Anticholinergic polypharmacy significantly impacts older adults through both acute adverse effects and long-term consequences, including cognitive impairment, falls, urinary retention, functional decline, and increased dementia risk and mortality.  Age-related pharmacokinetic and pharmacodynamic changes make this population particularly vulnerable to medication-related anticholinergic burden.

The Pharmacy Quality Alliance (PQA) Polypharmacy: Use of Multiple Anticholinergic Agents (Poly-ACH) quality measure was proposed to address medication safety and polypharmacy in older adults. This measure assesses the percentage of patients ≥ 65 years prescribed ≥ 2 unique anticholinergic medications for ≥ 30 cumulative days.

This became a CMS Part D Star Rating measure in 2025, aligning with American Geriatrics Society (AGS) Beers Criteria recommendations, with results impacting 2027 Medicare ratings. CMS determines concurrent use of anticholinergics through prescription dates of service and days’ supply. Patients in hospice care are excluded from the measure. See below for a patient case on how to approach:

Patient Case:

RJ is a 78-year-old female with overactive bladder, depression, irritable bowel syndrome, diabetes, and insomnia. Previously independent, she presents with her husband for post-hospitalization follow-up after experiencing confusion, behavioral changes, and a fall requiring emergency evaluation and treatment for a urinary tract infection.

Current Medications:

• Oxybutynin ER 10 mg daily
• Escitalopram 20 mg daily
• Metformin ER 1000 mg twice daily
• Melatonin 3 mg at bedtime
• Dicyclomine 20 mg four times daily
• Loperamide 2 mg daily as needed for loose stools

Additionally, her husband mentions she’s been taking ZzzQuil (diphenhydramine) at night since her insomnia worsened with a recent cold.

Question: Which is the most appropriate next step in managing RJ’s medication regimen considering recommendations from the AGS Beers Criteria?

1. Continue her current regimen since her symptoms resulted from her urinary tract infection
2. Review and deprescribe anticholinergic medications as clinically appropriate, assess for safer alternatives, and monitor improvement
3. Change escitalopram to another agent to better manage behavioral symptoms
4. Discontinue escitalopram and melatonin as these are inappropriate in older adults

Answer:

B - RJ’s multiple anticholinergic medications likely contributed to cognitive impairment, behavioral change, falls, and urinary retention that may have predisposed her to the UTI further exacerbating these symptoms. The PQA Poly-ACH measure guides providers to identify and reduce anticholinergic burden in older adults when clinically appropriate. See clinical interventions below for specific examples.

Clinical Interventions:

• In collaboration with RJ’s urologist, oxybutynin was switched to mirabegron 25 mg daily, providing comparable efficacy with reduced anticholinergic burden.
• With shared decision-making, dicyclomine was tapered after RJ reported minimal benefit.  Dietary modifications and psyllium were initiated for IBS management.
• Diphenhydramine was discontinued as it is inappropriate for insomnia in older adults given its anticholinergic effects and tolerance development.
• Cognitive behavioral therapy for insomnia (CBT-I) referral was provided as the first-line treatment for chronic insomnia.
• Ramelteon 8 mg at bedtime was prescribed for sleep-onset insomnia pending insurance approval
• Two week follow-up was scheduled to monitor outcomes.

References:

1. PQA Medication Safety Measures. Pharmacy Quality Alliance. Accessed October 10, 2025. https://www.pqaalliance.org/medication-safety
2. New 2025 CMS Medication Safety Measures: What Providers Need to Know. Commonwealth Care Alliance. Accessed October 10, 2025. https://www.commonwealthcarealliance.org/provider-news/new-2025-cms-medication-safety-measures-what-providers-need-to-know
3. By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372
4. Wehran T, Eidam A, Czock D, et al. Development and Pilot Testing of an Algorithm-Based Approach to Anticholinergic Deprescribing in Older Patients. Drugs Aging. 2024;41(2):153-164. doi:10.1007/s40266-023-01089-3
5. Braithwaite E, Todd OM, Atkin A, et al. Interventions for reducing anticholinergic medication burden in older adults-a systematic review and meta-analysis. Age Ageing. 2023;52(9):afad176. doi:10.1093/ageing/afad176
6. Campbell NL, Hines L, Epstein AJ, Walker D, Lockefeer A, Shiozawa A. A 12-Year Retrospective Study of the Prevalence of Anticholinergic Polypharmacy and Associated Outcomes Among Medicare Patients with Overactive Bladder in the USA. Drugs Aging. 2021;38(12):1075-1085. doi:10.1007/s40266-021-00901-2
7. Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;165(2):125-133. doi:10.7326/M15-2175