Anticholinergic Medication Use in Veterans Affairs Long‐Term Care Residents: Clinical Patterns and Opportunities for Deprescribing

BACKGROUND: Anticholinergic exposure is common in nursing homes; however, the true burden may be underestimated, particularly due to over-the-counter agents such as first-generation antihistamines that are not consistently captured in prior claims-based studies. This gap limits accurate characterization of anticholinergic use and its clinical implications in older adults. PARTICIPANTS AND SETTING: Veterans aged ≥ 65 years with stays ≥ 90 days (N = 45,183) residing in US Department of Veterans Affairs (VA) Community Living Centers (CLC). This study is a secondary data analysis of residents identified during fiscal years 2007-2019. METHODS: True anticholinergic exposure through barcode-based medication administration dispensing records allowed daily measurement of anticholinergic exposure, with follow-up extending from admission to discharge, death, or April 1, 2025. Anticholinergic medication use was defined as use ≥ 4 days per week during the CLC stay. Drugs were identified using VA classifications aligned with the 2023 American Geriatrics Society Beers Criteria and grouped into nine anticholinergic classes. Outcomes included prevalence, duration, and number of anticholinergic drug classes used; patterns by dementia status; and temporal trends over time. RESULTS: Among 45,183 CLC residents, 33.4% (n = 15,074) used anticholinergic medications. Residents with dementia (n = 20,254) showed substantial exposure to neuropsychiatric anticholinergics, including second-generation antipsychotics (30.6%) and antiparkinsonian agents (10.1%). First-generation antihistamine use remained high in this group (29.5%). Residents without dementia (n = 24,929) more frequently received antihistamines (34.4%), bladder antimuscarinics (23.7%), and skeletal muscle relaxants (11.1%). From FY2007-2019, anticholinergic use declined modestly, with decreases in antihistamines (12.1%-8.8%), antidepressants (6.8%-3.5%), and antiemetic/antivertigo agents (5.2%-1.2%). Most residents used a single anticholinergic class, increasing from 75.5% to 82.2% over time. CONCLUSIONS: Although some anticholinergic classes may be clinically necessary, our findings highlight potentially underrecognized and modifiable sources of exposure, particularly first-generation antihistamines, underscoring the need for deprescribing efforts.