Introduction and Hypothesis <p>The objective of this study is to quantify baseline Anticholinergic Cognitive Burden (ACB) scores among women presenting to a urogynecology practice with overactive bladder (OAB) symptoms and to examine patient characteristics associated with higher baseline ACB scores.</p> Methods <p>This retrospective study included women 18 years of age and older presenting as a new patient for evaluation of OAB at an academic urogynecology practice in 2022. A total of 242 patients met the inclusion criteria. Patient baseline characteristics, including medications, were abstracted from the electronic medical record. ACB scores were assessed using a validated four-point scale. OAB treatment after the initial visit was also abstracted.</p> Results <p>The median ACB score was 1, with 37% of patients having a high-risk ACB score (≥3). Anticholinergics were prescribed to 3% of patients, with 71% of these having high-risk baseline ACB scores. Beta-3 agonists were prescribed to 15%, with 46% of these having high-risk baseline scores. Forty-three percent of patients prescribed beta-3 agonists did not initiate therapy owing to cost. High-risk ACB scores were associated with comorbidities such as hypertension, diabetes, anxiety, and depression. Patients with high-risk ACB scores were more likely to receive sacral neuromodulation.</p> Conclusions <p>Many women with OAB have high-risk baseline ACB scores. Although anticholinergics remain commonly prescribed, their cognitive risks necessitate careful patient assessment. Increasing use of safer alternatives such as beta-3 agonists and addressing cost barriers can improve OAB management. Future research should focus on reducing anticholinergic use and addressing inequity in treatment access.</p>