ArticleDrugs & aging2025
Comparison of Anticholinergic Burden Scales and Their Association with Cognitive and Functional Impairment in Older Adults: A Cross-Sectional Study Using the REPOSI Database.
Article in Drugs & aging, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 6 papers.
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Who cites it
6 citing papers in PubMed.
- Anticholinergic Burden Scoring in Orthogeriatric Patients: A Two-Cycle Quality Improvement Audit.Cureus · 2026Article
- Differences in Anticholinergic Exposure Assessment Across Burden Scales and Exposure Measures in a Population-Based Study: Implications for Targeted Deprescribing in Older Adults.Drugs & aging · 2026Article
- Cognitive function in the context of pharmacogenetic CYP2D6 variability and anticholinergic burden in older adults - results from the ActiFE study.European journal of clinical pharmacology · 2026Article
- Anticholinergic burden interacts with age and AIDS history to amplify frailty in people with HIV.British journal of clinical pharmacology · 2026Article
- Anticholinergic burden in community-dwelling older adults: prevalence, associated factors, and agreement between measurement scales.Frontiers in pharmacology · 2026Article
- CALS and ACB Scales are Associated with Physical and Cognitive Impairment and Predict Mortality in Nursing Home Residents.Drugs - real world outcomes · 2025Article
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Abstract
backgroundThe increasing use of anticholinergic medications in older adults with multiple chronic conditions raises significant concerns regarding their cumulative anticholinergic burden, which is linked to several adverse outcomes. This study aimed to compare existing anticholinergic burden scales to identify those most effective at correlating drug-induced anticholinergic load with cognitive and functional impairment. In addition, we proposed a new classification system on the basis of published scales to optimally correlate total anticholinergic burden with observed clinical deficits.
methodsThis cross-sectional study analyzed data from the REPOSI registry, which collects clinical and therapeutic information on patients aged 65 years and older admitted to internal medicine and geriatric wards across Italy. Anticholinergic exposure was assessed using 20 established anticholinergic burden scales from literature. In addition, seven experimental scales were developed on the basis of published scales and various mathematical functions (maximum, mode, median, and mean) to evaluate potential differences in measuring anticholinergic load. Outcomes included cognitive impairment, assessed using the Short Blessed Test (SBT), and functional independence, measured by the Barthel Index (BI). A zero-inflated negative binomial model was applied to analyze associations between anticholinergic burden and each outcome. Given the variability in drug scoring across published scales, we developed seven experimental scales using different mathematical functions (maximum, mode, median, and mean) to standardize scoring. Three versions included a null-score adjustment to account for drugs omitted in some scales, ensuring a more comprehensive measure of anticholinergic burden.
resultsAmong 7735 patients, higher anticholinergic burden was consistently associated with increased cognitive impairment (SBT) and physical dependency (BI) across all existing and proposed scales. The modified Anticholinergic Risk Scale (mARS) scale showed the strongest associations with cognitive (rate ratio [RR] 1.10, 95% confidence interval [CI] 1.06, 1.13; P < 0.0001) and physical impairment (RR 1.18, 95% CI 1.11, 1.24; P < 0.0001), indicating an 18% higher risk of dependency per unit increase, while the CRIDECO Anticholinergic Load Scale (CALS) scale exhibited the best model fit. Our newly developed scales confirmed these associations, with the median with null score and the mean with null score scale showing the strongest link to cognitive impairment (RR 1.07, 95% CI 1.05, 1.09; P < 0.0001) and the strongest association with physical dependency (RR 1.11, 95% CI 1.08, 1.15; P < 0.0001).
conclusionsScales that identify a greater proportion of patients with at least one anticholinergic drug may provide a more comprehensive assessment of anticholinergic burden in clinical practice. While no single scale demonstrated a definitive advantage across all outcomes, these scales may identify patients at risk. Prioritizing the use of scales with broader coverage could enhance clinical decision-making and optimize management of polypharmacy in older adults and recognize its potential impact on cognitive and functional outcomes.
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