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Changes in anticholinergic load from regular prescribed medications in palliative care as death approaches

Department of Palliative and Supportive Services, Flinders University, Daw Park, South Australia; Department of Palliative Care, Braeside Hospital, Prairiewood, and University of New South Wales, South West Sydney Clinical School, New South Wales

D Currow

Department of Palliative and Supportive Services, Flinders University, Daw Park, South Australia david.currow{at}flinders.edu.au

J Plummer

Department of Anaesthesia and Pain Management, Flinders Medical Centre, Bedford Park, South Australia

R Seidel

Department of Palliative and Supportive Services, Flinders University, Daw Park, South Australia

R Carnahan

The University of Oklahoma College of Pharmacy, Tulsa, Oklahoma

AP Abernethy

Department of Palliative and Supportive Services, Flinders University, Daw Park, South Australia; Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, North Carolina

Although there is an understandable emphasis on the side effects of individual medications, the cumulative effects of medications have received little attention in palliative care prescribing. Anticholinergic load reflects a cumulative effect of medications that may account for several symptoms and adverse health outcomes frequently encountered in palliative care. A secondary analysis of 304 participants in a randomised controlled trial had their cholinergic load calculated using the Clinician-Rated Anticholinergic Scale (modified version) longitudinally as death approached from medication data collected prospectively by study nurses on each visit. Mean time from referral to death was 107 days, and mean 4.8 visits were conducted in which data were collected. Relationships to key factors were explored. Data showed that anticholinergic load rose as death approached because of increasing use of medications for symptom control. Symptoms significantly associated with increasing anticholinergic load included dry mouth and difficulty concentrating (P < 0.05). There were also significant associations with increasing anticholinergic load and decreasing functional status (Australia-modified Karnofsky Performance Scale; and quality of life (P < 0.05). This study has documented in detail the longitudinal anticholinergic load associated with medications used in a palliative care population between referral and death, demonstrating the biggest contributor to anticholinergic load in a palliative care population is from symptom-specific medications, which increased as death approached.

Key Words: anticholinergic load • palliative care • prescribing • symptom control • terminal care

Palliative Medicine, Vol. 23, No. 3, 257-265 (2009)
DOI: 10.1177/0269216309102528


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