Anticholinergic Burden Recognition and Management in Older Hospitalised Patients

Abstract Background In older patients, drugs with anticholinergic properties have well-known negative effects on cognition and functional capacity. ‘Anticholinergic burden’ (ACB) describes the cumulative adverse clinical effects of anticholinergic drugs in patients. This prospective study examined whether ACB in older patients is recognised following acute hospital admission and if prescribers act to reduce ACB before discharge. Methods A convenience sample of 143 unselected patients aged ≥70 admitted via the Emergency Department with acute illness were identified from locally stored patient records and assessed within 48 hours post-admission. Chart reviews were then conducted to collect demographic, diagnostic and functional variables. Pre-admission anticholinergic burden was calculated using validated Anticholinergic-Cognitive-Burden-Scale (ACB), Swedish-Anticholinergic-Burden-Scale (Swe-ABS), and German-Anticholinergic-Burden-Scale (GABS) scales. Pre-discharge medication lists were evaluated to reassess patients’ ACB using these same scales. Results On admission, 59 patients (41.3%) had an anticholinergic burden score of ≥2 on at least one scale, indicating moderate-to-high ACB, increasing to 62(43.4%) at discharge. Hospital admission significantly impacted ACB across all three scales, with score on each scale more frequently increasing than decreasing compared to pre-admission (ACB:p<0.001, SABS:p=0.008, GABS:p=0.01). When assessing high ACB-scoring drugs, 8 drugs had ACB scores of 3 (high-risk) on ≥2 scales, quetiapine being the most frequently prescribed high-risk drug. Higher ACB scores were significantly associated with polypharmacy across all three scales (p<0.001) as well as with dementia, comorbidity burden (Charlson Index) and increasing age. Conclusion Measurable ACB is substantially prevalent in unselected older acutely-ill patients pre-admission (41.3%) and pre-discharge (43.4%). Despite the known avoidable risks from ACB, hospitalisation did not significantly reduce exposure to anticholinergic drugs. Increased awareness and optimisation of medication regimens are essential to minimise ACB as an avoidable risk to cognitive and functional health of older hospitalised patients. ACB screening at admission and pre-discharge during routine medication review is feasible for ACB detection and reduction.