Yes, several medications with high anticholinergic burden may be commonly used in ways that unintentionally contribute to cumulative anticholinergic effects, often going unrecognized by clinicians and patients alike.
While anticholinergic burden is typically considered in the context of well-known drug classes like first-generation antipsychotics and tricyclic antidepressants, there is growing evidence that many other commonly prescribed medications with milder anticholinergic activity can contribute cumulatively to a high anticholinergic burden, particularly when prescribed concurrently.
Such medications include certain cardiovascular drugs (e.g., beta-blockers like atenolol and metoprolol, and diuretics like furosemide), anticonvulsants (e.g., carbamazepine), and some antihistamines, especially first-generation agents. These drugs often have a low individual anticholinergic score but collectively can raise total burden unnoticed by prescribers because their anticholinergic effects may be secondary or less overt clinically, thus termed 'occult' contributors to anticholinergic burden Gebreyohannes et al. 2025Rahoo et al. 2025 Gebreyohannes et al. 2025,Rahoo et al. 2025.
Furthermore, some psychotropic medications used for neuropsychiatric symptoms in dementia patients, such as quetiapine, prednisolone (a corticosteroid with indirect anticholinergic effects), and olanzapine, also contribute significantly to anticholinergic burden and are frequently prescribed in older adults, sometimes without clear awareness of their anticholinergic properties Rahoo et al. 2025 Rahoo et al. 2025.
In addition, over-the-counter and commonly used agents like warfarin and nifedipine, which are not traditionally classified as anticholinergic, have been found to contribute an anticholinergic score of 1 in some expert scales, hence adding covertly to the overall burden in polypharmacy contexts Gebreyohannes et al. 2025 Gebreyohannes et al. 2025.
Importantly, such latent anticholinergic exposure is clinically significant because cumulative anticholinergic burden correlates with adverse outcomes including cognitive impairment, falls, delirium, hospitalisation, and mortality, especially in older adults or those with dementia NICE CKS,NICE NG97,Gebreyohannes et al. 2025,Rahoo et al. 2025.
Therefore, in clinical practice, medications with mild or secondary anticholinergic effects—often cardiovascular drugs, anticonvulsants, certain psychotropics, and some over-the-counter agents—should be scrutinized as hidden contributors to anticholinergic burden during medication reviews, particularly in polypharmacy situations.
UK guidelines recommend cautious prescribing and regular medication review in vulnerable populations but do not specifically highlight this occult contribution, which recent literature increasingly emphasizes Gebreyohannes et al. 2025Rahoo et al. 2025 NICE CKS,Gebreyohannes et al. 2025,Rahoo et al. 2025.
Key References
- CKS - Palliative care - secretions
- CKS - Poisoning or overdose
- NG97 - Dementia: assessment, management and support for people living with dementia and their carers
- CKS - Psychosis and schizophrenia
- (Gebreyohannes et al., 2025): Anticholinergic burden and its associated factors among adult outpatients in a resource-limited setting: a cross-sectional study.
- (Rahoo et al., 2025): Anticholinergic Burden and Its Association with Hospitalisation Risk and Causes of Admission in Older Adults with Mild Cognitive Impairment or Dementia.
- (Wei et al., 2025): Polypharmacy, anticholinergic burden and oral microbiome among U.S. middle-aged and older adults: a representative national survey.