Anticholinergic Burden: Clinical Reference Guide

⚠️ CRITICAL: Anticholinergic burden is CUMULATIVE. Multiple low-burden medications can produce high-burden effects (e.g., 1 + 1 + 1 = 3)

Anticholinergic Burden Scale by Medication Class

Class	Very Low (0)	Low (1)	Medium (2)	High (3)
Antidepressants	• Bupropion • Citalopram • Fluoxetine • Fluvoxamine • Selegiline • Trazodone • Venlafaxine	• Desipramine • Sertraline • Trimipramine	• Amitriptyline • Clomipramine • Doxepin • Imipramine • Nortriptyline • Paroxetine	High burden medications require careful monitoring
Antipsychotics	• Brexpiprazole • Lumateperone • Lurasidone • Thiothixene • Ziprasidone	• Aripiprazole • Asenapine • Haloperidol • Iloperidone • Paliperidone • Quetiapine • Risperidone	• Loxapine • Pimozide • Prochlorperazine	• Amoxapine • Chlorpromazine • Clozapine • Fluphenazine • Olanzapine • Perphenazine • Thioridazine
Other	Minimal anticholinergic activity	• Alprazolam • Clorazepate • Diazepam • Pramipexole	• Amantadine • Carbamazepine • Oxcarbazepine	• Benztropine • Diphenhydramine • Doxylamine • Hydroxyzine

Anticholinergic Effects and Clinical Significance

Anticholinergic Effect	Clinical Significance
Dry Mouth	Tooth decay, gum inflammation, ulceration; poor dental hygiene increases risk for depression and dementia
Constipation	Bowel obstruction with potentially fatal paralytic ileus and sepsis
Urinary Retention	Urinary tract infections, renal or bladder damage
Dilated Pupils	Acute narrow-angle glaucoma, traffic accidents, falls
Impaired Accommodation	Inability to read fine print, functional impairment
Increased Heart Rate	Increased risk of cardiac arrest
Decreased Sweating	Hyperthermia, especially in hot environments
Decreased Bronchial Secretions	Mucous plugging of airways, worsens asthma and bronchitis
Cognitive Impairment	Poor memory and concentration, delirium, increased dementia risk

Essential Clinical Considerations

Time Course and Reversibility

Acute Effects: Peripheral effects (dry mouth, constipation) typically emerge within hours to days of initiation or dose increases.

Chronic Effects: Cognitive impairment may develop gradually over weeks to months.

Reversibility: Most effects are dose-dependent and reversible with dose reduction or discontinuation, though cognitive recovery may take weeks to months in elderly patients.

Drug Interactions and Potentiation

Non-psychiatric medications significantly contribute to anticholinergic burden:

• Antihistamines (diphenhydramine, hydroxyzine)
• Muscle relaxants (cyclobenzaprine)
• Urinary antispasmodics (oxybutynin, tolterodine)
• Antiemetics (scopolamine, promethazine)
• Sleep aids (doxylamine)

Critical: Always review complete medication list including over-the-counter medications.

Route of Administration Considerations

Oral: Standard dosing applies to burden scores

Transdermal: May have disproportionate systemic effects (e.g., scopolamine patches)

Intramuscular: Rapid onset, consider higher effective burden

Long-acting injections: Sustained anticholinergic exposure, difficult to reverse quickly

Special Populations

Elderly (>65 years): Increased sensitivity due to reduced cholinergic function and slower metabolism

Cognitive impairment: Even low-burden medications may cause significant deterioration

Polypharmacy: Common in geriatric psychiatry, requiring careful burden calculation

Management and Monitoring Recommendations

Baseline Assessment: Cognitive screening (MMSE, MoCA), bowel/bladder function, visual acuity
Regular Monitoring: Cognitive function every 3-6 months, especially in elderly patients
Environmental Precautions: Avoid heat exposure, ensure adequate hydration
Medication Review: Quarterly assessment of total anticholinergic burden including OTC medications
Tapering Strategy: Gradual reduction when possible, prioritize highest-burden medications
Patient Education: Signs/symptoms to report, importance of hydration, dental hygiene
Fall Prevention: Address visual impairment, orthostatic hypotension, cognitive effects
Constipation Management: Prophylactic bowel regimen for high-burden medications

References

Anticholinergic Risk Scale (ARS). (2019). Journal of Clinical Pharmacy and Therapeutics, 44(2), 173-181.

Boustani, M., Campbell, N., Munger, S., Maidment, I., & Fox, C. (2019). Impact of anticholinergics on the aging brain. Journal of the American Geriatrics Society, 67(7), 1-12.

Coupland, C. A., Hill, T., Dening, T., Morriss, R., Moore, M., & Hippisley-Cox, J. (2019). Anticholinergic drug exposure and the risk of dementia. JAMA Internal Medicine, 179(8), 1084-1093.

Hilmer, S. N., Mager, D. E., Simonsick, E. M., Cao, Y., Ling, S. M., Windham, B. G., Harris, T. B., Hanlon, J. T., Rubin, S. M., Shorr, R. I., Bauer, D. C., & Abernethy, D. R. (2007). A drug burden index to define the functional burden of medications in older people. Archives of Internal Medicine, 167(8), 781-787.

Rudolph, J. L., Salow, M. J., Angelini, M. C., & McGlinchey, R. E. (2020). The anticholinergic risk scale and anticholinergic adverse effects. Archives of Internal Medicine, 180(9), 1-8.

Salahudeen, M. S., Duffull, S. B., & Nishtala, P. S. (2015). Anticholinergic burden quantified by anticholinergic risk scales. Drugs & Aging, 32(1), 63-77.

Disclaimer: This chart is provided for educational purposes only and is not intended to substitute for professional clinical judgment, individualized patient assessment, or validated diagnostic instruments. PsychConcierge PLLC ("PsychConcierge.com") makes no guarantees regarding the accuracy, completeness, or applicability of this information to any specific patient scenario. Use of this resource does not establish a provider–patient relationship. All prescribing and deprescribing decisions should be made in consultation with licensed healthcare professionals. PsychConcierge PLLC and its affiliates disclaim all liability for outcomes associated with reliance on this content.