This audit aimed to understand the practice of advance care planning with regard to cardiopulmonary resuscitation (CPR) in an older adult inpatient setting and to ultimately improve practices to conform to nationally set standards.

The aims of the audit were:

1. (1) To determine the prevalence of advance care planning decisions relating to CPR in patients admitted to two older adult psychiatric wards at Thurrock Community Hospital.

2. (2) To confirm that the practice of discussion and documentation of ‘Do Not Attempt Cardiopulmonary Resuscitation' (DNA-CPR) decisions is consistent with current national standards.

First, we scrutinized whether the patient's preferences for CPR as a life-sustaining treatment were documented or known to the primary care physician at the time of admission, and whether there was a DNA-CPR order in place at the time of admission.

Next, we looked at whether a discussion about CPR was facilitated with the patient (or those close to the patient) during the admission, whether the patient was involved in the discussion surrounding CPR and the reasons for their exclusion (if excluded), and at what point in time during the admission this discussion was carried out and whether it was properly documented.

Finally, we assessed the level of completion of the DNA-CPR form itself.

Total sample: 38 patients.

13 out of 38 patients (34.21%) had a DNA-CPR form in place.

10 out of 13 DNA-CPR forms (76.92%) were complete in all aspects.

Discussion relating to DNA-CPR was not carried out in 29 out of 38 patients (76.32%) during their current admission.

Mental Capacity Assessments and Best Interest meetings were not documented as having been carried out as was necessary in the 4 patients (0%) who did not have a designated Lasting Power of Attorney.

Discussions about advance care planning and DNA-CPR were not being carried out in a timely manner as per the national guidelines.

A recent Cochrane review published in December 2023 concluded that “no trials found that interventions to reduce anticholinergic burden led to any other improvements in cognition compared to usual care”. We describe the case of a 62-year-old lady who developed significant cognitive decline following the initiation of a low dose of procyclidine, which was rapidly reversed upon stopping the medication.

We present the case of a 62-year-old lady with a diagnosis of schizo-affective disorder, whose symptoms had been stabilized on a regime of lithium carbonate 500mg nocte, sulpiride 400mg BD and fluoxetine 20mg OD. When the patient presented to the outpatient clinic, she was noted to have bilateral coarse tremors and slight cogwheel rigidity. Procyclidine was started at a dose of 5mg OD to manage these extrapyramidal side-effects.

Following this, family members reported that the patient had difficulty initiating and following conversations. Short-term memory was affected and she was observed to have reduced attention span. These problems were reportedly getting worse with time, with a simultaneous decline in functional abilities. She was no longer able to carry out her daily shop, and family members ensured that she was no longer driving as they had concerns about her road safety. She stopped taking procyclidine after 1 month and notably, these problems ceased within one week of stopping the medication.

Cognitive testing confirmed that the patient was cognitively intact after procyclidine was stopped. The patient scored 96 on the ‘Addenbrooke's Cognitive Examination’ scale, which falls within the normal range. The ‘Instrumental Activities of Daily Living’ scale was administered to assess functioning at the time of the cognitive impairment. This returned a score of 1/8, indicating that there was significant functional impairment secondary to cognitive impairment when prescribed procyclidine. The ‘Informant Questionnaire on Cognitive Decline in the Elderly’ was administered to objectively quantify the extent of cognitive decline as noted by family. This returned a score of 4.3, confirming that the patient's cognition had indeed been worse when compared with her baseline.

Our case report highlights the rapid improvement in cognition with the removal of anticholinergic burden in a 62-year-old female. Our report can, therefore, be a harbinger for more robust trials to determine the efficacy of interventions to reduce anticholinergic burden in preserving or improving cognition.

It is important to monitor for any change in cognition when prescribing anticholinergic medication in at-risk individuals.