Anticholinergic burden: recommendations

• Anticholinergic medicactions are widely used in older adults, who are particularly susceptible to the adverse effects of these medications.
• The use of anticholinergic medications has been associated to an increased risk of falls, impaired cognitive and physical function, and mortality, although evidence is not conclusive. Adverse effects are cumulative, variable and dose-dependent, and many occur over the long-term.
• Anticholinergic burden is defined as the cumulative effect of taking one or more medications that are capable of developing anticholinergic adverse effects. It is essential to quantify the burden in older adults -particularly the most vulnerable- to assess the anticholinergic risk and adopt the necessary steps to reduce it.
• To quantify the anticholinergic burden there are various tools that are not directly comparable. Within our context, the Anticholinergic Burden Calculator provides the opportunity to measure the anticholinergic burden a patient receives and to identify the medications on which to act and optimise treatment.
• In older adults, particularly the most vulnerable, guidance recommends to avoid or minimise the use of anticholinergics and especially avoid their concomitant administration. Prescribe this medication for a clear and precise indication, at low doses, for the shortest possible time, and prioritise those with low activity.
• It is important to quantify the anticholinergic burden before prescribing the medication and regularly once prescribed. It is also important to monitor patients during treatment to detect anticholinergic adverse effects, with a special emphasis in patients with dementia, cognitive impairment or falls.
• If there is a suspicion of anticholinergic adverse effects and/or the anticholinergic burden a patient receives is high or very high, it is essential to optimise treatment, and to consider reducing the burden and deprescribing anticholinergics.
• Discontinuation of anticholinergics should be a shared decision between doctor and patient. It is important to prioritise the order of discontinuation, stopping medicines one at a time, abruptly or gradually, on a case-by-case basis. Discontinuation may be done by replacing medication with a non-pharmacological alternative or with a medication (of the same or different group) with less anticholinergic activity, as well as by reducing the dose or the frequency of administration.