Interventions to reduce anticholinergic burden

Nakham et al. aimed to determine the contents of the interventions designed to reduce ACB in older adults on polypharmacy mediation regimes, and the clinical and cost effectiveness of these.¹⁴⁴ The findings were mixed where one study showed statistically significant improvement in the Medication Appropriateness Index, and another found improvement in sedative side effect. The list below sets out the recommendations of action to be taken to address anticholinergic burden.^{25,133,135,136,138,140,141,144,137,139}(see Methods for deriving evidence-based guidance for methodology).

Recommendations to address anticholinergic burden (based on three GLs, two of high quality, and the third of low quality, and eight SRs, five of high quality, two acceptable, and one of low quality)

1 - Strong recommendation

Prescribers should practice caution when prescribing medicines with ACB, prescribing only the minimum needed, especially for older adults, people with frailty, or people with complex multimorbidities. This is due to the association between ACB and mortality and increased risk of cognitive impairment, dementia, and delirium.

2 - Strong recommendation

A person-centred approach should be taken when assessing the impact of harm of anticholinergic medication and the benefits when discontinuing anticholinergic drugs.

3 - Conditional recommendation

Prescribers should carefully consider if the benefits of prescribing a drug with ACB are greater than the risks.

4 - Conditional recommendation

Prescribers could consider minimising prescribing of drugs with ACB as part of assessment of falls risk for those people with the highest level of ACB (e.g. ACBS⩾4), which might be indicative of the greatest risk of falls.

5 - Conditional recommendation

There is some evidence that a pharmacist undertaking patient medication review and then feeding back to the prescriber can lead to a significant reduction in ACB.

6 - Strong recommendation

In patients with dementia,¹³³ perform a medication review to minimise medicines that may adversely affect cognitive function. Avoid prescribing of anticholinergics with acetylcholinesterase inhibitors. As part of the review, a MMSE may be helpful to assess impact of medication.