Association between gait performance at discharge and total anticholinergic burden in elderly patients after hip fracture surgery: A single-center retrospective cohort study

• Higher Total ACB was associated with needing physical assistance for walking. • The association held in the prespecified primary model and in sensitivity analyses. • Overall discrimination was modest; the 75–84-year subgroup had higher discrimination. • Total ACB should be considered an adjunct risk signal rather than a stand-alone tool. • Admission JARS scoring may inform care planning; interventional studies are needed. Although the association between total anticholinergic burden (Total ACB) and rehabilitation outcomes following hip fracture (HF) surgery has been suggested, the specific impact of Total ACB on gait performance remains uncertain. This study aimed to investigate the relationship between Total ACB and gait performance at hospital discharge. This retrospective cohort study included 273 patients with HFs (median age: 87 [interquartile range (IQR): 80–91], 78.8% female) admitted to a 320-bed acute care hospital between April 2017 and August 2023. The primary outcome was gait performance at discharge, evaluated using the Functional Ambulation Categories (FAC), with FAC ≤2 defined as requiring physical assistance. Total ACB was assessed using the Japanese Anticholinergic Risk Scale. Multivariable logistic regression and receiver operating characteristic (ROC) analyses were conducted to estimate associations and quantify discrimination. Total ACB was significantly associated with limited gait performance at discharge (FAC ≤2) after adjustment for predefined covariates, and the association remained in sensitivity analyses. ROC analysis showed modest discrimination, with the highest discrimination in the 75–84 age group. Higher Total ACB was associated with a greater likelihood of requiring physical assistance for walking at discharge after HF surgery. Given the modest overall discrimination, these findings are hypothesis-generating. An age-stratified analysis suggested higher discrimination in those aged 75–84 years, but this subgroup result is exploratory and not part of the primary conclusion. We did not evaluate whether deprescribing or modifying anticholinergic therapy improves gait outcomes; external validation and interventional studies are needed before clinical implementation.