The Anticholinergic Burden of Psychotherapeutics
Transcript:
Desiree Matthews: Welcome, everyone. Today, we're going to be discussing anticholinergic burden and practical strategies for deprescribing. My name is Desiree Matthews. I'm a board-certified psychiatric nurse practitioner, and today, we have two of my lovely colleagues, Dr Jonathan Meyer and Dr Leslie Citrome, with us here today.
Dr Jonathan Meyer: Hi, my name is Jonathan Meyer. I'm a voluntary clinical professor of psychiatry at the University of California in San Diego.
Dr Leslie Citrome: I'm Dr Citrome. I'm a clinical professor of psychiatry and behavioral sciences at New York Medical College in Valhalla, New York.
Desiree Matthews: Thank you. Today, we're going to be having a wonderful discussion about understanding anticholinergic medications and how they act both centrally and peripherally. We also want to discuss how that may lead to unintended drug side effects. We're also going to learn how to use available tools on how to calculate anticholinergic burden as well as discuss practical strategies today to help guide patients and care partners through that deprescribing process, including methods to avoid cholinergic rebound.
So now, let's talk about the anticholinergic burden of psychotherapeutics. We talked a bit about this, the anticholinergic burden, and why it's a concern. We can get unintended side effects peripherally, worsening cognition—certainly something that we don't want to do, especially in our mental health population where they're already struggling. Are there any specific callouts to anticholinergics that you can think of that maybe aren't used for drug-induced movement disorders?
Dr Citrome: Well, certainly, you know this has been a big, big problem. When I first started training in psychiatry, we would use tricyclic antidepressants, which have an anticholinergic burden. We would combine it with certain first-generation antipsychotics, which also have a high anticholinergic burden, and on top of that, we use benztropine. So, the three together would sometimes make our older patients delirious. We would actually induce an anticholinergic delirium.
Dr Meyer: In addition to that, there are medications used for somatic conditions, and the classic are those for overactive bladder. Among those medicines, the most offending in terms of a peripheral and central adverse effect is oxybutynin, the least defending this trospium, and the others are somewhat in the middle. That's why people are focused on total burden, using things such as the Beers list. Sure, let people know each individual molecule may contribute incrementally, but the sub-total, as Dr Citrome said, may be quite devastating to the patient, particularly when you have a lot of central anticholinergic burden.
Desiree Matthews: It sounds like it's really important for us not to just consider what we're using in psychiatry, but many of the individuals that we're treating in psychiatry. They're taking a lot of these other medical medications, so really getting a good medication history is what it sounds like needs to happen.
Dr Meyer: I think one thing to appreciate is that it's the sum total, and there are ways to actually quantify this. People have done reviews; there was one in the Journal of Clinical Pharmacology in 2021, which looked at all the anticholinergic burden scales out there. Many of these were developed for research, but the one that is available to all clinicians is called the ACB scale. You can go to the website acbcalc.com; it’s not perfect because it doesn't take into account the dose, and I think we recognize all these scales have limitations. But my favorite quote in this area is ‘Don't let perfect be the enemy of the good.’ This is a pretty good tool for helping you to assess the total burden across all the medications your patient is taking.
Desiree Matthews: Thank you for that practical resource. Well, I think that's all we have time for now, but as always, It was wonderful to have this discussion with you guys today. Thank you, everyone, for joining us on this topic about anticholinergics with good colleagues of mine. If you want to learn more about this topic or other mental health topics, please visit Psych Congress Network to learn more.
