OBJECTIVES: No consensus has been reached regarding which anticholinergic scoring system works most effectively in clinical settings. The aim of this population-based cohort study was to compare the impact of anticholinergic burden, as defined by different scales, on emergency room visits, all-cause hospitalization, fracture-specific hospitalization and incident dementia among older people. METHODS: From Taiwan’s Longitudinal Health Insurance Database, we retrieved monthly information about anticholinergic drug use measured by the Anticholinergic Risk Scale (ARS), Anticholinergic Cognitive Burden Scale (ACB) and Drug Burden Index - Anticholinergic component (DBI-Ach) for 116,043 people aged 65 and older during a 10-year follow-up. We used generalized estimating equations (GEE) to examine the association between anticholinergic burden and adverse outcomes, and stratified by age (65-74, 75-84, 85+). RESULTS: In the first year after cohort enrollment, the average monthly anticholinergic burden measured by the ARS, ACB and DBI-Ach was 0.26, 0.60 and 0.04, respectively. Compared to the ARS and DBI-Ach, the ACB showed a strong dose-response relationship with risk for each of the adverse outcomes, particularly in people aged 65-84. For example, in people aged 65-74, ACB scores = 1-4+, emergency room visits: adjusted odds ratio (aOR) ranged from 1.41-2.25, all-cause hospitalization: aOR ranged from 1.32-1.92, fracture-specific hospitalization: aOR ranged from 1.10-1.71, incident dementia: aOR ranged from 3.13-10.01).  CONCLUSIONS: The ACB scale is more selective than the ARS and the DBI-Ach in identifying medications likely to cause adverse outcomes, including emergency room visits, all-cause hospitalization, fracture-specific hospitalization and incident dementia in the elderly.