Anticholinergic burden and adverse outcomes in older adults with hearing loss: a nationwide Korean cohort study

South Korea is rapidly becoming a super-aged society, with high healthcare utilization contributing to polypharmacy and frequent use of anticholinergic medications among older adults. Hearing loss is highly prevalent in this population and is associated with adverse outcomes, including falls, cognitive impairment, and mortality, while anticholinergic burden has been associated with increased risks. This study aimed to characterize anticholinergic medication use and inform risk stratification in older adults with hearing loss using a nationwide cohort. To characterize anticholinergic medication use among older adults with hearing loss and to evaluate its association with the risk of falls and fractures, emergency department (ED) visits, dementia, and mortality, in order to inform risk stratification within this population. A population-based retrospective cohort study. The study analyzed data from the Korean National Health Insurance Database (NHID) spanning from 2018 to 2021. A total of 598,152 individuals aged ≥ 65 years diagnosed with hearing loss were included after excluding those with cancer, genetic hearing loss, fractures, or dementia. The anticholinergic burden was assessed using the Korean Anticholinergic Burden Scale (KABS). Participants were categorized into anticholinergic burden (score > 0) and no-burden (score = 0) groups. Cox regression analysis estimated hazard ratios (HRs) for falls, fractures, ED visits, dementia, and mortality, adjusting for age, sex, lifestyle factors, and comorbidities. Approximately 37.4% of participants were exposed to anticholinergic burden. After full adjustment, anticholinergic burden was associated with increased risks of falls and fractures (HR 1.20; 95% CI, 1.18–1.23), ED visits (HR 1.21; 95% CI, 1.14–1.25), dementia (HR 1.17; 95% CI, 1.15–1.19), and mortality (HR 1.05; 95% CI, 1.03–1.07). Sensitivity analyses excluding weak anticholinergic agents or extending the exposure window yielded similar or stronger associations for most outcomes. In older adults with hearing loss, anticholinergic burden was common and was associated with an increased risk of multiple adverse health outcomes. These findings suggest that anticholinergic burden remains a clinically relevant medication-related risk marker in this population and highlight the importance of careful medication management in older adults with sensory impairment in the context of rapid population aging and high healthcare use.