Anticholinergic burden and antipsychotic treatment

One medicine, several clinical questions

An antipsychotic can appear in an anticholinergic evidence table and in a treatment guideline for an entirely different reason. The table describes a particular source’s classification. The treatment guideline addresses whether and how the medicine may help a defined disorder. Reading the first as a complete judgment on the second loses the central reason the medicine was prescribed.

This spotlight explains the boundary between those questions. It does not rank antipsychotics, assign a class-wide value, or reproduce individual medication profiles. The useful comparison is between evidence statements: what a source says about anticholinergic properties, what is known about treatment response, and what remains uncertain in the present clinical context.

Antipsychotic class labels are too broad for score assignment

“First generation” and “second generation” describe broad groupings. They are not anticholinergic scale entries. A value attached to one named medicine should not be transferred to another member of the class. Similarly, a source’s decision to include a drug does not establish that every source uses the same rationale, evidence threshold, or category.

The review of burden scales by Vennard and colleagues documents differences in scale development and coverage and identifies no universal gold standard. That is a reason to retain the original source identity, rather than resolve a disagreement by majority vote or average. Vennard et al., 2026

The primary medicine may not be the only contributor

When reviewing an antipsychotic regimen, distinguish the antipsychotic from medicines added to address other symptoms. A regimen-level classification can reflect several contributors. Replacing the name of the whole regimen with the name of the antipsychotic may wrongly attribute all exposure to that medicine.

An informative record lists the contributors separately and explains their clinical roles. It also identifies whether an adjunct is regular, occasional, historical, or uncertain. This is especially useful when comparing two visits: a changed burden description might reflect an adjunct, a reconciliation correction, or a different source version rather than a change in antipsychotic treatment.

Treatment benefit needs its own account

The decision to continue or change an antipsychotic includes response, the person’s experience, relevant adverse effects, and the consequences of a change. NICE’s guidance emphasizes documenting the expected benefits and risks and the rationale for continuing, changing, or stopping treatment. A burden classification cannot replace that therapeutic account. NICE CG178

For example, “classified by this source” and “previously effective for this person” can both be true. The first makes a medication-related question visible. The second helps determine what options can reasonably be considered. The review becomes less useful if either fact is omitted to make the conclusion appear simpler.

Dose, formulation, and timing are context rather than arithmetic shortcuts

A source may categorize an ingredient without modeling the dose actually used. That does not make dose irrelevant clinically. It means the source category and the person’s exposure history answer different questions. Dividing the category because a dose is lower, or multiplying it because a dose is higher, would introduce a transformation the original source did not validate.

The same care applies to oral and long-acting preparations, immediate and modified release products, and medicines used only during an episode. Record the preparation and administration history. Do not assume that changing the preparation changes a published ordinal category, and do not infer equivalent clinical exposure from a shared ingredient name alone.

How to discuss a discrepancy between sources

Begin with identity: are both records about the same ingredient or product? Next inspect the source versions and the state of the evidence. A disagreement between two published values differs from a value in one source and no public entry in another. If a source note explains a route limitation or a publication anomaly, include it in the comparison.

The appropriate output is descriptive: the named sources classify the medicine differently, and those differences remain visible. A clinician can then decide whether a source is applicable to the question being asked. The directory should not create an unsupported winner by selecting the category that best fits a preferred treatment decision.

A useful medication discussion

Bring three items to the conversation: the original source observations, the medicine’s documented purpose and benefit, and the specific concern prompting review. Add actual co-medication use and prior treatment experience when available. This gives the prescriber enough context to assess a concern without pretending that the table contains a complete comparative effectiveness analysis.

Limitations of a class spotlight

Antipsychotic treatment encompasses different diagnoses, illness stages, populations, and formulations. The psychosis cognition literature cannot establish a comprehensive safety ranking across these uses. This article also does not compare efficacy or provide switching instructions. Its contribution is to keep a medication’s anticholinergic evidence connected to, but distinct from, the broader treatment assessment.

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.