Anticholinergic burden measures predict older people's physical function and quality of life: A systematic review

Carrie Stewart, Kaisa Yrjana, Mitrysha Kishor, Roy L. Soiza, Martin Taylor-Rowan, Terence J Quinn, Yoon K. Loke, Phyo Kyaw Myint

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OBJECTIVES: This systematic review (PROSPERO CRD42019115918) compared the evidence behind anticholinergic burden (ACB) measures and their ability to predict changes in older people's physical function and quality of life.

DESIGN: Eligible cohort or case-control studies were identified systematically using comprehensive search terms and a validated search filter for prognostic studies. Medline (OVID), EMBASE (OVID), CINAHL (EMBSCO), and PsycINFO (OVID) databases were searched. Risk of bias, using Quality in Prognosis Studies tool, and quality of evidence, using the Grading of Recommendations, Assessment, Development and Evaluation, were assessed.

SETTING AND PARTICIPANTS: People aged 65 years and older from any clinical setting.

MEASURES: Any ACB measures were accepted (including the anticholinergic domain of the Drug Burden Index). Any global/multidimensional measure for physical function and/or quality of life was accepted for outcome.

RESULTS: Thirteen studies reporting associations between ACB and physical function (n = 10) or quality of life (n = 4) were included. Exposure measures included Anticholinergic Cognitive Burden Scale, Anticholinergic Drug Scale, Anticholinergic Risk Scale, Clinician Rated Anticholinergic Score, and the anticholinergic domain of the Drug Burden Index. All studies were rated moderate risk of bias in ≥2 Quality in Prognosis Studies categories with 5 rated high risk in ≥1 categories. Seven of 10 studies (5251 of 7569 participants) reported significant decline in physical function with increased burden. All 4 studies (2635 participants) reporting quality of life demonstrated similar association with increased burden. High risk of biases and inadequate data reporting restricted analysis. There was no evidence to support one measure being superior to another.

CONCLUSIONS AND IMPLICATIONS: The evidence supports association between increased ACB and future impairments in physical function and quality of life. No conclusion can be made regarding which ACB measure has the best prognostic value. Well-designed longitudinal studies are required to address this. Clinicians should be aware of patient's anticholinergic burden and consider alternative medications where appropriate.

Original languageEnglish
Pages (from-to)56-64
Number of pages9
JournalJournal of the American Medical Directors Association
Issue number1
Early online date21 Jul 2020
Publication statusPublished - Jan 2021


  • Anticholinergics
  • adverse outcomes
  • measurement scales
  • older adults
  • prognostic study

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