Anticholinergic burden and orthostatic symptoms in older adults after a fall

Introduction

Orthostatic hypotension (OH) in older adults is a risk factor for falls. Anticholinergic medications may contribute to OH through autonomic dysfunction, but evidence for symptom-specific outcomes remains inconsistent. This study examined the association between anticholinergic burden and OH symptoms in older adults presenting to the emergency department (ED) after a fall.

Methods

We conducted a cross-sectional study among adults aged ≥ 65 years presenting to the ED of Amsterdam UMC after a fall between 2014 and 2024. OH symptoms were assessed using the validated CAREFALL Triage Instrument. The primary outcome was the presence of any OH symptom. Secondary outcomes included individual OH-related symptoms (dizziness, lightheadedness, blurred or double vision, and headache). Anticholinergic burden was quantified using the Anticholinergic Cognitive Burden (ACB) scale and categorized as 0, 1, or ≥2. Logistic regression analyses were adjusted for age, sex, polypharmacy, diabetes mellitus, hypertension, cardiovascular disease, and cognitive complaints. Effect modification by age, sex, and polypharmacy was assessed using interaction terms, followed by stratified analyses when statistically significant (p <0.05).

Results

A total of 1279 participants were included (mean age 80.9 years; 63.5% women), of whom 40.3% used at least one anticholinergic medication. An ACB score ≥ 2 was associated with higher odds of OH symptoms compared with ACB 0 (adjusted OR 1.63, 95% CI 1.13-2.33). A significant interaction with sex was found. In women, ACB ≥2 was associated with OH symptoms (adjusted OR 1.88, 95% CI 1.19-2.97), but not in men. Symptom-specific analyses showed associations of ACB≥ 2 with lightheadedness, blurred or double vision, and headache, but not dizziness.

Conclusion

Anticholinergic burden was associated with OH-related symptoms in older adults presenting after a fall, particularly in women. These findings suggest sex-specific vulnerability to anticholinergic adverse effects and support cautious prescribing in older adults at risk of falls.