Anticholinergic medications associated with falls and frailty in people ageing with HIV

Dr Jessica Doctor (bottom right) at CROI 2022.

The use of anticholinergic medication is associated with recurrent falls in people living with HIV, Dr Jessica Doctor from Guy’s and St Thomas’ Hospital in London told the virtual Conference on Retroviruses and Opportunistic Infections (CROI 2022) yesterday. Anticholinergics also appeared to be associated with frailty.

Anticholinergic medications are commonly prescribed to treat mental health conditions, urinary incontinence and allergies. However, many different medications confer some degree of anticholinergic effect. In fact, what these drugs have in common is that they block a body chemical – acetylcholine – which is involved in major functions of the nervous system, such as attention, urination, intestinal transit and heart rhythm regulation.

Anticholinergics have well-known side effects, from dry mouth to urinary retention and cognitive impairment. In the general ageing population, their long-term use is also associated with poorer age-related outcomes, including falls and frailty. Additionally, the drugs have been associated with cognitive dysfunction.

Could these risks increase in ageing people with HIV, among whom 15 to 30% are thought to use anticholinergics? Jessica Doctor and colleagues tested this question by investigating associations of anticholinergics with falls and frailty among older people with HIV who participate in POPPY.

POPPY is an observational cohort study examining the effects of ageing on the clinical outcomes of people with HIV in the UK and Ireland. This analysis focused on the group of older people living with HIV, aged over 50, in the cohort.

A total of 699 patients were included in the cross-sectional analysis. All medications other than antiretrovirals that they received on entering the study were scored for their anticholinergic potential, using three relevant scales, and each medicine that scored ≥1 was considered anticholinergic.  

Data were collected on recurrent falls (more than two self-reported falls in the previous month) and frailty (more than three criteria in the modified Fried Frailty Index: unintentional weight loss, exhaustion, low energy expenditure, low grip strength, and slow walking speed). Associations with recurrent falls and frailty were assessed, adjusting for covariates which could act as confounders: demographic/lifestyle factors, the number of non-anticholinergic medications, co-morbidities and depressive symptoms.

Participants had a median age of 57, 88% were male, 86% White and 14% unemployed. Almost all (99%) participants were on antiretroviral therapy, 92% had a suppressed viral load and 89% had a CD4 count over 350.

Recurrent falls were reported by 63 of 673 participants (9%), while 126 out of 609 (21%) met the frailty criteria. Taking an anticholinergic medication was reported by 123 patients (27%), with 63 (9%) receiving at least two of these drugs.

The most commonly prescribed anticholinergics were:

  • Codeine (12%).
  • Citalopram (12%).
  • Loperamide (9%).
  • Amitriptyline (7%).

Compared to non-users, participants using any anticholinergic medication were more likely to be single (69% vs 60%, p = 0.01), unemployed (17% vs 13%, p = 0.05), and use recreational drugs (31% vs 23%, p = 0.05). They were also more likely to have severe depressive symptoms (16% vs 10%, p = 0.001), a higher number of co-morbidities (4.19 vs 2.76, p < 0.001) and take more than five non-anticholinergic co-medications (70% vs 44%, p = <0.001).

Those using anticholinergic drugs were more likely to report falls (17% vs 6% in non-users, p < 0.001) and to meet the frailty criteria (32% vs 17%, p < 0.001). This was confirmed after adjustment for demographic, lifestyle and clinical factors: odds ratio 1.9 (95% CI 0.9-0.4, p = 0.08) for falls, and OR 1.7 (95% CI 0.9-3.0, p = 0.08) for frailty.

The risk of recurrent falls increased significantly when two or more anticholinergic drugs were taken (OR 3.6; 95% CI 1.4-9.4). This was after adjusting for demographic, lifestyle and clinical factors. Although of borderline statistical significance, the same trends were observed with regards to frailty.

Jessica Doctor said these findings are in line with most existing worldwide data from the general geriatric population. As anticholinergic drugs are prescribed in a quarter of people with HIV, she advised that clinicians be aware of the association of these drugs with falls and frailty, and stop prescriptions for them wherever possible. 


Doctor J et al. Anticholinergic medications associated with falls and frailty in people with HIV. Conference on Retroviruses and Opportunistic Infections, abstract 35, 2022.

View the abstract on the conference website.