B-QuiCK: Anticholinergic burden in older people

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B-QuiCK: Anticholinergic burden in older people

Anticholinergic burden refers to the cumulative effect of taking medicines with anticholinergic activity. Older people are at higher risk of anticholinergic burden due to age-related changes in physiology, and increased likelihood of multiple morbidities requiring management with anticholinergic medicines.

Figure 1. Overview of adverse anticholinergic effects.

Assessing the anticholinergic burden

Assess anticholinergic burden in any patient who is prescribed at least one anticholinergic medicine (Table 1) and may be at higher risk of anticholinergic adverse effects based on their age or frailty status:

  • When initiating a new medicine
  • After discharge from hospital
  • If there is a history of falls or any other symptoms with a potential anticholinergic cause, e.g. deteriorating oral health (Figure 1)
  • Opportunistically

The assessment of anticholinergic burden may involve:

  1. A comprehensive medicines review to determine what medicines the patient is currently taking, including any over-the-counter medicines or complementary and alternative medicines
  2. Establishing the reason each medicine was prescribed. Also ask about adherence and any adverse effects that may be related to a medicine.
  3. Identifying which medicines have anticholinergic activity and could be contributing to the patient’s anticholinergic burden. Table 1 can be used as a general guide to the most commonly prescribed anticholinergic medicines; the properties of other medicines can be checked using the NZF.

Consider referring patients at higher risk of medicines related harm to a clinical pharmacist for a medicines review of their prescription and over-the-counter medicines

Strategies for reducing anticholinergic burden

Optimise non-pharmacological management strategies

Non-pharmacological interventions may help to reduce the required dose of, or overall need for, medicines with anticholinergic activity while still managing the condition, e.g. sleep hygiene for insomnia or behavioural distraction techniques for pain conditions.

Deprescribing anticholinergic medicines

  • Factors to consider when deciding whether a medicine should be reduced or stopped include:
    • Is the original indication for this medicine still relevant?
    • Could any reported adverse effects be caused by this medicine?
    • Does the prescribed medicine still provide benefit for the patient and does that outweigh the risk of potential adverse effects?
    • What are the patient’s therapeutic goals at their stage of life?
    • Has there been any change in the patient’s clinical condition that may render the currently prescribed medicine or dose inappropriate?
    • Is there another medicine for the relevant indication that may be more appropriate for this patient? (see: “Switching to another medicine with lower anticholinergic activity” below)
  • Deprescribe one medicine at a time to simplify the process for the patient, and allow recognition and correct attribution of discontinuation symptoms
  • Gradually taper medicines with anticholinergic activity, to avoid cholinergic discontinuation syndrome (refer to main article for further information on: “Cholinergic discontinuation syndrome”)
    • Reduce the prescribed dose by 25 – 50% over a period of one to four weeks; a more gradual taper may be required for patients using anticholinergic medicines long-term, e.g. antipsychotics
    • Use alternate day dosing if available medicine strengths are not appropriate for tapering
  • Monitor closely in the first one to three days for anticholinergic withdrawal symptoms, and after approximately seven days for recurrence of symptoms associated with the condition originally being treated
  • Patients who develop withdrawal symptoms or a reoccurrence of their original symptoms should restart the medicine at the lowest tolerated dose and reattempt a slower tapered reduction after 6 – 12 weeks

Switching to another medicine with lower anticholinergic activity

Patients who still require pharmacological management may benefit from switching to medicines with lower or no anticholinergic activity, if available (Table 3)

Anticholinergic medicines cannot always be avoided

Checklist when prescribing anticholinergic medicines in older people:

  • Review the current medicine regimen before adding a medicine with anticholinergic activity
  • Choose medicines with limited anticholinergic activity
  • Aim for a short duration of the lowest effective dose
  • Conduct a baseline cognitive assessment
    • Also establish a baseline for co-morbidities that may worsen when taking anticholinergic medicines, e.g. glaucoma, tachyarrhythmias, benign prostate hypertrophy and constipation
  • Provide patients and carers with clear instructions regarding what adverse effects to look out for and when to seek medical attention if they develop
  • Re-evaluate the patient regularly if treatment is required for an extended period
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