Definition: The cumulative effect of one or more medicines with anticholinergic properties taken by an individual.
Mechanism: Anticholinergic drugs work by inhibiting the neurotransmitter acetylcholine, which is essential for numerous central and peripheral nervous system functions. Acetylcholine plays a critical role in cognition, memory, bowel motility, urinary function, and other physiological processes. Therefore, excessive blockade due to high anticholinergic burden can lead to various complications.
Common Uses: Anticholinergic medications are often used for allergies (antihistamines), depression (antidepressants), and behavioral changes in dementia (antipsychotics).
Intentional vs. Unintended Effects: In some instances, anticholinergic effects are intended (e.g., histamine H1 receptor antagonists for allergies), while in others, these effects are a side effect (e.g., antipsychotics).
Importance of Managing Anticholinergic Burden
Adverse Effects: High anticholinergic burden can lead to negative health outcomes, such as:
Falls and Injuries: Increased risk of falls due to effects such as dizziness and confusion.
Cognitive Impairment: Associated with confusion and cognitive decline, especially concerning for elderly patients.
Other Adverse Effects: Dry mouth, constipation, and urinary retention are common peripheral anticholinergic side effects.
Poor Health Outcomes Related to Anticholinergic Burden in Older People
Increased Dementia Risk: 50% higher risk of developing dementia.
Higher Mortality: 30% increase in mortality risk.
Reducing Anticholinergic Burden
Medication Review: Regular review of a patient’s medication list is crucial, particularly for older adults and those with polypharmacy.
Anticholinergic Burden Calculator(ACB):
Scoring Systems Used:
German Anticholinergic Burden Score and the Anticholinergic Cognitive Burden Scale are recognized for their validity and reliability in assessing anticholinergic burden.
Safety-Oriented Approach: The ACB calculator combines data from both scales and, when discrepancies arise, incorporates the higher value for enhanced safety considerations.
Deprescribing: Where clinically appropriate, consider reducing or stopping medications with high anticholinergic activity.
Alternatives: Consider using medications with lower anticholinergic activity or other non-pharmacological approaches where appropriate.
Deprescribing Anticholinergic Medicines:
Definition:
Deprescribing is a planned, supervised process involving dose reduction or cessation of a medicine that may no longer be beneficial or could be causing harm.
Indications for Deprescribing:
Consider deprescribing when a patient is identified as having a moderate-to-high anticholinergic burden.
Communication and Consent:
Engage in discussions with the patient, their family, or carers to understand the patient’s goals and expectations.
Obtain consent to proceed with the agreed deprescribing options.
Ensure the chosen approach is clearly documented in the overall care plan.
Considerations for Deprescribing Anticholinergic Medicines:
Lack of Specific Guidelines:
No established guidelines or position statements solely focused on reducing Anticholinergic Cognitive Burden (ACB).
Some deprescribing guides exist for anticholinergic medications such as antipsychotics, benzodiazepines, urinary antimuscarinics, opioids, and antihistamines.
Benefits of Deprescribing
(Based on 2019 New Zealand Study – Ailabouni N, Mangin D, Nishtala PS. DEFEAT-polypharmacy: deprescribing anticholinergic and sedative medicines feasibility trial in residential aged care facilities. International Journal of Clinical Pharmacy. 2019;41(1):167-7))
Collaborative medication reviews with pharmacists and general practitioners resulted in:
Significant median decrease in Drug Burden Index (DBI) scores after six months.
Reduction in adverse effects and falls.
Improvement in depression and frailty scores.
Assessment of Dose Dependency:
Higher doses lead to greater risks of both short-term and long-term adverse effects.
Evaluating both potency and dosage helps provide a comprehensive view of a patient’s anticholinergic load.
Factors In Favour of Deprescribing:
Patients with Dementia:
Higher risk of cognitive decline with cholinesterase inhibitors due to anticholinergic antagonistic effects.
High Risk of Falls:
Consider the additive effects of sedating medications on fall risk, such as drowsiness and mydriasis.
High ACB Patients:
High ACB is linked to negative outcomes, including cognitive and physical impairment, increased hospital admissions, and higher mortality rates.
Factors Against Deprescribing:
Specific Conditions or Scenarios:
Antipsychotics for schizophrenia, bipolar disorder, or severe behavioural and psychological symptoms of dementia (BPSD).
Tricyclic Antidepressants (TCAs) for severe/recurrent depression or neuropathic pain.
SSRIs and SNRIs for severe/recurrent depression, obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD), etc.
Benzodiazepines for severe anxiety, grief, alcohol withdrawal, or acute insomnia.
Oxybutynin for urinary incontinence with improving symptoms and tolerable adverse effects.
Antihistamines for chronic allergic conditions when other treatments fail.
Low ACB Patients:
When patients have a low ACB and show no apparent or significant anticholinergic adverse effects, deprescribing may not be immediately necessary.
Continued monitoring and reassessment are advised, particularly when new medications are introduced.
Medicines and Their Risk of Withdrawal Events or Symptom Recurrence:
Higher Risk (Tapering Needed):
Benzodiazepines
Antipsychotics
Antidepressants
Opioids
Sedating Antihistamines
Lower Risk (Tapering Not Needed):
Less Sedating Antihistamines
Urinary Anticholinergics
Monitoring Withdrawal Effects:
Short-Term Monitoring (Within 1–3 Days):
Withdrawal Symptoms: Symptoms may appear within 1–3 days following dose reduction.
Common Symptoms: Irritability, anxiety, insomnia, and sweating.
Long-Term Monitoring (Beyond 7 Days):
Recurrence of Symptoms: Symptoms may recur or new symptoms may develop within 1–2 weeks after dose reduction or cessation.
Additional Considerations:
Duration: Withdrawal symptoms are generally mild and may last up to 6–8 weeks.
Management of Severe Symptoms: If severe symptoms such as tachycardia, profuse and persistent sweating, severe anxiety, or severe insomnia occur, it is recommended to restart at the previous lowest effective dose.
Veterans’MATES Helping your patients with cognitive impairment to live well at home This factsheet provides health professionals with information about medicines that contribute to cognitive impairment, and Department of Veterans’ Affairs-funded cognitive, dementia and memory assistive aids.
Veterans’MATES Helping veterans learn to sleep well This factsheet provides health professionals with information about cognitive behavioural therapy for insomnia (CBTi) as the first-line treatment and a guide for tapering hypnotic use.
