(Editors Note: Earlier this week, I received a phone call from an older IC patient who was suffering from severe side effects while using Amitriptyline. While it was helping reduce her pain, she was struggling with side effects. In talking with her, one thing that I noticed was that she was having trouble following the conversation. She wasn’t sharp, nor was she functioning well cognitively. She also lacked inspiration to try pretty much any self-help tip. I had to wonder if she was struggling with a well known complication to anticholinergic medications which, if taken in large quantities, have been proven to affect brain function in older patients. I think it’s worth reprinting this article, first published in the IC Optimist magazine in Spring 2012.  – Jill Osborne)

seniorsanticholinergicriskDid you know that several of the medications commonly prescribed for bladder disorders, known as anticholinergics, can adversely affect brain function? Anticholinergics block acetylcholine, a chemical messenger that plays a critical in memory and cognitive function. Amitriptyline, oxybutynin, hydroxyzine and even some over the counter cold medicines such as Tylenol PM can have anticholinergic effects.

In 2012, a New York Times article (“Cocktail of Popular Drugs May Cloud Brain”) brought this issue to the forefront by discussing a new study from England which followed 13,000 men and women, 65 years or older, for two years and found that those taking more than one anticholinergic drug scored lower on tests of cognitive function than those who were not using any such drugs.(1)

According to the NY Times, at least 20% of the 36 million Americans 65 years or older take at least one anti-cholinergic medication. We asked Robert Moldwin MD for his take on this issue. He said “Anticholinergic agents are well-known to have CNS effects. Most individuals taking agents such as ditropan, sanctura, etc. have little if any notable effect. If a patient does has some effect, they can simply stop the medication. Most clinicians worry about the use of these agents in the elderly or in those with preexisting mental status changes.” 

The challenge, however, is that many different medications can have anticholinergic properties which can cumulatively add to a patient’s risk. A study of approximately 4000 older adults in Indianapolis found that patients who used three or more of these drugs for 90 days or longer were nearly three times as likely to experience mild cognitive impairment than someone who had not taken any.(2)

The Anticholinergic Burden List was developed by scientists at the Regenstrief Institute and can be used to assess this risk by ranking drugs based upon their anticholinergic activity.(3) A score of zero means no effect while a score of 3 is for severe effects. Some of the medications used by IC patients are scored as follows:

Score of 1: Possible Anticholinergic Effect

  • Cimetidine (Tagamet)
  • Codeine
  • Diazepam (Valium)
  • Fentanyl
  • Morphine
  • Prednisone

Score of 2: Definite Anticholinergic Effect

  • Cyclobenzaprine (Flexeril)
  • Meperidine (Demerol)

Score of 3: Definite Severe Anticholinergic Effect

  • Amitriptyline (Elavil)
  • Hydroxyzine (Atarax, Vistaril)
  • Hyoscyamine (Anaspaz)
  • Imipramine (Tofranil)
  • Nortriptyline (Pamelor)
  • Oxybutynin (Ditropan)
  • Tolterodine (Detrol)

If you are 65 years of age or older and/or if you take one or more of these medications on a regular basis, ask your physician to review your prescriptions and evaluate your “cumulative anticholinergic burden.” ACH load can be adjusted in several ways. Dr. Moldwin said “The trick is to limit these side effects often through changes in medications, dosing, dosing intervals, type of application (creams, intravesical instillations, transvaginal/transrectal) and type of therapy (biofeedback, neurostimulation, Botox).”

1. Rabin R. Cocktail of Popular Drugs May Cloud Brain. New York Times Health Science. February 27, 2012 – http://well.blogs.nytimes.com/2012/02/27/cocktail-of-populardrugs-may-cloud-brain/
2. Fox C et al. Anticholinergic medication use and cognitive impairment in the older population: the medical research council cognitive function and ageing study. J Am Geriatr Soc. 2011 Aug;59(8):1477-83. http://www.ncbi.nlm.nih.gov/pubmed/21707557
3. Anticholinergic Cognitive Burden Scale. A publication of the Indiana Discovery Network For Dementia, Regenstrief Institute Inc. 2010 – http://www.indydiscoverynetwork.org/AnticholinergicCognitiveBurdenScale.html