electronic-record calculations could make risk information easier to access during care and help pharmacists prioritize reviews. Dr. Kate Best, the study’s first author and an associate professor of applied statistics at the University of Leeds, said around 50% of older adults in the UK are prescribed at least one anticholinergic medicine annually. The reported figure describes prescribing prevalence, not the share of patients who will experience harm.
Falls and delirium can have serious effects on older people’s health and wellbeing. The researchers also cite other possible adverse effects of anticholinergic medicines, including constipation, difficulty emptying the bladder and dry mouth. Whether ACMI-supported reviews reduce these outcomes, or NHS costs, remains to be established.
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From Risk Model to NHS Records
Anticholinergic medicines are used for a range of conditions, and their effects can be present in drugs prescribed for other purposes. Clinicians have long recognized concerns about cumulative exposure, but identifying an individual’s combined burden can require checking several medicines and estimating their associated risks.
The research team says ACMI was designed to be incorporated into existing electronic patient record systems, rather than accessed through a separate website. Alongside the Bradford primary-care pilot, researchers led by Dr. Aseel Abuzour and Andy Clegg studied embedding the system in hospital records at two NHS trusts. The article reports that the clinical system is live and in use there.
The team is now piloting ACMI in several geriatric medicine and orthopedic hip-fracture wards to examine whether wider use in hospital care is feasible. The work addresses the gap between developing a prediction model and making it part of routine clinical workflows.
““While an anticholinergic medication might sometimes be the best treatment, with so many drugs that have this unintended side effect, anticholinergic burden can easily accumulate and pose a significant risk.””
— Dr. Kate Best, associate professor of applied statistics at the University of Leeds and the study’s first author
Outcomes and Wider Use Remain Open
The available report does not say that ACMI has already reduced falls, delirium, dementia or hospital admissions. It describes a risk prediction index and its implementation; the size of any effect on patient outcomes has not been established in the information provided. A predicted risk is not a certainty that an individual will experience an event.
It is also unclear how many patients have been assessed through the live hospital system, how often it has prompted medication reviews, or whether those reviews changed prescribing. The report does not provide details about the score thresholds used to prioritize patients or the costs and staffing needed to extend implementation.
While the index was tested using large datasets from England and Wales, the current deployment described is limited to two NHS trusts, with additional ward pilots underway. The authors’ technical specification may support adaptation elsewhere, but it does not mean the system is already available across the NHS.
Ward Pilots Will Test Feasibility
The research team says it is piloting ACMI in several geriatric medicine and orthopedic hip-fracture wards to examine the feasibility of broader use in secondary care. Results from those pilots could help show how the system fits into hospital workflows and whether further implementation is practical.
Other organizations could use the technical specification to develop an equivalent system for their electronic records, according to the researchers. Any wider adoption would depend on local implementation. Further evidence would also be needed to determine whether reviews prompted by the index lead to safer prescribing or fewer falls and episodes of delirium.
Key Questions
What does the Anticholinergic Medication Index do?
The ACMI scores a patient’s anticholinergic medication burden in relation to risks of delirium and falls. Its purpose is to help clinicians identify people who may need a medication review, not to make treatment decisions automatically.
Is the tool already being used in the NHS?
Yes. The related electronic decision-support system, ACMICS, is live and in use at two NHS trusts. The report does not describe it as available across the NHS.
Has the tool been shown to prevent falls or delirium?
The report describes development, validation and implementation, but does not establish that ACMI has reduced falls or delirium. Its effect on patient outcomes remains unclear.
Does a high score mean a patient should stop a medicine?
No. A score is intended to help prioritize a clinical medication review. The researchers note that an anticholinergic medicine may still be the best treatment for a patient; changes should be considered by the patient’s health care team.
Source: medicalxpress.com
