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. 2021 Nov;38(11):977-994.
doi: 10.1007/s40266-021-00895-x. Epub 2021 Nov 9.

Quantifying Anticholinergic Burden and Sedative Load in Older Adults with Polypharmacy: A Systematic Review of Risk Scales and Models

Sweilem B Al Rihani  1 , Malavika Deodhar  1 , Lucy I Darakjian  1 , Pamela Dow  1 , Matt K Smith  1 , Ravil Bikmetov  1 , Jacques Turgeon  1   2 , Veronique Michaud  3   4
Affiliations

Quantifying Anticholinergic Burden and Sedative Load in Older Adults with Polypharmacy: A Systematic Review of Risk Scales and Models

Sweilem B Al Rihani et al. Drugs Aging. 2021 Nov.

Abstract

Background: Patients taking medication with high anticholinergic and sedative properties are at increased risk of experiencing poor cognitive and physical outcomes. Therefore, precise quantification of the cumulative burden of their drug regimen is advisable. There is no agreement regarding which scale to use to simultaneously quantify the burden associated with medications.

Objectives: The objective of this review was to assess the strengths and limitations of available tools to quantify medication-related anticholinergic burden and sedative load in older adults. We discuss specific limitations and agreements between currently available scales and models and propose a comprehensive table combining drugs categorized as high, moderate, low, or no anticholinergic or sedative activity as excerpted from the selected studies.

Methods: A targeted search was carried out using the National Library of Medicine through PubMed using medical subject heading terms and text words around the following search terms: (anticholinergic OR sedative) AND (load OR burden OR scale) for studies published between 1 January 1945 and 5 June 2021. In addition, the following databases were searched using the same terms: MEDLINE-EBSCO, APA PsycInfo, CINAHL Plus, Cochrane Library, Scopus, OAIster, OVID-MEDLINE, Web of Science, and Google Scholar. Screening by titles was followed by an abstract and full-text review. After blind evaluation, agreement between reviewers was reached to establish drug characteristics and categories.

Results: After 3163 articles were identified, 13 were included: 11 assigned risk scores to anticholinergic drugs and two to sedative drugs. Considerable variability between anticholinergic scales was observed; scales included between 27 and 548 drugs. We generated a comprehensive table combining the anticholinergic and sedative activities of drugs evaluated and proposed a categorization of these drugs based on available scientific and clinical evidence. Our table combines information about 642 drugs and categorizes 44, 25, 99, and 474 drugs as high, moderate, low, or no anticholinergic and sedative activity, respectively.

Conclusions: Variability and inconsistency exists among scales used to categorize drugs with anticholinergic or sedative burden. In this review, we provide a comprehensive table that proposes a new categorization of these drugs. A longitudinal study will be required to validate the new proposed anticholinergic and sedative burden catalog in an evidence-based manner.

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Conflict of interest statement

Sweilem B Al Rihani, Malavika Deodhar, Lucy I Darakjian, Pamela Dow, Matt K Smith, Ravil Bikmetov, Jacques Turgeon, and Veronique Michaud are employees and shareholders of Tabula Rasa HealthCare.

Figures

Fig. 1
Fig. 1
PRISMA flowchart. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols flowchart of the study
Fig. 2
Fig. 2
Percentage of drugs listed in each anticholinergic potency group for each scale. Stacked bar chart for the 11 anticholinergic scales showing the percentage and number of drugs in each anticholinergic potency group, with 0 for no anticholinergic activity, 1 for low, 2 for moderate, and 3+ for high. The number in parentheses is the total number of drugs in each scale. Bars with no text are less than 6%. AAS Anticholinergic Activity Scale, ABC Anticholinergic Burden Classification, AC Anticholinergic activity, ACB Anticholinergic Cognitive Burden scale, ADS Anticholinergic Drug Scale, AEC Anticholinergic Effect on Cognition, ALS Anticholinergic Load Scale, ARS Anticholinergic Rating Scale, KABS Korean Anticholinergic Burden Scale, mACB modified Anticholinergic Cognitive Burden scale
Fig. 3
Fig. 3
Score agreement between the 11 anticholinergic scales. Heatmap showing Spearman’s rank correlation coefficient between scores for medications common to each pair of scales. Coefficients that were not statistically significant (p ≥ 0.05) are left blank. AAS Anticholinergic Activity Scale, ABC Anticholinergic Burden Classification, ACB Anticholinergic Cognitive Burden scale, ADS Anticholinergic Drug Scale, AEC Anticholinergic Effect on Cognition, ALS Anticholinergic Load Scale, ARS Anticholinergic Rating Scale, KABS Korean Anticholinergic Burden Scale, mACB modified Anticholinergic Cognitive Burden scale
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