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Sixteen studies satisfied the inclusion criteria from an initial 496 studies. Fifteen studies identified a significant negative association of anticholinergic burden with mobility measures. One study did not find an association between anticholinergic intervention and mobility measures. Five studies included in the meta-analyses showed that anticholinergic burden significantly decreased walking speed (0.079 m/s ± 0.035 MD ± SE,95% CI: 0.010 to 0.149, p = 0.026), whilst a meta-analysis of four studies showed that anticholinergic burden significantly decreased physical function as measured by three variations of the Instrumental Activities of Daily Living (IADL) instrument 0.27 ± 0.12 (SMD ± SE,95% CI: 0.03 to 0.52), p = 0.027. The results of both meta-analyses had an I 2 statistic of 99% for study heterogeneity. Egger’s test did not reveal publication bias. Conclusion of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, United States Alcohol and drug misuse and treatment in adults from Public Health England's (PHE’s) national drug treatment monitoring system (NDTMS). Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made.

Drug misuse data included in this release are sourced from the Crime Survey for England and Wales (CSEW). Our User guide to crime statistics for England and Wales provides detailed information about the crime survey.This systematic review aimed to synthesise data from published studies regarding the association between anticholinergic burden and mobility. The studies were critically appraised for the strength of their evidence. Methods The specialist physicians had worked for a median of 15 years (cohort 1) and 16.5 years (cohort 2) in the tertiary care of patients with SUD. Approximately three out of four participants worked in acute care hospitals, with the remainder working in rehabilitation clinics ( Table 1). Average Overall Harm

Anticholinergic Cognitive Burden Scale (ACB) developed by Boustani et al. [ 24] is based on a systematic literature review of medicines with known anticholinergic activity. The ACB scale included medicines that were likely to have a negative impact on cognition [ 27, 28]. A multi-disciplinary panel assessed individual drugs to have none, possible, or definite anticholinergic properties with a score ranging from 0 to 3. ACB scale reported 88 medicines with known anticholinergic activity. Studies that employed the ACB scale have shown that higher anticholinergic burden predicts cognitive impairment in older people. In addition, the study conducted by Pasina L et al. showed that anticholinergic burden quantified by the ACB scale predicted impairment in physical functioning [ 27]. The drug-related mortality rate per million population in Great Britain using the EMCDDA definition was the highest on record, at 76 per million. The mortality rate in Scotland was 229 per million in 2017, the highest rate reported in Europe in that year. A citation analysis was performed to identify and compare the clinical utility of individual anticholinergic rating scales to quantify anticholinergic burden and to evaluate its association with adverse outcomes (cognitive, functional, mortality) in older people. Studies that used the rating scales for assessing the adverse outcomes in older people are reported in this review. Rudolph JL, Salow MJ, Angelini MC, ET AL (2008). The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med. doi: 10.1001/archinternmed.2007.106.Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med. 2008;168(5):508–13. The Anticholinergic Risk Scale (ARS) score was developed based on a ranking system developed by Rudolph et al. [ 19]. A literature review of 500 medicines known to possess anticholinergic activity was conducted by a group of geriatricians and pharmacists within the Veterans Affairs Boston Healthcare System. The authors considered the affinity for the muscarinic receptor, experimental reporting of anticholinergic activity, and literature review on anticholinergic adverse effects. This information was used to rank medicines for anticholinergic activity on a scale of 0 to 3, with 0 indicating no known anticholinergic activity and 3 indicating definite/high anticholinergic activity. A total of 49 medicines with known anticholinergic activity were reported in the ARS scale. The clinical outcomes validated using the ARS scale were cognitive, functional, quality of life, length of hospital stay, and mortality. The ARS was validated in a veteran’s population derived from a single medical centre limiting its external validity. Higher ARS scores in veteran and primary care patients were shown to be associated with anticholinergic adverse events [ 19]. Thirteen per cent of people starting drug treatment in Great Britain in 2018 reported primary use of powder cocaine. There has been a notable increase in the proportion of people starting treatment for powder cocaine use in Scotland and Wales in recent years. Uusvaara J, Pitkala K, Kautiainen H, Tilvis R, Strandberg T. Association of Anticholinergic Drugs with Hospitalization and Mortality among Older Cardiovascular Patients. Drugs Aging. 2011;28(2):131–8. The overall prevalence of drug use reported in the UK has remained relatively stable throughout the last decade. However, the most recent surveys covering England and Wales, and Scotland reported the highest prevalence of drug use in the past 10 years.

Tune LE. Anticholinergic effects of medication in elderly patients. J Clin Psychiatry. 2001;62 Suppl 21:11–4. Powder cocaine is the most commonly used stimulant in the UK. The prevalence of use in the last year reported in England and Wales in 2018 to 2019 (2.9%) was the highest since 2008 to 2009. Lifetime use among 15 year olds in England increased from 2% in 2013 to 4.2% in 2018, and was 5.4% in Scotland in the same year. Landi F, Russo A, Liperoti R, Cesari M, Barillaro C, Pahor M, et al. Anticholinergic drugs and physical function among frail elderly population. Clin Pharmacol Therapeut. 2007;81(2):235–41.Some new psychoactive substances (NPS) were previously legal to supply if they were not already controlled under the Misuse of Drugs Act 1971. However, under the Psychoactive Substances Act 2016, all of these are now illegal to supply, produce and import. In 2017, 3,284 drug-related deaths ( DRDs) occurred in Great Britain using the European Monitoring Centre for Drugs and Drug Addiction ( EMCDDA) definition, which is deaths caused directly by the consumption of at least one illicit drug. Data from the Crime Survey for England and Wales (CSEW) showed no change in the overall level of any drug use (see Glossary for definition) in the last year for the year ending June 2022 compared with the year ending March 2020. Campbell N, Perkins A, Hui S, Khan B, Boustani M. Association between prescribing of anticholinergic medications and incident delirium: a cohort study. J Am Geriatr Soc. 2011;59 Suppl 2:S277–81. We cordially thank Jennifer Haverkemper, MSc (Psychology), for her assistance in developing the questionnaire for Cohort 1, and Ann-Christin Kanti, MD, for data entry and maintenance. We also thank Gabriele Lührmann, chief secretary of the Department for Psychiatry, Psychotherapy, and Psychosomatics at the EVK Castrop-Rauxel for organizing correspondence with colleagues. We also thank the many physicians who kindly took the time to participate in this project. Supplementary Material