Anticholinergic Burden Measures Predict Older People’s Physical Function and Quality of Life: A Systematic Review

Carrie Stewart* (Corresponding Author), Kaisa Yrjana, Mitrysha Kisshor, Roy L. Soiza, Martin Taylor-Rowan, Terence J. Quinn, Yoon K. Loke, Phyo Kyaw Myint

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

13 Citations (Scopus)
7 Downloads (Pure)


Objectives: This systematic review (PROSPERO CRD42019115918) compared the
evidence behind anticholinergic burden 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 GRADE, were assessed.

Setting and Participants: People aged 65 years and older from any clinical setting.

Measures: Any anticholinergic burden measures were accepted (including the
anticholinergic domain of the Drug Burden Index). Any global/ multi-dimensional measure for physical function and/ or quality of life was accepted for outcome.

Results: Thirteen studies reporting associations between anticholinergic burden 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 QUIPS categories with five rated high risk in ≥ 1 categories. Seven of ten studies (5,251 of 7,569 participants) reported significant decline in physical function with increased burden. All four studies (2,635 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 anticholinergic burden 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

Bibliographical note

Funding: This work was supported by The Dunhill Medical Trust [grant number RPGF1806/66].

Acknowledgements: Our funder (Dunhill Medical Trust) had no role in the design,
methods, data collection, analysis or preparation of this


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


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