High anticholinergic burden at admission associated with in‐hospital mortality in older patients: A comparison of 19 different anticholinergic burden scales

Abstract

Although no gold standard exists to assess a patient's anticholinergic burden, a review identified 19 anticholinergic burden scales (ABSs). No study has yet evaluated whether a high anticholinergic burden measured with all 19 ABSs is associated with in‐hospital mortality and length of stay (LOS). We conducted a cohort study at a Swiss tertiary teaching hospital using patients' electronic health record data from 2015–2018. Included were patients aged ≥65 years, hospitalised ≥48 h without stays and >24 h in intensive care. Patients' cumulative anticholinergic burden score was classified using a binary (<3: low, ≥3: high) and categorical approach (0: no, 0.5–3: low, ≥3: high). In‐hospital mortality and LOS were analysed using multivariable logistic and linear regression, respectively. We included 27,092 patients (mean age 78.0 ± 7.5 years, median LOS 6 days). Of them, 913 died. Depending on the evaluated ABS, 1370 to 17,035 patients were exposed to anticholinergics. Patients with a high burden measured by all 19 ABSs were associated with a 1.32‐ to 3.03‐fold increase in in‐hospital mortality compared with those with no/low burden. We obtained similar results for LOS. To conclude, discontinuing drugs with anticholinergic properties (score ≥3) at admission might be a targeted intervention to decrease in‐hospital mortality and LOS.

Comparative analysis of anticholinergic burden scales to explain iatrogenic cognitive impairment and self-reported side effects in the euthymic phase of bipolar disorders: results from the FACE-BD cohort

“…We replicated the lack of association between cognitive impairment in bipolar patients and Anticholinergic Drug Scale values reported by Eum et al (2017). Previous use of Chew's scale showed its association with cognitive impairment in elderly patients (Lampela et al, 2013;Lisibach et al, 2021), whereas the Anticholinergic Toxicity Scale has been shown to be strongly associated with delirium and mortality in elderly patients (Lisibach et al, 2022a(Lisibach et al, & 2022b, but no study has explored their association with cognitive performance for individuals with psychiatric disorders. Indeed, Chew's scale was designed based exclusively on in vitro measures of serum anticholinergic activity and the Anticholinergic Toxicity Scale was designed based on the affinity for muscarinic receptors deduced from the molecular structure of the drug: neither of the two scales were designed based on clinical observations, making our results quite unexpected.…”

Evaluation of the association of anticholinergic burden and delirium in older hospitalised patients – A cohort study comparing 19 anticholinergic burden scales

“…This study was approved by the Swiss ethics review committee (EKNZ Project ID: 2018–01000). A similar study investigating the association of the ACH burden with in‐hospital mortality and length of stay was published using the same data set 29 …”

“…A similar study investigating the association of the ACH burden with in‐hospital mortality and length of stay was published using the same data set. 29 …”

“…For each of the 19 ABSs identified and described in our systematic review, 8 the cumulative ACH burden score was calculated using a list of all drugs scored from our previously published study. 29 Drugs not scored in one of the ABSs were assumed to have no ACH activity (zero points). Four ABSs did not use a 4‐point grading system (0: no to 3: high).…”

“…We mapped the medication orders to their active ingredient based on the Anatomical Therapeutic Chemical Classification System (World Health Organization, Geneva, Switzerland) following a semi-automated process as described by Siebenhüner et al 34 For each of the 19 ABSs identified and described in our systematic review, 8 the cumulative ACH burden score was calculated using a list of all drugs scored from our previously published study. 29 Drugs not scored in one of the ABSs were assumed to have no ACH activity (zero points). Four ABSs did not use a 4-point grading system (0: no to 3: high).…”