Anticholinergic Burden: Score 2

The Anticholinergic Burden list compiles drugs with possible to definite anticholinergic activity, with moderate to very strong muscarinic receptor activity. The Pharmacy Commons score of 3, 2, or 1 is derived from the Anticholinergic Risk Scale (ARS) and the Anticholinergic Burden (ACB) Calculator. Scores reflect risk stratification based on potency. A score of 1 indicates possible or moderate anticholinergic potential, often based on in vitro muscarinic receptor affinity. A score of 2 indicates strong or definite clinical anticholinergic effects. A score of 3 denotes very strong potential with established severe risks, such as drug-induced delirium. Scores are not meant to indicate therapies to avoid but instead create awareness across a patient's medication regimen to assess cumulative burden. Higher total scores support a dose-dependency for adverse clinical outcomes. Thus, a total cumulative score of 3 or higher represents a critical risk threshold, with 70% of patients experiencing at least two anticholinergic adverse effects. Cumulative risk primarily involves peripheral symptoms (constipation, dry mouth, urinary retention), and severe central or systemic outcomes (confusion, falls, cognitive decline, incident dementia, increased mortality, and delirium). Anticholinergic adverse effects disproportionately affect older adults due to age-related pharmacokinetic changes, thus presenting an increase in all-cause mortality. Single point increases over 3 total points may accrue a 26% increased risk of death, primarily due to the consequences of falls. To calculate the Anticholinergic Burden score, sum the medications on the regimen. When a medication is not found on the list, this indicates two possibilities: insufficient evidence to support that drug therapy as increasing risk, or the relative novelty of a therapy to be assigned a score. For example, liraglutide (Victoza) had been present on some lists; current evidence does not support it as burdensome; thus, it was removed for current interactions. We plan to ship a feature within the Medication Reconciliation tool to calculate patients' risk scores.