Setting

This audit is designed to be carried out within the setting of an out-patient memory clinic in old age psychiatry.

Background

Acetylcholinesterase inhibitors are licensed and widely used for the treatment of dementia. There is a potential for cardiac side-effects from these medications, particularly in the elderly population. This is due to their cholinergic effect, acting to slow the heart rate down by enhancing vagal activity. This bradycardiac effect has led to concerns about serious arrhythmias or heart block, but could also lead to pre-syncope due to a slow pulse. Dizziness leading to falls in older people could have serious consequences, such as fractures or intracranial bleeds. Rowland et al (2007) addressed this issue of cardiac complications in a review of randomised controlled trials of the three cholinesterase inhibitors, and recommended that a minimal level of cardiac monitoring is suitable.

Standards

Standards were taken from a protocol suggested by Rowland et al (2007) and were as follows:

ᐅ All patients considered for treatment with cholinesterase inhibitors in the memory clinic should have a symptom enquiry and pulse check at baseline.

ᐅ All patients currently on treatment with cholinesterase inhibitors in the memory clinic should have a symptom enquiry and pulse check at each 6-monthly follow-up visit.

Method

Data collection

A report was generated showing all patients seen in a memory clinic over a defined period. This could be obtained from a computer system or clinic records. Patients were included in the audit only if they were currently receiving treatment with cholinesterase inhibitors, or were due to start such treatment. The medical notes for these patients were then obtained and analysed.

For all patients already on a cholinesterase inhibitor (and those due to start treatment with one), the presence in the notes of the following was recorded:

ᐅ demographic details

ᐅ presence or absence of any pre-existing cardiac disease

ᐅ previous treatment with a rate-altering medication, other than cholinesterase inhibitors

ᐅ the presence or absence of symptoms of dizziness, syncope, falls or ‘funny turns’

ᐅ a pulse rate check.

In addition, for patients already on a cholinesterase inhibitor, the notes were checked for documentation of which medication they were on, its dose and duration of treatment.