Anticholinergic medication use in people with dementia in primary care: an exploration of evidence and perspectives

  • Bara'a Shawaqfeh

Student thesis: Doctoral ThesisDoctor of Philosophy


Introduction: The use of anticholinergic medications remains widespread amongst people with dementia, despite acknowledged impairments to cognitive function and increased mortality rates in this population. The aim of this PhD thesis was to explore the current evidence and perspectives of key stakeholders in relation to the use of anticholinergic medications among people with dementia in primary care.Methods: A systematic review was conducted to identify the evidence for interventions to reduce anticholinergic burden among people with dementia in primary care. A qualitative approach was used to understand patients’ and carers’ experiences and perspectives about the use of anticholinergic medications in people with dementia through the analysis of posts (n=341) from an online discussion forum for those affected by dementia. A self-administered, postal questionnaire was distributed to all registered community pharmacies in Northern Ireland (n=526) to explore community pharmacists’ knowledge of anticholinergic burden in dementia and their perceptions of the role they can play in the management of anticholinergic burden amongst people with dementia. Finally, a scoping review was conducted to investigate the recruitment and retention of people with dementia in clinical trials (n=129) focused on evaluating the pharmacological management of the cognitive symptoms of dementia. All data were analysed using appropriate techniques.Results: The systematic review, which found no studies eligible for inclusion, highlighted the lack of interventions developed to reduce anticholinergic burden among people with dementia in primary care settings. Analysis of discussion forum posts emphasised how commonly anticholinergic medications are prescribed for people with dementia. Several factors were found to influence a prescriber’s decision to prescribe anticholinergic medications in this population, as perceived by patients and carers (i.e. assessment of risks and benefits of starting a medication, knowledge regarding the use of anticholinergic medications, shared decision-making between the patient, carer and healthcare professional(s), presence of non-cognitive symptoms, and whether a medication had been used prior to the patient receiving their dementia diagnosis) and a range of effects and outcomes were described. Carers’ lack of knowledge about the risks of using anticholinergic medications in people with dementia were highlighted. Community pharmacists were found to lack knowledge about anticholinergic burden in dementia, did not use any anticholinergic burden scales in the course of their practice, and rarely discussed anticholinergic burden with patients, carers, or other healthcare professionals. However, they were positive about their role in future interventions to manage anticholinergic burden in patients with dementia as part of a multidisciplinary primary healthcare team. The low response rate achieved in this study (15%) limited the generalisability of these findings to the wider community pharmacist population. The scoping review identified common reasons for exclusion of people with dementia from clinical trials, recruitment approaches utilised, and reasons why people with dementia discontinued their participation in clinical trials.Discussion and conclusion: The research presented in this thesis has identified a lack of high-quality evidence for interventions to reduce anticholinergic burden in people with dementia in primary care. Work is also needed to address community pharmacists’ and carers’ knowledge deficits about anticholinergic burden in people with dementia. Whilst further research is needed to develop, implement and evaluate interventions to reduce anticholinergic burden among PwD in primary care, researchers need to carefully consider how people with dementia can be included and retained in clinical trials to ensure that these interventions can be fully evaluated in the target population.

Thesis embargoed until 31st July 2026
Date of AwardJul 2024
Original languageEnglish
Awarding Institution
  • Queen's University Belfast
SponsorsAl-Zaytoonah University of Jordan
SupervisorHeather Barry (Supervisor), Carmel Hughes (Supervisor) & Bernadette McGuinness (Supervisor)


  • Dementia
  • Anticholinergic
  • primary care

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