Medication review for anticholinergic exposure in psychiatry

The deliverable is a useful review note

A completed anticholinergic review should leave the next clinician able to reconstruct the medication history, understand the concern, and see what remains unresolved. A standalone total cannot do that. This guide offers a structure for documenting a review in psychiatry while protecting the original source evidence and the treatment history.

NICE describes medication review as a structured examination undertaken with the person receiving care. The practical point here is that the review should connect medicine information to agreed goals and problems. NICE NG5 The framework below is an educational application of that principle, not a validated intervention or a patient-specific deprescribing protocol.

Establish the question before collecting a score

Write the reason for review in observable terms. Examples include a new concern about attention, uncertainty about an old adjunct, or conflicting medication lists after discharge. These examples identify different information needs. Starting with the concern prevents the lookup result from defining a problem that was never assessed.

Also record the treatment priorities that should remain part of the discussion. A review concerned about unwanted effects still needs an account of what has helped, what previous changes were tried, and what the person considers most important. Those details cannot be reconstructed from ingredient names.

Build the exposure record

For each current medicine, record the exact name, preparation, route, instructions, and actual pattern of use when known. Distinguish regular treatment from occasional use. Keep discontinued or uncertain entries separate until reconciled. Identify the source of the information, especially when the prescription record and the person’s account differ.

The aim is not to fill every field with an assumption. An unknown route or unclear frequency should remain explicit. A transparent incomplete record is more useful than a complete-looking record built from defaults. Medication identity must also be resolved before treating two product names as two contributors or merging them as one.

Create an evidence ledger

An evidence ledger is simply a record of each finding and where it came from. For a UnifiedACB observation, retain the medication concept, literal source label, source version, published value, rating state, and any relevant note. For a supplemental geriatric criterion, record the criterion separately with its dose, route, indication, or condition qualification.

This makes it possible to distinguish three common situations: disagreement between published values, absence from a selected source, and a qualified criterion whose applicability is unresolved. They need different explanations. A single “high/low” label hides that distinction and is difficult to audit later.

Interpret the concern alongside the ledger

Ask what information would make a medication contribution more or less plausible. Relevant questions may concern the timing of actual use, the onset of the complaint, the current illness state, or another medicine effect. The source evidence identifies candidates for discussion; it does not prove which one caused the problem.

If the concern is cognition, specify the observed difficulty or test outcome. If it is a movement symptom, document the clinical assessment rather than assume the symptom itself identifies a treatment. A review becomes less reliable when broad labels such as “foggy” or “EPS” are treated as though they already contain the needed diagnosis.

Separate decisions, proposals, and unresolved questions

The note should distinguish an action already taken from an option being discussed. A proposed taper is not a completed exposure change. A request to clarify a medicine is not evidence that it has been discontinued. Keeping these states separate prevents later clinicians from interpreting symptoms against an incorrect treatment timeline.

If no medication change is appropriate, the review can still have a useful outcome: a corrected list, an explanation of source disagreement, a clarified indication, or a plan to evaluate the concern. Success should not be defined solely by a lower burden description.

A documentation example

The following is a generic record structure, not a clinical case: “Review prompted by a concentration concern. Current scheduled and occasional medicines reconciled; one frequency remains uncertain. Original source classifications recorded separately. No missing entry converted to zero. Treatment benefit and prior changes discussed. The prescribing team will clarify actual occasional use and reassess the defined concern before making a medication decision.”

That account tells a future reviewer what is known, what is uncertain, and what comes next. It also avoids asserting that a classification caused the complaint. A fuller clinical note would add the relevant patient assessment and the team’s actual plan.

Follow-up needs an outcome and an owner

Identify who will complete each unresolved task and what observation will be reviewed. If treatment changes, record the rationale and the outcome being monitored. If treatment remains unchanged, record why continued observation or another assessment is appropriate. A later source update should be distinguishable from a later clinical change.

Evidence limits

The intervention reviews cited below largely concern older adults and should not be treated as proof that this documentation framework improves psychiatric outcomes. The framework has not been presented as a tested UnifiedACB clinical intervention. It is a way to keep the reasoning inspectable while decisions remain grounded in the person’s assessment and care plan.

References

1. 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
2. Georgiou R, et al. Anticholinergic Burden and Cognitive Performance in Patients With Schizophrenia: A Systematic Literature Review. Front Psychiatry. 2021;12:779607. Source
3. 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
4. Braithwaite E, et al. Interventions for reducing anticholinergic medication burden in older adults: a systematic review and meta-analysis. Age Ageing. 2023;52:afad176. Source
5. Taylor-Rowan M, Alharthi AA, Noel-Storr AH, et al. Anticholinergic deprescribing interventions for reducing risk of cognitive decline or dementia in older adults with and without prior cognitive impairment. Cochrane Database Syst Rev. 2023;12:CD015405. doi:10.1002/14651858.CD015405.pub2. Source
6. National Institute for Health and Care Excellence. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes. NG5. 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.