Anticholinergic Burden Scoring in Orthogeriatric Patients: A Two-Cycle Quality Improvement Audit

Anticholinergic burden is relevant to medication review in older surgical patients, but routine documentation may be incomplete.

The objective of this study is to compare documented Anticholinergic Cognitive Burden (ACB) assessment before and after a multicomponent quality-improvement intervention.

This single-centre retrospective quality-improvement audit compared two independent cohorts of surgical patients aged ≥65 years in June 2023 and April 2024. Staff education, posters, and a proforma incorporating ACB and medication-review prompts were introduced between cycles. Process outcomes were compared using Fisher's exact test. The pooled cross-sectional association between ACB and the composite cognitive-screen outcome was exploratory and unadjusted.

Seventy-two patients were included: 33 at baseline and 39 at re-audit. ACB documentation increased from 0/33 (0.0%) to 15/39 (38.5%), an absolute increase of 38.46 percentage points (95% CI 21.35-54.10; p<0.001). Documented medication review increased from 1/33 (3.0%) to 19/39 (48.7%; p<0.001), and documented medication modification from 1/33 (3.0%) to 10/39 (25.6%; p=0.009). ACB-category distributions did not differ significantly (p=0.910). The composite cognitive outcome was present in 16/25 (64.0%) patients with ACB ≥2 and 7/47 (14.9%) with ACB 0-1, corresponding to an unadjusted prevalence ratio of 4.30 (95% CI 2.04-9.04). This association was limited by the small sample, different preoperative cognitive instruments, and absence of confounder adjustment.

Documented ACB assessment and medication-review processes increased between cycles, but implementation remained incomplete. A reduction in medication burden or improvement in patient-centred outcomes was not established.