Chief Investigator: Dr Kinda Ibrahim Associate Professor, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton

Team: Dr Stephen Lim, Principal Clinical Research Fellow, Honorary Consultant Geriatrician, Academic Geriatric Medicine, University Hospital Southampton.

 Dr Eloise Radcliffe, Senior Research Fellow, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton

Dr Emily Smith, Research Fellow, Pharmacy, University Hospital Southampton

Dr Cathrine McKenzie, Pharmacy and Critical Care, University Hospital Southampton

Mr Andrew Bates, Critical Care Nurse, Research Manager and NIHR Clinical Doctoral Research Fellow, University Hospital Southampton.

Dr Andy Fox, Consultant Pharmacist Medicines Safety, University Hospital Southampton, Southampton General Hospital

Dr Sara Mckelvie, Clinical lecturer, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton.

Mr Edward Hewertson, Geriatric consultant, Medicine for Older People, University Hospital Southampton, Southampton, General Hospital

Prof Tracey Sach, Professor in Health Economics, Faculty of Medicine, University of Southampton

Mrs Sarah Bennett, Medicine for Older People Lead Pharmacist, Pharmacy Department, University Hospital Southampton, Southampton General Hospital

Mr Kenny Fraser, co-founder of TRISCRIBE.

Mrs Pam Holloway and Mr Neil Wilson (Patient representatives)

Start: 1 October 2024

Duration: 31 March 2026

Partners: University Hospital Southampton NHS Foundation Trust, Triscribe Limited, Health Innovation Wessex.

Why this research is important?

It is estimated that over one third of all older adults are prescribed medication which are known to have “anticholinergic” side effects. These anticholinergic side effects can include an increased risk of falls, delirium, and memory problems. People who have a high number of anticholinergic medications have an increased risk of these side effects. This can be measured as their anticholinergic burden (ACB). Several tools have been developed to assess the ACB score, by checking a person’s medication list, with the aim of reducing these medications where possible (deprescribing).

The study aim

The project team worked with a company to design an online tool which can calculate the total ACB score for patients using their electronic medication list. It can also list the individual anticholinergic medications contributing to that score. Patients with high ACB score will be highlighted to healthcare staff including pharmacists, nurses, and doctors. In this project, we plan to understand how this tool can be used by clinicians in older persons wards to reduce the number of anticholinergic medications prescribed where appropriate.

Our approach

Working with doctors and pharmacists in one large hospital, we agreed how the tool should be used. First, pharmacists with check weekly using the digital tool how many patients have high ACB scores. Then they would highlight in patients’ medical notes the list of medications with high anticholinergic effects using a sticker note. The doctor looking after the patient then sees the note which would prompt him/her to either stop the drug, reduce the dose or switch to a safer drug.

We will test this intervention among 50 patients admitted to older people wards. We will collect information before and after receiving the intervention including number and type of medications prescribed, quality of life, and cognition. We will also talk to staff and patients to understand their views about the intervention, any challenges, and how to improve the process.

Involving patients and public

Two patient and public contributors have been actively involved in developing this research proposal. They represent an older person with comorbidity and polypharmacy and a carer, and both have lived experience of managing polypharmacy following hospital admission. They will continue to provide input on study procedures and materials and contribute to plans for sharing the findings.

What did we find?

We found that there is very little research on prescribing for older people with heart failure, especially those aged over 75. No studies looked at frailty, which is important for understanding how well treatments work in this group. Very few studies reported on ethnicity, and none considered people’s socio-economic background. Only a small number included information about quality of life, and none were carried out in primary care settings.

•Overall, this means there is not enough good evidence to clearly understand the benefits of heart failure treatments for older people.

•Some medications may help, particularly a group called SGLT-2 inhibitors (also known as “gliflozins,” such as dapagliflozin), but it is difficult to say how much benefit they provide. In addition, side effects may make these treatments harder to tolerate and could increase the risk of harm for some patients.

We found that for research on stopping or reducing (deprescribing) heart failure medications for older people is also limited. Stopping medicines during a sudden worsening of symptoms may be harmful. However, the available evidence is limited and varies in quality, and it does not properly consider people living with frailty. This highlights an important gap in research and a need for better evidence to guide safe treatment decisions.

What did we do with this new knowledge

We have presented findings at the South West Society for Academic Primary Care conference in Oxford, and later in the year at the European Geriatric Medicine Society in France, and are publishing the results of the two systematic reviews in two peer-review widely read journals. We also plan to share the findings with We will share findings with the National Clinical Director for Prescribing in England, Prof. Tony Avery, and the British Geriatric Society (BGS) and present the findings to the South West BGS group. This will ensure the findings reach decision-makers who design and fund future clinical trials.

The impact of this research is in contributing to the evidence base and identifying critical gaps in knowledge about how heart failure medications are used in frail older populations. It highlights the underrepresentation of these groups in clinical trials and the limited evidence available to guide deprescribing. This will inform priorities for future research, while also supporting greater awareness among clinicians of the need for personalised, context-specific prescribing and shared decision-making. In the long-term this will contribute to safer prescribing, reduced medication-related harm, improved quality of life, and fewer avoidable hospital admissions.

What Next?

•This is a complex and challenging area of research. Our work has highlighted variation in approaches to prescribing, as well as differences in the challenges faced by healthcare professionals across disciplines and care settings.

•It is clear that further high-quality clinical trials are needed to address the important gaps we have identified—particularly the lack of robust evidence on prescribing and deprescribing for older people with heart failure who are living with frailty and multiple long-term conditions.

•We will share findings with the National Clinical Director for Prescribing in England, Prof. Tony Avery, and the British Geriatric Society (BGS) and present the findings to the South West BGS group.

•We hope our findings will contribute to the recent ongoing public debate on medicines optimisation in frail older people, and will shape and inform future research, supporting the development of clearer, more relevant evidence to guide care for this population.