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anticholinergic burden (ACB) score

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

The anticholinergic cognitive burden (ACB) scale and other lists with similar names are methods of quantifying the risk of harm to people taking medicines with anticholinergic activity. Anticholinergic medicines are associated with an increased risk of cognitive impairment [1], falls [2] and delirium [3]

  • drugs other than those given for their anticholinergic properties, e.g. antihistamines and antipsychotics, are included on the list

  • the risk is cumulative, so to calculate the overall risk, the score is added up for each of the medicines being taken being taken. A score of three or more is significant, but risks are thought to increase further with higher scores

  • study evidence showed that anticholinergic burden is weakly associated with poorer cognition, but there is little evidence for associations with brain structure (4)

 

 

Some examples [source 5] - this is by no means exhaustive:

 

 

 

ACB score 1

ACB score 2

ACB score 3

Atenolol

Codeine

Colchicine

Diazepam

Digoxin

Haloperidol

Fentanyl

Furosemide

Loperamide

Morphine

Nifedipine

Ranitidine

Warfarin

Carbamazepine

Pethidine

Amitriptyline

Chlorphenamine

Clozapine

Hydroxyzine

Olanzapine

Oxybutynin

Paroxetine

Promethiazine

Tolterodine

 

Anticholinergic burden scores can be a useful way of assessing anticholinergic burden (ACB) (6)

  • https://www.acbcalc.com
    • risks of anticholinergics increase with each additional point scored, with an increase in mortality associated with the number and ACB potency of the medication prescribed
      • a combined ACB score of 3+
        • leads to an increased risk of admission for falls and fractures; cognitive decline; dry mouth, constipation, and blurred vision
      • ACB scores can give a useful guide to the risk of anticholinergic adverse events, although they do not consider drug dose, or offer an estimate of individual risk
  • consider tapering when stopping anticholinergic medications to avoid withdrawal effects, which may include nausea and sweating

Contributor: Dr Nick Bradshaw (January 2014)

Reference:

  • [1] Campbell N, Boustani M, Limbil T, Ott C, Fox C, Maidment I, Schubert CC, Munger S, Fick D, Miller D, Gulati R.The cognitive impact of anticholinergics: a clinical review. ClinInterv Aging. 2009;4:225-33. Epub 2009 Jun 9. Review.
  • [2] Aizenberg D, Sigler M, Weizman A, Barak Y.Anticholinergic burden and the risk of falls among elderly psychiatric inpatients: a 4-year case-control study.IntPsychogeriatr. 2002 Sep;14(3):307-10.
  • [3] Best O, Gnjidic D, Hilmer SN, Naganathan V, McLachlan AJ.Investigating polypharmacy and drug burden index in hospitalised older people.Intern Med J. 2013 Aug;43(8):912-8. doi: 10.1111/imj.12203.
  • [4] Mur, J, Marioni, RE, Russ, TC, Muniz-Terrera, G, Cox, SR. Anticholinergic burden in middle and older age is associated with lower cognitive function, but not with brain atrophy. Br J Clin Pharmacol. 2023.
  • [5]http://www.uea.ac.uk/mac/comm/media/press/2011/june/anticholinergics+study+drug+list
  • [6] Smith H, Fligelstone H. Reducing patient and planetary harms from high anticholinergic burden medication BMJ 2024; 384 :e075708 doi:10.1136/bmj-2023-075708

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