The Brown Bag: Anticholinergic Burden and the Emergencies That Hide
Mr. E is eighty-one, brought in with “worsening dementia”, and his daughter has emptied a carrier bag of medicine bottles onto your table. Tick what is actually in the bag and watch the anticholinergic burden build on the body map beside it — a leading reversible cause of apparent dementia. Then take six older adults whose presentations look alike and tell the emergencies apart.
What is actually in the bag
Include the over-the-counter bottles — they are the ones nobody lists. The number on each is its anticholinergic score; a running total of 3 or more is the level at which confusion, falls and functional decline start to show.
Six older adults. Six emergencies that hide.
Each one arrived on a medical or psychiatric ward looking like “confusion” or “agitation”. Name what is actually happening.
Anticholinergic burden
0
Total anticholinergic score
An empty bag. Tick the bottles on the left.
What you take to the prescriber
A sudden change in mental status in an older adult is delirium until proven otherwise — and the first three things to check are medications, infection and urinary retention. “Sundowning” is a description of timing, never a diagnosis, and it should never stop a work-up.
Discriminators you have unlocked
Answer a case on the left and its one distinguishing feature is written here permanently.
Late-life depression, or dementia?
Cognitive testing during a depressive episode can show genuine deficits — the picture historically called pseudodementia. It matters because it is reversible.
Depression is not a normal part of ageing, and suicide risk in later life is the highest of any age group, particularly in men over seventy-five: fewer attempts, far higher lethality, less warning, and frequent recent contact with a primary care provider. Ask directly, and bring means safety — firearms and stockpiled medication — into the conversation with the patient and, with permission, the family.