Anticholinergic burden in psychosis care

Start with the phase of care

A list assembled during an acute psychotic episode may serve a different purpose from a long-term maintenance regimen. Before interpreting any burden classification, establish what the list represents: admission orders, medicines actually administered, a discharge prescription, or the regimen the person is currently taking. This prevents a temporary order from being mistaken for continuing exposure and makes the review relevant to the decision at hand.

The workflow below is educational. It helps a team assemble a defensible evidence summary; it does not select an antipsychotic, recommend withdrawal, or set a target score. NICE’s psychosis guidance treats antipsychotic treatment as an individual therapeutic trial with documented indications, benefits, adverse effects, and reasons for change. NICE CG178

1. Reconstruct the reason for each medicine

Record the primary treatment, any medicine used to manage treatment-related symptoms, and medication for unrelated conditions. For each entry, distinguish an active indication from an indication copied forward from an old record. If the reason is unknown, preserve “indication unclear” as an unresolved item rather than guessing.

The exercise can expose a question that a scale cannot answer: whether the present combination still corresponds to the treatment plan. It can also show why a superficially simple suggestion to remove a contributor would be incomplete. A medicine may have been retained because an earlier change was poorly tolerated or because the clinician is still evaluating a symptom that prompted its use.

2. Record administration, not just availability

An as-needed medicine on an order sheet is not necessarily taken every day. Document the relevant period of actual use and the source of that information. A patient’s account, a caregiver’s observation, and a medication administration record are different evidence sources and may disagree. Record the discrepancy rather than selecting the version that produces the lowest total.

Also check for duplicate names, old prescriptions, and medicines supplied by another clinician. A brand name and its generic name may represent one exposure; a similar ingredient name may instead refer to a different product. Resolve the identity before comparing source values.

3. Inspect contributor rows by source

Use UnifiedACB to identify the exact concept and examine each available source-specific observation. Keep the source version and route or formulation note in the review. An unlisted entry should remain unlisted. A published zero should remain tied to the source that printed it.

If sources disagree, describe the disagreement directly. Do not choose the higher value merely to appear cautious, or the lower value to make the regimen appear acceptable. The practical question is why the records differ and whether either source has a limitation relevant to the formulation or population being considered.

4. Define the clinical concern separately

Name what is being assessed: a cognitive complaint, an observed movement problem, a bowel concern, or another issue. Include its onset and course relative to medication use. Avoid recording only a burden category, because that leaves the next clinician unable to tell what outcome needs follow-up.

A hypothetical documentation example is: “The medication history includes scheduled and occasional treatment. Source classifications differ for one contributor. The current question is daytime attention; the timing of actual as-needed use is not yet established.” This is not a patient case or a treatment recommendation. It illustrates how to state evidence and uncertainty without turning an exposure classification into a diagnosis.

5. Agree on ownership and follow-up

A review is incomplete when it produces a concern but no clear owner. Identify which clinician will reconcile an ambiguous medicine, who can explain a previous treatment trial, and how the patient’s priorities will enter the discussion. Any actual treatment decision should include an assessment of benefit, potential adverse effects, and the consequences of change.

The follow-up question should be meaningful even if the burden classification stays the same. Has the medicine history been clarified? Is the concern better characterized? Did an agreed intervention change the outcome being monitored? This keeps the review connected to clinical care rather than treating a lower number as the sole definition of success.

Common handoff errors

• Sending a total without the medicines and source version that produced it.
• Counting every available as-needed order as if it were scheduled administration.
• Describing an absent scale entry as evidence of safety.
• Recording a proposed medication change as though it had already occurred.
• Carrying forward an acute-care adjunct without documenting whether its indication continues.

Where this workflow stops

The cited psychosis literature gives a reason to examine anticholinergic exposure, but it does not establish the best regimen for a particular person. A source lookup cannot adjudicate an acute psychiatric assessment or predict relapse after a change. The defensible output is a reconciled history, a traceable source summary, and a clinical question with an owner and a follow-up plan.

References

1. Mancini V, et al. Anticholinergic Burden and Cognitive Function in Psychosis: A Systematic Review and Meta-Analysis. Am J Psychiatry. 2025;182:349-359. Source
2. Vennard O, Stewart C, Tolia M, Soiza RL, Myint PK. Anticholinergic Medication Burden Scales: A Systematic Review. J Am Geriatr Soc. 2026;74(6):1771-1784. Source
3. Georgiou R, et al. Anticholinergic Burden and Cognitive Performance in Patients With Schizophrenia: A Systematic Literature Review. Front Psychiatry. 2021;12:779607. Source
4. National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. CG178. Recommendations. Source

Disclosure

Funding: None. Conflict of interest: None declared for the UnifiedACB educational project.

Educational evidence summary. This content does not provide patient-specific medical advice and does not replace clinical judgment, medication reconciliation, or prescribing guidance.