**8. Practical considerations for the use of anticholinergic agents in older agents**

Anticholinergic medications are readily available over-the-counter. First generation antihistamines are available as single ingredients or in multiple symptom cough and cold products. Anticholinergics are marketed as over-the-counter sleep aids and for urinary incontinence [51–54]. A recent study examining older adults' medication decision making and behavior in regards to the use of anticholinergic over-the-counter medications found that while seniors were concerned about adverse drug events, they were not aware of age-related risk associated with the use of anticholinergic medications [55].

Anticholinergic agents are used at end-of-life (EOL) for relief of nausea in those with a vestibular component and more commonly, to provide symptomatic relief of excessive secretions. However, data is lacking to support the use of these drugs for this latter indication [56, 57].

Given the poor risk versus benefit of anticholinergics in older adults, there has been a movement to deprescribe these medications in the elderly. The DEFEATpolypharmacy was a deprescribing feasibility trial conducted among 46 residential care residents in New Zealand that targeted the use of anticholinergic and sedative medications in older adults. Utilizing peer-reviewed deprescribing guidelines and a collaborative pharmacist-led medication review approach, investigators were able to demonstrate a 0.34 decrease in DBI scores at 6 months. The total number of medications were reduced by 2.13 medications per patient. There was a statistically significant reduction in the number of falls in the past 90 days. There was also a significant improvement in frailty scores. A significant decline was also observed in psychiatric, neurological, autonomic and other adverse events with a decrease in psychiatric adverse events of 1.8 three months after deprescribing and increasing to 2.24 after 6 months; other potential adverse events fell by 2.8 at the end of three months and 4.24 at 6 months post initiation of the deprescribing intervention. Participants also reported lower depression scores after six months. Cognition and quality of life were unchanged [58].

Unfortunately, anticholinergics are sometimes prescribed as part of the prescribing cascade to manage urinary incontinence associated with the use of acetylcholinesterase inhibitors. A population-based retrospective cohort study of 44,884 older adults with dementia conducted in Canada found that there was an increased risk (adjusted hazard ratio 1.55) of subsequently receiving an anticholinergic agent following the initiation of acetylcholinesterase inhibitors [59]. The *Choosing Wisely* campaign, an initiative of the American Board of Internal Medicine Foundation, is designed to promote conversations between clinicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary. Dialog has started about the use of anticholinergic agents in older adults. In June 2016, the American Academy of Nursing made the following recommendation: "Don't administer "prn" (i.e., as needed) sedative, antipsychotic or hypnotic medications to prevent and/or treat delirium without first assessing for, removing and treating the underlying causes of delirium and using nonpharmacologic delirium prevention and treatment approaches". Anticholinergics are clearly identified as deliriogenic medications [60].

In June 2020, the American Urogynecologic Society (AUS) issued a recommendation stating to "avoid using anticholinergic medication to treat overactive bladder in women older than 70". This recommendation was based on the AUS's concern over the ability of anticholinergic drugs to impair cognition, increase the risk of developing dementia and cause drowsiness and constipation, all potentially detrimental adverse effects in older adults [61].
