Many common drugs have anticholinergic effects that add together: bladder antimuscarinics, tricyclic antidepressants, paroxetine, first-generation antihistamines such as chlorphenamine and promethazine, and some antipsychotics. In older adults the cumulative load is linked to confusion, falls, constipation and urinary retention.
Use a scale such as the Anticholinergic Cognitive Burden score at medication review, and look for lower-burden alternatives — particularly for sleep, itch and bladder symptoms.
- Score anticholinergic burden at every medication review in older adults.
- Avoid first-generation antihistamines for sleep or itch in older patients.
- Prefer lower-burden options for overactive bladder and depression where possible.
- Review anticholinergic drugs first in patients with confusion, falls or constipation.
Why it matters
Small effects from several drugs add up to delirium and falls.
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