Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Drugs & Aging
Published in: Drugs & Aging 6/2018

01-06-2018 | Systematic Review

Anticholinergic Drug Burden Tools/Scales and Adverse Outcomes in Different Clinical Settings: A Systematic Review of Reviews

Authors: Tomas J. Welsh, Veronika van der Wardt, Grace Ojo, Adam L. Gordon, John R. F. Gladman

Published in: Drugs & Aging | Issue 6/2018

Login to get access

Abstract

Background

Cumulative anticholinergic exposure (anticholinergic burden) has been linked to a number of adverse outcomes. To conduct research in this area, an agreed approach to describing anticholinergic burden is needed.

Objective

This review set out to identify anticholinergic burden scales, to describe their rationale, the settings in which they have been used and the outcomes associated with them.

Methods

A search was performed using the Healthcare Databases Advanced Search of MEDLINE, EMBASE, Cochrane, CINAHL and PsycINFO from inception to October 2016 to identify systematic reviews describing anticholinergic burden scales or tools. Abstracts and titles were reviewed to determine eligibility for review with eligible articles read in full. The final selection of reviews was critically appraised using the ROBIS tool and pre-defined data were extracted; the primary data of interest were the anticholinergic burden scales or tools used.

Results

Five reviews were identified for analysis containing a total of 62 original articles. Eighteen anticholinergic burden scales or tools were identified with variation in their derivation, content and how they quantified the anticholinergic activity of medications. The Drug Burden Index was the most commonly used scale or tool in community and database studies, while the Anticholinergic Risk Scale was used more frequently in care homes and hospital settings. The association between anticholinergic burden and clinical outcomes varied by index and study. Falls and hospitalisation were consistently found to be associated with anticholinergic burden. Mortality, delirium, physical function and cognition were not consistently associated.

Conclusions

Anticholinergic burden scales vary in their rationale, use and association with outcomes. This review showed that the concept of anticholinergic burden has been variably defined and inconsistently described using a number of indices with different content and scoring. The association between adverse outcomes and anticholinergic burden varies between scores and has not been conclusively established.
Appendix
Available only for authorised users
Literature
1.
Salahudeen MS, Duffull SB, Nishtala PS. Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review. BMC Geriatr. 2015;15:31.CrossRefPubMedPubMedCentral
2.
Cardwell K, Hughes CM, Ryan C. The association between anticholinergic medication burden and health related outcomes in the ‘oldest old’: a systematic review of the literature. Drugs Aging. 2015;32(10):835–48.CrossRefPubMed
3.
Durán CE, Azermai M, Vander Stichele RH. Systematic review of anticholinergic risk scales in older adults. Eur J Clin Pharmacol. 2013;69(7):1485–96.CrossRefPubMed
4.
Zimmerman KM, Salow M, Skarf LM, et al. Increasing anticholinergic burden and delirium in palliative care inpatients. Palliat Med. 2014;28(4):335–41.CrossRefPubMed
5.
Ancelin ML, Artero S, Portet F, et al. Non-degenerative mild cognitive impairment in elderly people and use of anticholinergic drugs: longitudinal cohort study. BMJ. 2006;332(7539):455–9.CrossRefPubMedPubMedCentral
6.
Carnahan RM, Lund BC, Perry PJ, et al. The relationship of an anticholinergic rating scale with serum anticholinergic activity in elderly nursing home residents. Psychopharmacol Bull. 2002;36(4):14–9.PubMed
7.
Villalba-Moreno AM, Alfaro-Lara ER, Pérez-Guerrero MC, et al. Systematic review on the use of anticholinergic scales in poly pathological patients. Arch Gerontol Geriatr. 2016;62:1–8.CrossRefPubMed
8.
Gnjidic D, Hilmer SN, Blyth FM, et al. Polypharmacy cutoff and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes. J Clin Epidemiol. 2012;65(9):989–95.CrossRefPubMed
9.
Campbell NL, Perkins AJ, Bradt P, et al. Association of anticholinergic burden with cognitive impairment and health care utilization among a diverse ambulatory older adult population. Pharmacotherapy. 2016;36(11):1123–31.CrossRefPubMedPubMedCentral
10.
Mayer T, Haefeli WE, Seidling HM. Different methods, different results–how do available methods link a patient’s anticholinergic load with adverse outcomes? Eur J Clin Pharmacol. 2015;71(11):1299–314.CrossRefPubMed
11.
Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.CrossRefPubMedPubMedCentral
12.
Whiting P, Savović J, Higgins JP, et al. ROBIS: a new tool to assess risk of bias in systematic reviews was developed. J Clin Epidemiol. 2016;69:225–34.CrossRefPubMedPubMedCentral
13.
Aizenberg D, Sigler M, Weizman A, et al. Anticholinergic burden and the risk of falls among elderly psychiatric inpatients: a 4-year case-control study. Int Psychogeriatr. 2002;14(3):307–10.CrossRefPubMed
14.
Ehrt U, Broich K, Larsen JP, et al. Use of drugs with anticholinergic effect and impact on cognition in Parkinson’s disease: a cohort study. J Neurol Neurosurg Psychiatry. 2010;81(2):160–5.CrossRefPubMed
15.
Kolanowski A, Fick DM, Campbell J, et al. A preliminary study of anticholinergic burden and relationship to a quality of life indicator, engagement in activities, in nursing home residents with dementia. J Am Med Dir Assoc. 2009;10(4):252–7.CrossRefPubMedPubMedCentral
16.
Campbell NL, Boustani MA, Lane KA, et al. Use of anticholinergics and the risk of cognitive impairment in an African American population. Neurology. 2010;75(2):152–9.CrossRefPubMedPubMedCentral
17.
18.
Fox C, Livingston G, Maidment ID, et al. The impact of anticholinergic burden in Alzheimer’s dementia-the LASER-AD study. Age Ageing. 2011;40(6):730–5.CrossRefPubMed
19.
Fox C, Richardson K, Maidment ID, et al. Anticholinergic medication use and cognitive impairment in the older population: the medical research council cognitive function and ageing study. J Am Geriatr Soc. 2011;59(8):1477–83.CrossRefPubMed
20.
Cai X, Campbell N, Khan BC, et al. Long-term anticholinergic use and the aging brain. Alzheimers Dement. 2013;9(4):377–85.CrossRefPubMed
21.
Koyama A, Steinman M, Ensrud K, et al. Long-term cognitive and functional effects of potentially inappropriate medications in older women. J Gerontol A Biol Sci Med Sci. 2014;69(4):423–9.CrossRefPubMed
22.
Koyama A, Steinman M, Ensrud K, et al. Ten-year trajectory of potentially inappropriate medications in very old women: importance of cognitive status. J Am Geriatr Soc. 2013;61(2):258–63.CrossRefPubMedPubMedCentral
23.
Pasina L, Djade CD, Lucca U, et al. Association of anticholinergic burden with cognitive and functional status in a cohort of hospitalized elderly: comparison of the anticholinergic cognitive burden scale and anticholinergic risk scale: results from the REPOSI study. Drugs Aging. 2013;30(2):103–12.CrossRefPubMed
24.
25.
Kidd AC, Musonda P, Soiza RL, et al. The relationship between total anticholinergic burden (ACB) and early in-patient hospital mortality and length of stay in the oldest old aged 90 years and over admitted with an acute illness. Arch Gerontol Geriatr. 2014;59(1):155–61.CrossRefPubMed
26.
Kashyap M, Belleville S, Mulsant BH, et al. Methodological challenges in determining longitudinal associations between anticholinergic drug use and incident cognitive decline. J Am Geriatr Soc. 2014;62(2):336–41.CrossRefPubMed
27.
Mangoni AA, van Munster BC, Woodman RJ, et al. Measures of anticholinergic drug exposure, serum anticholinergic activity, and all-cause postdischarge mortality in older hospitalized patients with hip fractures. Am J Geriatr Psychiatry. 2013;21(8):785–93.CrossRefPubMed
28.
Lanctôt KL, O’Regan J, Schwartz Y, et al. Assessing cognitive effects of anticholinergic medications in patients with coronary artery disease. Psychosomatics. 2014;55(1):61–8.CrossRefPubMed
29.
Sittironnarit G, Ames D, Bush AI, et al. Effects of anticholinergic drugs on cognitive function in older Australians: results from the AIBL study. Dement Geriatr Cogn Disord. 2011;31(3):173–8.CrossRefPubMed
30.
Carnahan RM, Lund BC, Perry PJ, et al. The Anticholinergic Drug Scale as a measure of drug-related anticholinergic burden: associations with serum anticholinergic activity. J Clin Pharmacol. 2006;46(12):1481–6.CrossRefPubMed
31.
Kersten H, Molden E, Tolo IK, et al. Cognitive effects of reducing anticholinergic drug burden in a frail elderly population: a randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2013;68(3):271–8.CrossRefPubMed
32.
Kersten H, Molden E, Willumsen T, et al. Higher anticholinergic drug scale (ADS) scores are associated with peripheral but not cognitive markers of cholinergic blockade: cross sectional data from 21 Norwegian nursing homes. Br J Clin Pharmacol. 2013;75(3):842–9.CrossRefPubMedPubMedCentral
33.
Lampela P, Lavikainen P, Garcia-Horsman JA, et al. Anticholinergic drug use, serum anticholinergic activity, and adverse drug events among older people: a population-based study. Drugs Aging. 2013;30(5):321–30.CrossRefPubMed
34.
Low LF, Anstey KJ, Sachdev P. Use of medications with anticholinergic properties and cognitive function in a young-old community sample. Int J Geriatr Psychiatry. 2009;24(6):578–84.CrossRefPubMed
35.
Juliebø V, Bjøro K, Krogseth M, et al. Risk factors for preoperative and postoperative delirium in elderly patients with hip fracture. J Am Geriatr Soc. 2009;57(8):1354–61.CrossRefPubMed
36.
Drag L, Wright S, Bieliauskas L. Prescribing practices of anticholinergic medications and their association with cognition in an extended care setting. J Appl Gerontol. 2012;31(2):239–59.CrossRef
37.
Kalisch Ellett LM, Pratt NL, Ramsay EN, et al. Multiple anticholinergic medication use and risk of hospital admission for confusion or dementia. J Am Geriatr Soc. 2014;62(10):1916–22.CrossRefPubMed
38.
Rudolph JL, Salow MJ, Angelini MC, et al. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med. 2008;168(5):508–13.CrossRefPubMed
39.
Kumpula EK, Bell JS, Soini H, et al. Anticholinergic drug use and mortality among residents of long-term care facilities: a prospective cohort study. J Clin Pharmacol. 2011;51(2):256–63.CrossRefPubMed
40.
Lowry E, Woodman RJ, Soiza RL, et al. Associations between the anticholinergic risk scale score and physical function: potential implications for adverse outcomes in older hospitalized patients. J Am Med Dir Assoc. 2011;12(8):565–72.CrossRefPubMed
41.
Lowry E, Woodman RJ, Soiza RL, et al. Clinical and demographic factors associated with antimuscarinic medication use in older hospitalized patients. Hosp Pract. 2011;39(1):30–6.CrossRef
42.
Koshoedo S, Soiza RL, Purkayastha R, et al. Anticholinergic drugs and functional outcomes in older patients undergoing orthopaedic rehabilitation. Am J Geriatr Pharmacother. 2012;10(4):251–7.CrossRefPubMed
43.
Landi F, Dell’Aquila G, Collamati A, et al. Anticholinergic drug use and negative outcomes among the frail elderly population living in a nursing home. J Am Med Dir Assoc. 2014;15(11):825–9.CrossRefPubMed
44.
Huang K, Chan F, Shih H, et al. Relationship between potentially inappropriate anticholinergic drugs (PIADs) and adverse outcomes among elderly patients in Taiwan. J Food Drug Anal. 2012;20(4):930–7.
45.
Bostock CV, Soiza RL, Mangoni AA. Associations between different measures of anticholinergic drug exposure and Barthel Index in older hospitalized patients. Ther Adv Drug Saf. 2013;4(6):235–45.CrossRefPubMedPubMedCentral
46.
Dispennette R, Elliott D, Nguyen L, et al. Drug Burden Index score and anticholinergic risk scale as predictors of readmission to the hospital. Consult Pharm. 2014;29(3):158–68.CrossRefPubMed
47.
Teramura-Grönblad M, Muurinen S, Soini H, et al. Use of anticholinergic drugs and cholinesterase inhibitors and their association with psychological well-being among frail older adults in residential care facilities. Ann Pharmacother. 2011;45(5):596–602.CrossRefPubMed
48.
Walter PJ, Dieter AA, Siddiqui NY, et al. Perioperative anticholinergic medications and risk of catheterization after urogynecologic surgery. Female Pelvic Med Reconstr Surg. 2014;20(3):163–7.CrossRefPubMed
49.
Cancelli I, Valentinis L, Merlino G, et al. Drugs with anticholinergic properties as a risk factor for psychosis in patients affected by Alzheimer’s disease. Clin Pharmacol Ther. 2008;84(1):63–8.CrossRefPubMed
50.
Cancelli I, Gigli GL, Piani A, et al. Drugs with anticholinergic properties as a risk factor for cognitive impairment in elderly people: a population-based study. J Clin Psychopharmacol. 2008;28(6):654–9.CrossRefPubMed
51.
Chew ML, Mulsant BH, Pollock BG, et al. Anticholinergic activity of 107 medications commonly used by older adults. J Am Geriatr Soc. 2008;56(7):1333–41.CrossRefPubMed
52.
Jessen F, Kaduszkiewicz H, Daerr M, et al. Anticholinergic drug use and risk for dementia: target for dementia prevention. Eur Arch Psychiatry Clin Neurosci. 2010;260(Suppl. 2):S111–5.CrossRefPubMed
53.
Han L, Agostini JV, Allore HG. Cumulative anticholinergic exposure is associated with poor memory and executive function in older men. J Am Geriatr Soc. 2008;56(12):2203–10.CrossRefPubMedPubMedCentral
54.
Agar M, Currow D, Plummer J, et al. Changes in anticholinergic load from regular prescribed medications in palliative care as death approaches. Palliat Med. 2009;23(3):257–65.CrossRefPubMed
55.
Yeh YC, Liu CL, Peng LN, et al. Potential benefits of reducing medication-related anticholinergic burden for demented older adults: a prospective cohort study. Geriatr Gerontol Int. 2013;13(3):694–700.CrossRefPubMed
56.
Han L, McCusker J, Cole M, et al. Use of medications with anticholinergic effect predicts clinical severity of delirium symptoms in older medical inpatients. Arch Intern Med. 2001;161(8):1099–105.CrossRefPubMed
57.
Best O, Gnjidic D, Hilmer SN, et al. Investigating polypharmacy and drug burden index in hospitalised older people. Intern Med J. 2013;43(8):912–8.CrossRefPubMed
58.
Gnjidic D, Cumming RG, Le Couteur DG, et al. Drug Burden Index and physical function in older Australian men. Br J Clin Pharmacol. 2009;68(1):97–105.CrossRefPubMedPubMedCentral
59.
Gnjidic D, Le Couteur DG, Abernethy DR, et al. Drug burden index and Beers criteria: impact on functional outcomes in older people living in self-care retirement villages. J Clin Pharmacol. 2012;52(2):258–65.CrossRefPubMed
60.
Gnjidic D, Le Couteur DG, Naganathan V, et al. Effects of drug burden index on cognitive function in older men. J Clin Psychopharmacol. 2012;32(2):273–7.CrossRefPubMed
61.
Gnjidic D, Bell JS, Hilmer SN, et al. Drug Burden Index associated with function in community-dwelling older people in Finland: a cross-sectional study. Ann Med. 2012;44(5):458–67.CrossRefPubMed
62.
Gnjidic D, Hilmer SN, Hartikainen S, et al. Impact of high risk drug use on hospitalization and mortality in older people with and without Alzheimer’s disease: a national population cohort study. PLoS ONE. 2014;9(1):e83224.CrossRefPubMedPubMedCentral
63.
Wilson NM, Hilmer SN, March LM, et al. Associations between drug burden index and physical function in older people in residential aged care facilities. Age Ageing. 2010;39(4):503–7.CrossRefPubMed
64.
Wilson NM, Hilmer SN, March LM, et al. Associations between drug burden index and falls in older people in residential aged care. J Am Geriatr Soc. 2011;59(5):875–80.CrossRefPubMed
65.
Wilson NM, Hilmer SN, March LM, et al. Associations between drug burden index and mortality in older people in residential aged care facilities. Drugs Aging. 2012;29(2):157–65.CrossRefPubMed
66.
Cao YJ, Mager DE, Simonsick EM, et al. Physical and cognitive performance and burden of anticholinergics, sedatives, and ACE inhibitors in older women. Clin Pharmacol Ther. 2008;83(3):422–9.CrossRefPubMed
67.
Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medications in older people. Arch Intern Med. 2007;167(8):781–7.CrossRefPubMed
68.
Lowry E, Woodman RJ, Soiza RL, et al. Drug burden index, physical function, and adverse outcomes in older hospitalized patients. J Clin Pharmacol. 2012;52(10):1584–91.CrossRefPubMed
69.
Lönnroos E, Gnjidic D, Hilmer SN, et al. Drug Burden Index and hospitalization among community-dwelling older people. Drugs Aging. 2012;29(5):395–404.CrossRefPubMed
70.
Dauphinot V, Faure R, Omrani S, et al. Exposure to anticholinergic and sedative drugs, risk of falls, and mortality: an elderly inpatient, multicenter cohort. J Clin Psychopharmacol. 2014;34(5):565–70.CrossRefPubMed
71.
Nishtala PS, Narayan SW, Wang T, et al. Associations of drug burden index with falls, general practitioner visits, and mortality in older people. Pharmacoepidemiol Drug Saf. 2014;23(7):753–8.CrossRefPubMed
72.
Bosboom PR, Alfonso H, Almeida OP, et al. Use of potentially harmful medications and health-related quality of life among people with dementia living in residential aged care facilities. Dement Geriatr Cogn Dis Extra. 2012;2(1):361–71.CrossRefPubMedPubMedCentral
73.
Minzenberg MJ, Poole JH, Benton C, et al. Association of anticholinergic load with impairment of complex attention and memory in schizophrenia. Am J Psychiatry. 2004;161(1):116–24.CrossRefPubMed
74.
Whalley LJ, Sharma S, Fox HC, et al. Anticholinergic drugs in late life: adverse effects on cognition but not on progress to dementia. J Alzheimers Dis. 2012;30(2):253–61.CrossRefPubMed
75.
Boustani M, Campbell N, Munger S, et al. Impact of anticholinergics on the aging brain: a review and practical application. Aging Health. 2008;4(3):311–20.CrossRef
76.
Summers WK. A clinical method of estimating risk of drug induced delirium. Life Sci. 1978;22(17):1511–6.CrossRefPubMed
77.
Mosby. Mosby’s drug consult for health professions. C.V. Mosby Publishing Co, Missouri; 2004.
78.
Physicians’ desk reference. 58th ed. Montvale (NJ): Thomson PDR; 2016.
79.
Gnjidic D, Hilmer SN, Blyth FM, et al. High-risk prescribing and incidence of frailty among older community-dwelling men. Clin Pharmacol Ther. 2012;91(3):521–8.CrossRefPubMed
80.
Klamer TT, Wauters M, Azermai M, et al. A novel scale linking potency and dosage to estimate anticholinergic exposure in older adults: the Muscarinic Acetylcholinergic Receptor Antagonist Exposure Scale. Basic Clin Pharmacol Toxicol. 2017;120(6):582–90.CrossRefPubMed
81.
Metadata
Title
Anticholinergic Drug Burden Tools/Scales and Adverse Outcomes in Different Clinical Settings: A Systematic Review of Reviews
Authors
Tomas J. Welsh
Veronika van der Wardt
Grace Ojo
Adam L. Gordon
John R. F. Gladman
Publication date
01-06-2018
Publisher
Springer International Publishing
Published in
Drugs & Aging / Issue 6/2018
Print ISSN: 1170-229X
Electronic ISSN: 1179-1969
DOI
https://doi.org/10.1007/s40266-018-0549-z

Other articles of this Issue 6/2018

Drugs & Aging 6/2018 Go to the issue

short communication

Dabigatran Levels in Elderly Patients with Atrial Fibrillation: First Post-Marketing Experiences

Leading Article

Morning Stiffness in Elderly Patients with Rheumatoid Arthritis: What is Known About the Effect of Biological and Targeted Agents?

Original Research Article

Potential Drug-Drug Interactions in a Cohort of Elderly, Polymedicated Primary Care Patients on Antithrombotic Treatment

Original Research Article

Efficacy and Safety of Analgesic Treatment for Depression in People with Advanced Dementia: Randomised, Multicentre, Double-Blind, Placebo-Controlled Trial (DEP.PAIN.DEM)

Original Research Article

Time in Therapeutic Range of Oral Vitamin K Antagonists in Hospitalized Elderly Patients

Therapy in Practice

Pre-exposure Prophylaxis for HIV Infection in the Older Patient: What can be Recommended?

ACC 2024 Congress Coverage

Heart Failure Video

Year in Review: Heart failure and cardiomyopathies

Watch now

Watch this official video from ACC.24. Dr. Biykem Bozkurt discuss last year's major advances in heart failure and cardiomyopathies.

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

16-04-2024 Type 2 Diabetes News

Incentivised to exercise

11-04-2024 Lifestyle Modifications News

New intervention for STEMI-related cardiogenic shock

10-04-2024 Myocardial Infarction News

» View more highlights on the ACC 2024 congress hub page

Image Credits