Thirty-two-year trends in anticholinergic burden and associated mortality among US older adults: a population-based study

Background Anticholinergic burden (AB) is linked to adverse health outcomes and mortality among older adults. Yet, the national trends in AB and its long-term mortality risk are not well-defined. Methods We analysed data from 16 188 older adults in the National Health and Nutrition Examination Survey (NHANES) spanning 32 years. AB was assessed using the 2023 American Geriatrics Society Beers Criteria® and four validated scales (ARS, ADS, ACB and ACSBC). Age-standardised prevalence trends were examined using survey-weighted logistic regression. Mortality outcomes were ascertained through linkage to the National Death Index and analysed with Cox proportional hazards models to estimate adjusted hazard ratios (HRs). Results From 1988–94 to 2017–March 2020, the prevalence of any strong anticholinergic medication use and high AB (score ≥ 3) declined significantly across all scales (all PTrend < .05). During a median follow-up of 81 months, 9006 deaths (49.3%) occurred. After comprehensive adjustment for covariates, high AB was independently associated with elevated all-cause mortality (ADS: HRs 1.65, 95% CI 1.51–1.81; ACB: HRs 1.54, 95% CI 1.41–1.68), cardiovascular mortality (ADS: HRs 1.94, 95% CI 1.71–2.20; ACB: HRs 1.66, 95% CI 1.46–1.88) and cancer mortality (ADS: HRs 1.40, 95% CI 1.18–1.68; ACB: HRs 1.31, 95% CI 1.09–1.57). Conclusions While the prevalence of AB among US older adults has declined over the past three decades, high exposure remains a strong, independent predictor of all-cause, cardiovascular and cancer mortality. These findings highlight the ongoing need for safer prescribing and sustained deprescribing initiatives in geriatric care.