Effect of Anticholinergic Drug Burden on Postoperative Delirium in Elderly Patients - Nested Case–Control Study

Q: What is postoperative delirium (POD) in elderly patients?

POD is an acute, transient neurocognitive disorder arising within the first week after surgery, marked by inattention, fluctuating consciousness, and abrupt cognitive dysfunction.

Q: What did the study find about higher ACB scores and POD risk?

Higher preoperative ACB scores were significantly associated with increased POD risk, with the strongest effect observed when ACB was ≥3 and cumulative incidence diverging from postoperative day 3.

Sep 29, 2026

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Postoperative delirium (POD) is a frequent complication after surgery in older adults. This nested case–control study examined whether preoperative anticholinergic drug burden is associated with POD within 7 days postoperatively. Patients aged 65+ receiving general anesthesia in China (April 2020–April 2022) were evaluated with the 3-Minute Diagnostic Interview for Confusion Assessment Method, and anticholinergic burden was quantified using the ACB scale. Higher ACB scores predicted increased POD risk, with divergence beginning around postoperative day 3.

LanguageEnglish

CategoryHealthcare

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Pages10

Reading Time25 min

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Abstract

Background

Methods

Results

Conclusion

Introduction

CNS Neuroscience & Therapeutics |
ORIGINAL ARTICLE OPEN ACCESS
Effect of Anticholinergic Drug Burden on Postoperative Delirium in Elderly Patients: A Nested Case–Control Study
Ting Zhang1,2,3 | Tianqi Shen4 | Ningxin Li1,2,3 | Xiaoying Zhang1,2,3 | Kai Zhang1,2,3 | Chang Liu1,2,3 | Bingbing Meng1,2,3 Shaohua Zhang1,2,3 | Guangyu Tang2,3 | Ziyi Zhang2,3 | Qiang Fu1,2,3 | Yanhong Liu1,2,3 | Jingsheng Lou1,2,3 |
Jiangbei Cao1,2,3 | Weidong Mi1,2,3 | Hao Li1,2,3
1Medical School of Chinese People's Liberation Army General Hospital (PLA), Beijing, China | 2Department of Anesthesiology, the First Medical Center, Chinese PLA General Hospital, Beijing, China | 3National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing,
China | 4Department of Anesthesiology and Combat Trauma Center, No. 984 Hospital of the PLA, Beijing, China Correspondence: Hao Li ([lihao301@126.com](lihao301@126.com)) | Weidong Mi ([wwdd1962@163.com](wwdd1962@163.com))
Received: 13 August 2025 | Revised: 5 December 2025 | Accepted: 18 December 2025
Keywords: aged | anticholinergic drug | case–control study | delirium | postoperative cognitive complications | | | --- | --- | | ABSTRACT
Background: Postoperative delirium (POD) is a common complication in elderly patients. This study aimed to investigate the association between preoperative anticholinergic drug burden and POD in elderly patients.
Methods: This nested case–control study included patients aged ≥65years who underwent general anesthesia between April 2020 and April 2022 at multiple hospitals in China. POD occurring within 7 days postoperatively was assessed using the 3-Minute Diagnostic Interview for Confusion Assessment Method. Preoperative anticholinergic drug burden was quantified using the Anticholinergic Cognitive Burden (ACB) scale. Univariate and multivariate logistic regression models with random effects were used to determine the association between ACB scores and POD occurrence. Kaplan–Meier survival analysis with log-rank tests was plotted to compare the cumulative POD incidence across groups. Subgroup analyses were performed to explore the relationship between ACB scores and POD occurrence within specific populations.
Results: Among 10,296 patients, 1131 (11.0%) developed POD. The study employed a 5:1 matched case–control design and included 1125 cases and 5296 matched controls. Univariate (odds ratio [OR]: 1. 230; 95% confidence interval [CI]: 1.119–1. 353, p < 0.001) and multivariate (adjusted OR: 1.118; 95% CI: 1.006–1.243, p = 0.037) analyses demonstrated a significant association between higher anticholinergic drug burden and increased POD risk. When analyzed categorically (ACB score 0 as reference), adjusted ORs were 1.100 (95% CI: 0.919–1.317; p = 0.296) for ACB = 1, 1.213 (95% CI: 0.831–1.771; p = 0.318) for ACB = 2, and 1.963 (95% CI: 1.253–3.076; p = 0.003) for ACB ≥3. Kaplan–Meier analysis demonstrated a significantly higher cumulative incidence of POD in the ACB ≥3 group (log-rank p< 0.001), with divergence starting on postoperative day 3.
Conclusion: A higher preoperative anticholinergic drug burden is associated with an increased risk of POD in elderly patients, particularly when the ACB scores are ≥3. | | | 1 | Introduction | patients requiring surgical treatment. Perioperative compli- | | The aging global population presents a growing challenge to public health systems, with an increasing number of elderly | cations in the elderly are common and often associated with poor prognoses, making their prevention a major clinical priority [1] . Postoperative delirium (POD) is an acute, transient | | Ting Zhang, Tianqi Shen and Ningxin Li contributed equally to this work and shared co-first authorship. | | | This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cit

FAQs

What is postoperative delirium (POD) in elderly patients?

POD is an acute, transient neurocognitive disorder arising within the first week after surgery, marked by inattention, fluctuating consciousness, and abrupt cognitive dysfunction.

How was anticholinergic drug burden measured in the study?

Preoperative anticholinergic drug burden was quantified using the Anticholinergic Cognitive Burden (ACB) scale.

What did the study find about higher ACB scores and POD risk?

Higher preoperative ACB scores were significantly associated with increased POD risk, with the strongest effect observed when ACB was ≥3 and cumulative incidence diverging from postoperative day 3.

Sep 29, 2026

Upload by Miles