Anticholinergic Syndrome Management

Clinical Presentation

The anticholinergic syndrome presents with central and peripheral manifestations, including agitated delirium, confusion, disorientation, hallucinations, anxiety, seizures, tachycardia, mild hyperthermia, mydriasis, dry mucous membranes, hot and dry skin, urinary retention, and decreased bowel sounds, as identified by the American College of Medical Toxicology 1

The American Academy of Clinical Toxicology recommends immediately stopping all anticholinergic medications that may be contributing to the syndrome, with common culprits including first-generation antihistamines, muscle relaxants, overactive bladder agents, tricyclic antidepressants, phenothiazines, and anticholinergics used to manage antipsychotic side effects 1, 2, 3
Physostigmine is the antidote of choice for severe anticholinergic toxicity, with a recommended dosing of 0.5-1 mg IV in adults and 0.01-0.02 mg/kg in children, according to the American College of Medical Toxicology 1

In elderly patients, anticholinergic medications are particularly problematic due to baseline cognitive impairment and reduced physiologic reserve, and strongly anticholinergic medications should be avoided entirely, as recommended by the American Geriatrics Society 1, 3
The Mayo Clinic recommends avoiding benztropine or trihexyphenidyl entirely in elderly patients with Alzheimer's disease on antipsychotics 3