Anticholinergic Cognitive Burden Score Research Articles

Potentially Inappropriate Medication, Anticholinergic Burden, and Mortality in People Attending Memory Clinics.

There is limited evidence regarding the association between potentially inappropriate medications (PIM) and mortality in older people with cognitive impairment. To examine whether use of medications considered to be potentially inappropriate in older people with cognitive impairment (PIMcog) and anticholinergic cognitive burden (ACB) were associated with mortality in people who attended memory clinics. Cross-sectional and longitudinal analyses of data from the Prospective Research In MEmory clinics (PRIME) study. Participants were community-dwelling people who attended nine memory clinics and had a diagnosis of mild cognitive impairment or dementia. PIMcog was defined as any medication considered potentially inappropriate for a person with cognitive impairment according to Beers or STOPP criteria. Anticholinergic burden was calculated using the ACB scale. Time-dependent Cox-proportional hazards regression was used to analyze associations between PIMcog use/ACB score and all-cause mortality over a three-year follow-up period. The regression model included the baseline variables: age, gender, education, cognitive diagnoses, total number of medications, disease-burden, cognition, physical function, and neuropsychiatric symptoms. Of 964 participants, 360 (37.3%) used one or more PIMcog at some time during the study; most commonly anticholinergics and sedatives. 624 (64.7%) participants used a medication with potential or definite anticholinergic properties (ACB>0) at some point during the study. Both PIMcog use (adjusted hazard ratio: 1.42 95% CI: 1.12-1.80) and ACB score (adjusted hazard ratio: 1.18 95% CI: 1.06-1.32) were associated with mortality. Use of PIMcogs and medications with anticholinergic properties was common among memory clinic patients and both were associated with mortality.

Role of anticholinergic burden in primary care patients with first cognitive complaints.

Drugs with anticholinergic properties might have a negative impact on cognition, but findings are still conflicting. The association was evaluated between anticholinergic drugs and cognitive performance in primary care patients with first cognitive complaints. From April 2013 to March 2014, 353 general practitioners administered the Mini-Mental State Examination (MMSE) to patients presenting with first cognitive complaints. Drug history was collected and the anticholinergic cognitive burden (ACB) was scored and categorized as ACB 0, ACB 1 and ACB 2+. A mixed effect linear regression model was used to assess the association between ACB and MMSE score. Of 4249 subjects entering the study (mean age 77 ± 8.2 years, 66.4% women and mean years of schooling 8.9 ± 4.5), 25.8% received at least one drug with anticholinergic action. According to multivariate analysis, and after adjustment for several confounders, subjects with ACB 2+ had a statistically significant lower MMSE score compared with those with ACB 0 (β -0.63; 95% confidence interval -1.19; -0.07). Subjects with ACB 1 had a non-statistically significant lower MMSE score than those with ACB 0 (β -0.11; 95% confidence interval -0.37; 0.15). Anticholinergic medication might affect cognitive function in people with first cognitive complaints. Alternatives should be taken into account when possible, balancing the benefits and harms of these medications.

Anticholinergic burden and cognitive function in a large German cohort of hospitalized geriatric patients

PurposePrevious studies suggest an association between use of anticholinergic drugs in elderly patients and cognitive impairment. However, there are still limited data on the association of anticholinergic drug use and cognitive impairment as well as contribution of individual drugs to anticholinergic load using large, well-documented patient cohorts treated in geriatric units from Europe.MethodsWe investigated 797,440 prescriptions to 89,579 hospitalized patients treated in geriatric units within the GiB-DAT database. Data of all patients discharged between 1 January 2013 and 30 June 2015 was included. The Anticholinergic Cognitive Burden (ACB) scale was used to classify anticholinergic drugs as definite (score 2 or 3) and possible anticholinergics (score 1). Cognitive function was determined using Mini-Mental State Examination (MMSE) and the standardized scale for dementia (4D+S).ResultsIn two multivariable logistic regression models age, sex, number of drugs and ACB total scores were identified as variables independently associated with cognitive impairment as measured by MMSE (odds ratio per ACB unit 1.114, 95% CI 1.099–1.130) or the diagnosis dementia (odds ratio 1.159 per ACB unit, 95% CI 1.144–1.173, both p < 0.0001). High anticholinergic load was associated with patients with severe cognitive impairment (p < 0.05 for all pairwise comparisons). ACB score 3 anticholinergic drugs contributed 77.9% to the cumulative amount of ACB points in patients with an anticholinergic load of 3 and higher.ConclusionsUsing a cross-sectional study design, a significant positive association between anticholinergic drug load and cognitive impairment in European patients treated in specialised geriatric units was found. The most frequently used definitve anticholinergic drugs were quetiapine, amitriptyline and carbamazepine.

Association of Anticholinergic Burden with Cognitive Impairment and Health Care Utilization Among a Diverse Ambulatory Older Adult Population.

To determine the association between Anticholinergic Cognitive Burden (ACB) score and both cognitive impairment and health care utilization among a diverse ambulatory older adult population. Retrospective cohort study. Medication exposure and other clinical data were extracted from the Regenstrief Medical Record System (RMRS), and cognitive diagnosis was derived from a dementia screening and diagnosis study. A total of 3344 community-dwelling older adults (age 65 yrs and older) who were enrolled in a previously published dementia screening and diagnosis study; of these, 3127 were determined to have no cognitive impairment, and 217 were determined to have cognitive impairment. The study followed a two-phase screening and comprehensive neuropsychiatric examination to determine a cognitive diagnosis, which defined cognitive impairment as dementia or mild cognitive impairment. The ACB scale was used to identify anticholinergics dispensed in the 12 months prior to screening. A total daily ACB score was calculated by using pharmacy dispensing data from RMRS; each anticholinergic was multiplied by 1, 2, or 3 consistent with anticholinergic burden defined by the ACB scale. The sum of all ACB medications was divided by the number of days with any medication dispensed to achieve the total daily ACB score. Health care utilization included visits to inpatient, outpatient, and the emergency department, and it was determined by using visit data from the RMRS. The overall population had a mean age of 71.5 years, 71% were female, and 58% were African American. Each 1-point increase in mean total daily ACB score was associated with increasing risk of cognitive impairment (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.004-1.27, p=0.043). Each 1-point increase in mean total daily ACB score increased the likelihood of inpatient admission (OR 1.11, 95% CI 1.02-1.29, p=0.014) and number of outpatient visits after adjusting for demographic characteristics, number of chronic conditions, and prior visit history (estimate 0.382, standard error [SE] 0.113; p=0.001). The number of visits to the emergency department was also significantly different after similar adjustments (estimate 0.046, SE 0.023, p=0.043). Increasing total ACB score was correlated with an increased risk for cognitive impairment and more frequent health care utilization. Future work should study interventions that safely reduce ACB and evaluate the impact on brain health and health care costs.

Estimated Budget Impact of Increased Use of Mirabegron, A Novel Treatment for Overactive Bladder.

BACKGROUND: Oral pharmacological treatment for overactive bladder (OAB) consists of antimuscarinics and the beta-3 adrenergic agonist mirabegron. Antimuscarinic adverse events (AEs) such as dry mouth, constipation, and blurry vision can result in frequent treatment discontinuation rates, leaving part of the OAB population untreated. Antimuscarinics also contribute to a patient’s anticholinergic cognitive burden (ACB), so the Beers Criteria recommends cautious use of antimuscarinics in elderly patients who take multiple anticholinergic medications or have cognitive impairment. Since mirabegron does not affect the cholinergic pathways, it is unlikely to contribute to a patient’s ACB. OBJECTIVE: To estimate the health care costs associated with the pharmacological treatment of OAB with mirabegron and antimuscarinics from U.S. commercial payer and Medicare Advantage perspectives, using a budget impact model. METHODS: For this budget impact model, 2 analyses were performed. The primary analysis estimated the b...

Anticholinergic Medication Burden and 5-Year Risk of Hospitalization and Death in Nursing Home Elderly Residents With Coronary Artery Disease

ObjectivesTo assess the association of the anticholinergic medication burden with hospitalization and mortality in nursing home elderly patients and to investigate the role of coronary artery disease (CAD). DesignLongitudinal (5-year) retrospective observational study. SettingNursing homes in Italy. ParticipantsA total of 3761 nursing home older residents. MeasurementsA comprehensive clinical and functional assessment was carried out through the interRAI long-term care facility instrument. The anticholinergic burden was assessed through the anticholinergic cognitive burden (ACB) scale. Occurrence of hospitalization/all-cause mortality was the primary composite outcome. First hospitalization and all-cause mortality were the secondary outcomes of the study. Hazard ratios (HRs) and subdistribution HRs were obtained through Cox and competing risk (death as competing event for hospitalization) models. ResultsWithin the sample (mean age 83 ± 7 years; 72% females) the incidence rate of the primary outcome was 10/100 person-year. After adjusting for potential confounders and compared with participants with an ACB of 0, those with an ACB of 1 [HR 1.46; 95% confidence interval (CI) 1.12–1.90] and ABC of 2+ (HR 1.41; 95% CI 1.11–1.79) presented an increased risk of developing the primary outcome. After stratification, the risk for the primary outcome increased along with the anticholinergic burden, only for participants affected by CAD (HR 1.53; 95% CI 0.94–2.50 and HR 1.71; 95% CI 1.09–2.68 for the ACB of 1 and ACB of 2+ groups). An ACB score of 2+ was marginally associated with first hospitalization, considering death as a competing risk, only for those with CAD (subdistribution HR 3.47; 95% CI 0.99–12.3). ConclusionsAnticholinergic medication burden is associated to hospitalization and all-cause mortality in institutionalized older adults. CAD increases such risk. The effectiveness and safety profile of complex drug regimens should be reconsidered in this population.

Potentially Inappropriate Medications and Anticholinergic Burden in Older People Attending Memory Clinics in Australia.

There has been limited research into potentially inappropriate medication (PIM) use and anticholinergic burden in patients attending memory clinics. The aim of this study was to explore the use of PIMs related to cognitive impairment (PIMcog), anticholinergic cognitive burden (ACB) and concomitant use of anticholinergic medications with cholinesterase inhibitors (ChEIs) in patients attending memory clinics. Cross-sectional analysis of baseline data from the Prospective Research In MEmory clinics (PRIME) study was performed. Participants were community-dwelling patients who attended nine memory clinics and had a diagnosis of mild cognitive impairment or dementia. PIMcog were defined as any medication considered potentially inappropriate for patients with cognitive impairment according to the Beers or STOPP criteria. Clinically significant ACB was defined as total score of ≥3 on the ACB scale. A total of 964 patients, mean age 77.6 years, were included. PIMcog were used by 206 (21.4%) patients. Anticholinergics and sedatives were the most common PIMcog. PIMcog use was associated with higher number of medications (adjusted OR 1.26; 95% CI 1.19-1.33) and with not having completed secondary level education (adjusted OR 1.71; 95% CI 1.01-2.89). One hundred and thirteen (11.7%) patients had a clinically significant ACB score (≥3). ChEIs were used by 575 patients and 65 (11.3%) of these had an ACB score ≥3. There was no statistically significant difference in ChEI use between patients with and without an ACB score ≥3. PIMcog use, clinically significant anticholinergic burden, and concurrent use of anticholinergics with ChEIs were prevalent in patients attending memory clinics. Efforts are needed to improve prescribing for people with cognitive impairment.

Anticholinergic burden is associated with recurrent and injurious falls in older individuals

ObjectiveWhile the anticholinergic activity of medications has been linked to cognitive decline, few studies have linked anticholinergic burden with falls in older people. We evaluated the relationship between anticholinergic burden and recurrent and injurious falls among community-dwelling older adults. Study designThis case-control study was performed on 428 participants aged ≥65 years, 263 cases with two or more falls or one injurious fall in the preceding 12 months, and 165 controls with no falls in the preceding 12 months. Anticholinergic burden was determined using the anticholinergic cognitive burden (ACB) scale. Upper and lower limb functional abilities were assessed with timed up and go (TUG), functional reach (FR) and grip strength (GS). Logistic regression analysis was employed to calculate the mediation effect of TUG, FR and GS on ACB associated falls. ResultsUnivariate analysis revealed a significant association between an ACB score of ≥1 with falls (OR, 1.8; 95% CI; 1.1–3.0; p=0.01) and significantly poorer TUG and FR. The association between ACB≥1 and falls was no longer significant after adjustment for either TUG (OR for ACB associated falls, 1.4; 95% CI, 0.88–2.4; p=0.14) or FR (OR for ACB associated falls, 1.4; 95% CI, 0.89–2.4, p=0.12) but remained significant with GS. ConclusionThe association between recurrent and injurious falls and the use of any medications listed in the ACB scale was mediated through gait and balance impairment but not by muscular weakness, providing a novel insight into the potential mechanistic link between ACB and falls. Future studies should determine whether TUG and FR measurements could help inform risk to benefit decisions where ACB medications are being considered.

A prescription survey about combined use of acetylcholinesterase inhibitors and anticholinergic medicines in the dementia outpatient using electronic medication history data from community pharmacies.

PurposeWe investigated prescriptions regarding the combined use of donepezil hydrochloride (DPZ) and anticholinergics for elderly outpatients in Japan to determine the impact that combination therapy has on decreasing their cognitive functions.MethodsUsing electronic medication records from 142 community pharmacies, outpatients older than 40 years of age taking DPZ, with or without other prescription medicines, were assessed over 6 years, beginning in 2007. We estimated the number of medicines administered along with DPZ, the number of anticholinergics administered along with DPZ, and the medicines’ anticholinergic cognitive burden (ACB) scale cumulative score based on data from the top four pharmacies that filled the highest number of prescriptions for DPZ for outpatients with dementia in 2010. Data were gathered from records of 431 patients; only three patients were younger than 60 years.ResultsThere was a 1.94-fold increase in the number of prescriptions including DPZ over 6 years. The proportion of patients to whom other medicines were administered along with DPZ was 65.6% (n=283) and the proportion of those taking at least one anticholinergic agent was 24.1% (n=104). The mean number of medicines among subjects taking at least one anticholinergic was 5.7, and the mean cumulative ACB score for anticholinergics contained in these medicines was 2.6. Among 104 patients to whom the anticholinergics were administered along with DPZ, two outpatients taking urologic medicines such as oxybutynin hydrochloride or tolterodine tartrate were found.ConclusionOur findings suggest that it is necessary to pay attention to a decline in cognitive function when prescribing multiple medicines, especially to elderly patients who have already been prescribed DPZ.

A predictive in vitro model of the impact of drugs with anticholinergic properties on human neuronal and astrocytic systems.

The link between off-target anticholinergic effects of medications and acute cognitive impairment in older adults requires urgent investigation. We aimed to determine whether a relevant in vitro model may aid the identification of anticholinergic responses to drugs and the prediction of anticholinergic risk during polypharmacy. In this preliminary study we employed a co-culture of human-derived neurons and astrocytes (NT2.N/A) derived from the NT2 cell line. NT2.N/A cells possess much of the functionality of mature neurons and astrocytes, key cholinergic phenotypic markers and muscarinic acetylcholine receptors (mAChRs). The cholinergic response of NT2 astrocytes to the mAChR agonist oxotremorine was examined using the fluorescent dye fluo-4 to quantitate increases in intracellular calcium [Ca2+]i. Inhibition of this response by drugs classified as severe (dicycloverine, amitriptyline), moderate (cyclobenzaprine) and possible (cimetidine) on the Anticholinergic Cognitive Burden (ACB) scale, was examined after exposure to individual and pairs of compounds. Individually, dicycloverine had the most significant effect regarding inhibition of the astrocytic cholinergic response to oxotremorine, followed by amitriptyline then cyclobenzaprine and cimetidine, in agreement with the ACB scale. In combination, dicycloverine with cyclobenzaprine had the most significant effect, followed by dicycloverine with amitriptyline. The order of potency of the drugs in combination frequently disagreed with predicted ACB scores derived from summation of the individual drug scores, suggesting current scales may underestimate the effect of polypharmacy. Overall, this NT2.N/A model may be appropriate for further investigation of adverse anticholinergic effects of multiple medications, in order to inform clinical choices of suitable drug use in the elderly.

Anticholinergic medications: an additional contributor to cognitive impairment in the heart failure population?

Patients with congestive heart failure (CHF) have a high prevalence of cognitive impairment and the association is multifactorial. In general, the burden of anticholinergic drugs has consistently been shown to be a risk factor for cognitive impairment in the elderly. The aim of this study was to assess the cognitive burden of medications in patients with CHF. This was a cross-sectional, retrospective, single-center study. The study was conducted in an outpatient setting. Patients who presented to a comprehensive heart failure clinic during a 1-month period were included. The primary outcomes of interest were mean anticholinergic cognitive burden (ACB) score of all medications and CHF medications (ACB-CHF), calculated based on the ACB Scoring Scale (ACB-SS). The ACB-CHF score was further dichotomized as 0 or 1 (low anticholinergic burden) versus 2 or 3 (high anticholinergic burden). A total of 182 patients were included. The mean ACB and ACB-CHF scores were 2.4 (range 0-13) and 1.0 (range 0-4), respectively, while 25.8 % of patients had an ACB-CHF score of 2 or 3. There was no association found between ejection fraction in patients with systolic heart failure and the ACB (p = 0.28) or ACB-CHF (p = 0.62) score. We conclude that patients with CHF have a substantial exposure to anticholinergic medications with adverse cognitive effects. This may be another important contributor to the increased prevalence of cognitive impairment in these patients.

Evaluation of anticholinergic burden of medications in older adults

ObjectivesTo calculate and describe the anticholinergic burden of medications in community-dwelling older adults and to identify patient-specific risk factors. DesignDescriptive cross-sectional study SettingCardinal Health Visiting Pharmacist Program, Columbus, OH, between August 2002 and August 2009. ParticipantsCommunity-dwelling adults 65 years or older who were referred through LifeCare Alliance (a provider of home-based senior services). InterventionComprehensive medication review records from medication therapy management (MTM) activities were used to calculate the anticholinergic burden using the anticholinergic cognitive burden (ACB) scale for each patient. Main outcome measureProportion of older adults in the community with a clinically relevant anticholinergic burden (defined as ACB score ≥3). ResultsFrom 341 included records, ACB score was calculated for all patients and an ACB score of 3 or greater was identified in 47.8% (n = 163) of patients. The odds increased significantly as the number of prescription (odds ratio 1.23 [95% CI 1.14–1.32], P < 0.001] and over-the-counter (1.17 [1.02–1.33], P = 0.02] medications increased. The odds also were significantly greater for patients with hypertension (3.01 [1.73–5.21], P < 0.001) and depression (2.6 [1.14–5.9], P = 0.02). ConclusionNearly one-half of community-dwelling older adults had a clinically relevant ACB score of 3 or greater. The ACB score could be used as a component of MTM services in a variety of practice settings to identify older adults who are at higher risk for potential central and peripheral adverse effects related to cumulative anticholinergic activity of their medications. Additional research to measure the clinical impact of ACB assessment and modification is needed.

Assessing Cognitive Effects of Anticholinergic Medications in Patients With Coronary Artery Disease

Cognitive function is a significant determinant of overall quality of life in patients with coronary artery disease. Medications prescribed to control vascular risk factors often have anticholinergic effects, which can cause central side effects and affect cognitive function. This cross-sectional study aimed to identify cognitive deficits associated with the use of anticholinergic medications in patients with coronary artery disease. Demographics, medications, and vascular risk factors were assessed for each patient by interview and chart review. Anticholinergic burden was estimated using the anticholinergic cognitive burden scale. Cognition was assessed objectively using a battery of neuropsychologic tests, including the California Verbal Learning Test second edition, Revised Brief Visuospatial Memory Test, Stroop test, Trail-Making Test Parts A and B, Digit-Symbol Coding, FAS test, and animal naming. Patients with coronary artery disease (mean ± standard deviation age 64.2 ± 9.1, 15.3% female) presented with 2.6 ± 1.4 vascular risk factors and were using 5.1 ± 1.8 medications. Scores on the anticholinergic cognitive burden scale wereassociated with poorerperformance on the Trail-MakingTest Part A (β =0.280, p=0.002), Trail-Making TestPart B (β=0.256, p=0.004), and animal naming(β=-0.212; p=0.015) tasks in models controlling for age, gender, years of education,number of vascular risk factors and total medications. Beta-blockers frequently prescribed in this population (i.e., metoprolol and atenolol) accounted for a large proportion of the total anticholinergic cognitive burden score, and their use was independently associated with poorer cognitive performance in a post hoc model including the anticholinergic estimate. Anticholinergic exposure was associated with poorer performance on tests of attention, speed, and executive function in patients with coronary artery disease.

Association of Anticholinergic Burden with Cognitive and Functional Status in a Cohort of Hospitalized Elderly: Comparison of the Anticholinergic Cognitive Burden Scale and Anticholinergic Risk Scale

Drugs with anticholinergic effects are associated with adverse events such as delirium and falls as well as cognitive decline and loss of independence. The aim of the study was to evaluate the association between anticholinergic burden and both cognitive and functional status, according to the hypothesis that the cumulative anticholinergic burden, as measured by the Anticholinergic Cognitive Burden (ACB) Scale and Anticholinergic Risk Scale (ARS), increases the risk of cognitive decline and impairs activities of daily living. This cross-sectional, prospective study (3-month telephone follow-up) was conducted in 66 Italian internal medicine and geriatric wards participating in the Registry of Polytherapies SIMI (Società Italiana di Medicina Interna) (REPOSI) study during 2010. The sample included 1,380 inpatients aged 65 years or older. Cognitive status was rated with the Short Blessed Test (SBT) and physical function with the Barthel Index. Each patient's anticholinergic burden was evaluated using the ACB and ARS scores. The mean SBT score for patients treated with anticholinergic drugs was higher than that for patients receiving no anticholinergic medications as also indicated by the ACB scale, even after adjustment for age, sex, education, stroke and transient ischaemic attack [9.2 (95 % CI 8.6-9.9) vs. 8.5 (95 % CI 7.8-9.2); p = 0.05]. There was a dose-response relationship between total ACB score and cognitive impairment. Patients identified by the ARS had more severe cognitive and physical impairment than patients identified by the ACB scale, and the dose-response relationship between this score and ability to perform activities of daily living was clear. No correlation was found with length of hospital stay. Drugs with anticholinergic properties identified by the ACB scale and ARS are associated with worse cognitive and functional performance in elderly patients. The ACB scale might permit a rapid identification of drugs potentially associated with cognitive impairment in a dose-response pattern, but the ARS is better at rating activities of daily living.

Controversies In Anticholinergic Medication Use And Cognitive Impairment

As many as 40% of older people are prescribed medications with anticholinergic activity. Studies have suggested the significant effect of anticholinergic medication on cognition but there is controversy. Objective: Analysis of 15908 patients impact of anticholinergic drugs on cognition. Methods: The anticholinergic burden scale (ABS) coded drugs 0 (none), 1 (mild), 2 (moderate), or 3 (severe). Scores were summed for each participant to give a total Anticholinergic Cognitive Burden (ACB) score. Study 1 MRC CFAS with 11,994 participants and cross sectional coding part of a 19 year longitudinal; Study 2 LASER-AD - Dementia Specific 18 month longitudinal with 224 participants. Study 3 SAP REDS USA 1 year follow up with 3690 participants. Study 1 MRC-CFAS - A statistically significant dose-response relation was observed between increasing ACB score and decreasing MMSE, e.g. those with an ACB score of 5 or greater were associated with making 21% (95%CI 8%-35%) more errors on the MMSE. The relationship with cognitive impairment was only seen for ACB conferred by Central Nervous System medications, in particular antipsychotics. Study 2 LASER AD - Anti-cholinergic burden had no significant effect on cognitive decline at 18 months as assessed by the ADAS-cog. The ADAS-cog decreased by a mean of 4.63 in the cohort of patients with an ACB of 0, compared with a mean decrease of 7.4 in patients with an ACB of>0 (mean difference=2.83; t=1.107; df=100; p=0.271; CI-2.24-7.9). Study 3 SAP REDS - Anticholinergic burden for 60 days was associated with a significant effect on cognitive decline as measured by the Community Screening Interview for Dementia odds ratio 1.55p<0.05 (CI-1.05-2.29) with a possible burden dose response effect. Conclusion: An inverse relation existed between the anticholinergic burden of current medication use and cognition in study 1 and study 3; in study 1 the association was driven by the ACB of CNS medications. However, in study 2 no association was detected. Thus the abandonment of use of medication with anticholinergic effects may not be warranted. Further research is required to determine the clinical relevance.

A Preliminary Study of Anticholinergic Burden and Relationship to a Quality of Life Indicator, Engagement in Activities, in Nursing Home Residents With Dementia

(1) To describe the anticholinergic burden experienced by nursing home residents with dementia using the Anticholinergic Cognitive Burden (ACB) Scale; and (2) to determine the association of anticholinergic burden and engagement in activity. Cross-sectional, using baseline data from an ongoing clinical trial. Nine nursing homes in Pennsylvania. Eighty-seven nursing home residents with dementia The ACB Scale was used to classify the severity of each resident's prescribed drugs' anticholinergic activity on cognition. Engagement in activity was measured by direct observation using a standard instrument. Across 775 observations, subjects were active approximately 54% of the time, doing nothing 24% of the time, and asleep over 21% of the time. Seventy-one (81.6%) subjects were prescribed at least one drug with anticholinergic properties and 32 (36.7%) were prescribed at least one drug with severe anticholinergic properties. On average, subjects had a total ACB score of 2.55 (+/- 1.9). Mental status (MMSE) and dependency (PGDRS) were associated with engagement, but use of anticholinergic drugs was not. Nursing home residents are prescribed many drugs with anticholinergic properties. The ACB Scale has utility as a tool to alert practitioners to high anticholinergic burden, who can then use this information when choosing between equally efficacious medications. Further study using larger samples of persons with dementia in earlier stages of the disease, and use of intense measurement designs are needed to more clearly determine the association of ACB with quality of life indicators.