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Background: Adverse effects of anticholinergic medi- risk of anticholinergic adverse effects was assessed using
cations may contribute to events such as falls, delirium, Poisson regression analysis.
and cognitive impairment in older patients. To further
assess this risk, we developed the Anticholinergic Risk Results: Higher ARS scores were associated with in-
Scale (ARS), a ranked categorical list of commonly pre- creased risk of anticholinergic adverse effects in the GEM
scribed medications with anticholinergic potential. The cohort (crude relative risk [RR], 1.5; 95% confidence in-
objective of this study was to determine if the ARS score terval [CI], 1.3-1.8) and in the primary care cohort (crude
could be used to predict the risk of anticholinergic ad- RR, 1.9; 95% CI, 1.5-2.4). After adjustment for age and
verse effects in a geriatric evaluation and management the number of medications, higher ARS scores in-
(GEM) cohort and in a primary care cohort. creased the risk of anticholinergic adverse effects in the
GEM cohort (adjusted RR, 1.3; 95% CI, 1.1-1.6; c statis-
tic, 0.74) and in the primary care cohort (adjusted RR,
Methods: Medical records of 132 GEM patients were 1.9; 95% CI, 1.5-2.5; c statistic, 0.77).
reviewed retrospectively for medications included on the
ARS and their resultant possible anticholinergic adverse Conclusion: Higher ARS scores are associated with sta-
effects. Prospectively, we enrolled 117 patients, 65 years tistically significantly increased risk of anticholinergic ad-
or older, in primary care clinics; performed medication verse effects in older patients.
reconciliation; and asked about anticholinergic adverse
effects. The relationship between the ARS score and the Arch Intern Med. 2008;168(5):508-513
T
HE POPULATION OF THE ergic load.12-17 Most importantly, the re-
United States is aging rap- duction of anticholinergic medications
idly, and the number of per- may be a modifiable risk factor to avoid
sons older than 65 years associated morbidity.
will double to 70 million by In response to this, we developed the An-
2030.1 Providing medical care for the ag- ticholinergic Risk Scale (ARS), which is a
ing patient presents challenges because tool for estimating the extent to which an
these patients are at risk of comorbidities individual patient may be at risk of anti-
and polypharmacy.2 Patients older than 65 cholinergic adverse effects that can lead to
years are prescribed a mean of 6 medica- cognitive dysfunction and delirium. The
tions.3 Age-related pharmacokinetic and ARS ranks medications for anticholiner-
pharmacodynamic changes increase the gic potential on a 3-point scale (0, no or low
Author Affiliations: Geriatric risk of adverse effects and interactions.4,5 risk; 3, high anticholinergic potential). The
Research, Education, and Although treatment guidelines such as ARS score for a patient is the sum of points
Clinical Center, Veterans Affairs the Beers criteria can be used to identify for his or her number of medications.
Boston Healthcare System medications that are considered inappro- The objective of this study was to vali-
(Drs Rudolph, Salow, Angelini, priate in adults older than 65 years,6 12% date the ARS score against clinical symp-
and McGlinchey), Division of to 21% of older patients in the United toms of anticholinergic toxic reactions in
Aging, Department of Medicine, States use such agents.7,8 Medications with a retrospective geriatric evaluation and
Brigham and Women’s Hospital anticholinergic properties have fre- management (GEM) cohort and also in a
(Drs Rudolph and quently been cited in the literature as caus- prospective older primary care popula-
McGlinchey), Massachusetts
ing an increase in adverse events.9,10 Such tion. We hypothesized that (1) the ARS
College of Pharmacy
(Dr Angelini), and Departments conditions often lead to consequences such score would be positively associated with
of Medicine (Dr Rudolph) and as falls, impulsive behavior, and loss of in- the risk of anticholinergic symptoms; (2)
Psychiatry (Dr McGlinchey), dependence.11,12 Higher rates of cognitive central adverse effects (falls, dizziness, and
Harvard Medical School, dysfunction and delirium are found in pa- confusion) would be more prevalent
Boston. tients experiencing a greater anticholin- among the GEM cohort than among the
(REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 5), MAR 10, 2008 WWW.ARCHINTERNMED.COM
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(REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 5), MAR 10, 2008 WWW.ARCHINTERNMED.COM
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(REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 5), MAR 10, 2008 WWW.ARCHINTERNMED.COM
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a 2 Test.
b Comparing Anticholinergic Risk Scale score of 0 vs 1 to 2.
c Comparing Anticholinergic Risk Scale score of 1 to 2 vs 3 or higher.
(REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 5), MAR 10, 2008 WWW.ARCHINTERNMED.COM
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(REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 5), MAR 10, 2008 WWW.ARCHINTERNMED.COM
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(REPRINTED) ARCH INTERN MED/ VOL 168 (NO. 5), MAR 10, 2008 WWW.ARCHINTERNMED.COM
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