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The Prognostic Utility of Anticholinergic Burden Scales: An Integrative Review and Gap Analysis

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Abstract

Background

Anticholinergic drugs are commonly prescribed, especially to older adults. Anticholinergic burden scales (ABS) have been used to evaluate the cumulative effects of multiple anticholinergics. However, studies have shown inconsistent results regarding the association between anticholinergic burden assessed with ABS and adverse clinical outcomes such as cognitive impairment, functional decline, and frailty. This review aims to identify gaps in research on the development, validation, and evaluation of ABS, and provide recommendations for future studies.

Method

A comprehensive search of five databases (MEDLINE, Embase, PsychInfo, CINAHL, CENTRAL) was conducted for relevant studies published from inception until 25 May 2023. Two reviewers screened for eligibility and assessed the quality of studies using different tools based on the study design and stage of the review framework. Research evidence was evaluated, and gaps were identified and grouped into evidence, knowledge, and methodological gaps, using evidence tables to summarize data.

Results

Several evidence, knowledge, and methodological gaps in existing development, validation, and evaluation studies of ABS were identified. There is no universally accepted scale, and there is a need to define a clinically relevant threshold for measuring total anticholinergic burden. The current evidence has limitations, underrepresenting low- and middle-income countries, younger individuals, and populations with cognitive disabilities. The impact of anticholinergic burden on frailty is also understudied. Existing evaluation studies provide limited evidence on the benefit of reducing anticholinergic burden on clinical outcomes or the safety of anticholinergic deprescribing. There is also uncertainty regarding optimal reduction, clinically significant anticholinergic burden thresholds, and cost effectiveness.

Conclusions

Future research recommendations to bridge knowledge gaps include developing a risk assessment framework, refining ABS scales, establishing a standardized consensus scale, and creating a longitudinal measure of cumulative anticholinergic risk. Strategies to minimize bias, consider frailty, and promote multidisciplinary and multinational collaborations are also necessary to improve patient outcomes.

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Authors and Affiliations

  1. Division of Experimental Medicine, McGill University, Montreal, QC, Canada

    Henry Ukachukwu Michael, Robyn Tamblyn & Nancy E. Mayo

  2. Centre for Outcomes Research & Evaluation, Research Institute of McGill University Health Centre (RI-MUHC), 5252 de Maisonneuve, 2B:43, Montréal, QC, H4A 3S5, Canada

    Henry Ukachukwu Michael & Nancy E. Mayo

  3. Department of Pharmacy, General Hospital, Aboh, Delta, Nigeria

    Okechukwu Enechukwu

  4. Department of Psychiatry, Faculty of Medicine, McGill University, Montreal, QC, Canada

    Marie-Josée Brouillette

  5. Chronic Viral Illness Service, McGill University Health Centre (MUHC), Montreal, QC, Canada

    Marie-Josée Brouillette

  6. Infectious Diseases and Immunity in Global Health Program, MUHC-RI, Montreal, QC, Canada

    Marie-Josée Brouillette

  7. Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, Montreal, QC, Canada

    Lesley K. Fellows

  8. School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada

    Nancy E. Mayo

  9. Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada

    Robyn Tamblyn

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  1. Henry Ukachukwu Michael
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  3. Marie-Josée Brouillette
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Correspondence to Henry Ukachukwu Michael.

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Funding

This project was supported by grants from the Canadian Institutes of Health Research (LKF, MJB, NEM, TCO-125272), the CIHR Canadian HIV Trials Network (CTN 273), and tuition support from the Department of Medicine, Division of Experimental Medicine, McGill University (HUM). None of these funding agencies played any role in the study’s design, data collection, analysis, or interpretation.

Conflict of interest

The authors declare that there are no conflicts of interest.

Availability of data and material

Data sharing not applicable to this article as no new datasets were generated or analyzed during the current study.

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Authors contributions

HUM was responsible for conceiving the study, data extraction, data synthesis and writing the manuscript. OE carried out data extraction. MJB, LKF, and RT provided guidance throughout the research and revised the manuscript. NEM supervised all aspects of the project and revised the manuscript.

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Michael, H.U., Enechukwu, O., Brouillette, MJ. et al. The Prognostic Utility of Anticholinergic Burden Scales: An Integrative Review and Gap Analysis. Drugs Aging 40, 763–783 (2023). https://doi.org/10.1007/s40266-023-01050-4

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