Summary
Highlights
Dr. Leslie Kernisan, a board-certified geriatrician, introduces anticholinergic medications as a top concern for older patients, especially those with memory issues. She explains that these drugs slow brain function, cause or worsen memory loss, and are linked to Alzheimer's and other dementias. Despite these known risks, they are widely prescribed, including many common over-the-counter options like Benadryl. Dr. Kernisan notes that neither most older adults nor many doctors are aware of these risks, making it crucial for individuals and families to understand and identify these medications.
Anticholinergics block the effects of acetylcholine, a vital neurotransmitter for brain cell communication involved in thinking, memory, and cognitive functions. Outside the brain, acetylcholine is crucial for the parasympathetic nervous system, which regulates 'rest and digest' functions. Blocking it can lead to side effects like dry eyes, dry mouth, and constipation. More concerning are the brain effects: decreased brain function, sedation, worsened memory loss, and increased fall risk in older, vulnerable brains. These drugs have the opposite effect of medications like Aricept (donepezil), which aim to boost acetylcholine in Alzheimer's patients.
The first type of common anticholinergic medication discussed are sedating antihistamines, such as diphenhydramine (Benadryl). Non-sedating antihistamines like loratadine (Claritin) are safer for older adults. The second type includes 'PM' versions of over-the-counter painkillers like Tylenol PM or Advil PM, which contain sedating antihistamines (diphenhydramine or doxylamine) as mild sedatives. These are strongly anticholinergic. For pain management, it's advised to take a straight painkiller and discuss sleep issues with a doctor for safer alternatives.
Medications for overactive bladder, such as oxybutynin (Ditropan), tolterodine (Detrol), and solifenacin (Vesicare), are the third type of anticholinergic. These drugs relax the bladder by blocking acetylcholine, which is heavily involved in bladder function. While common for urinary issues in older adults, they are significantly anticholinergic. Dr. Kernisan recommends exploring alternative management strategies with a healthcare provider, particularly for those with memory loss symptoms, before using these medications chronically.
The fourth category includes medications for vertigo, motion sickness, or nausea, such as meclizine (Antivert) and dimenhydrinate (Dramamine). Meclizine, often used for benign positional vertigo, can be replaced by physical therapy. Dr. Kernisan shares an example of a patient who was taking meclizine for dizziness caused by low blood pressure, illustrating the importance of identifying the true cause of symptoms. Occasional use of these medications might be acceptable, but frequent use should be reconsidered.
The fifth type comprises medications prescribed for itching, often strong oral antihistamines like diphenhydramine (Benadryl) or hydroxyzine (Vistaril). Topical creams or addressing dry skin with moisturizers may be safer alternatives. The sixth type is an older class of antidepressants, tricyclic antidepressants (TCAs), such as amitriptyline (Elavil) and nortriptyline (Pamelor), which are sometimes prescribed for nerve pain. Newer, safer medications exist for nerve pain and depression. The shingles vaccine is recommended over TCAs for preventing post-herpetic neuralgia.
The seventh type of anticholinergic medication is muscle relaxants, commonly prescribed for back or neck pain, with cyclobenzaprine (Flexeril) being a prime example. These are quite anticholinergic and should be used cautiously, as other methods can often manage pain effectively. In addition, paroxetine (Paxil), an SSRI antidepressant, is an anticholinergic outlier within its class. Geriatricians typically avoid prescribing it, preferring safer SSRIs like escitalopram (Lexapro), citalopram (Celexa), or sertraline (Zoloft) for older adults.
Three groups should prioritize avoiding anticholinergics: individuals concerned about current memory/thinking, those diagnosed with mild cognitive impairment or dementia, and people aiming to minimize future Alzheimer's risk. The risk is associated with cumulative use (duration and dose). For those taking over-the-counter anticholinergics, stopping them is generally safe. For prescribed medications, consult a healthcare provider or pharmacist to explore alternatives, reduce dosage, or switch to safer options. If an anticholinergic is deemed necessary, focus on other strategies to maintain cognitive health, as benefits may outweigh risks when no suitable alternatives exist.