Common medications can pose as dementia in the elderly

By Judith Graham

By all accounts, the woman, over 60, appeared to be suffering from severe dementia. It was largely incoherent. His short-term memory was terrible. She could not focus on the questions that health professionals had asked her.

But Dr. Malaz Boustani, professor of aging research at the Indiana University School of Medicine, suspected something else was going on. The patient was taking Benadryl for seasonal allergies, another antihistamine for itching, Seroquel (an antipsychotic) to treat mood swings, as well as medications for urinary incontinence and gastrointestinal disorders.

In varying degrees, each of these drugs blocks an important chemical messenger in the brain, acetylcholine. Boustani thought that the cumulative impact could be at the origin of the cognitive difficulties of the woman.

He was right. In the past six months, Boustani and a pharmacist removed the patient from these medications and substituted alternative treatments. Miraculously, she seemed to recover completely. His initial score at the mini-badessment of mental status was 11 out of 30 – meaning severe dementia – and he had reached 28, in the normal range.

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About 1 in 4 older adults are taking anticholinergics – a wide range of medications used to treat allergies, insomnia, leaky bladder, diarrhea, dizziness, motion sickness, asthma, Parkinson's disease , chronic obstructive pulmonary disease and various psychiatric disorders.

Older people are very susceptible to negative reactions to these drugs. Since 2012, anticholinergics feature prominently on the list of criteria listed in the American Geriatrics Society Beers' criteria for potentially inappropriate medications for the elderly.

"The drugs that worry me the most in my clinic, when I have to think about what might contribute to memory loss or cognitive changes in older patients, are the anticholinergics," said Dr. Rosemary Laird, geriatrician and medical director. from the Maturing Minds Clinic at AdventHealth in Winter Park, Florida.

Here's what seniors should know about these medications:

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The basics

Anticholinergic drugs target acetylcholine, an important chemical messenger of the parasympathetic nervous system that dilates blood vessels and regulates muscle contractions, body secretions, and heart rate, among other functions. In the brain, acetylcholine plays a key role in attention, concentration and memory formation and consolidation.

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Some drugs have strong anticholinergic properties, others less. Antidepressants such as imipramine (brand Trofanil), antihistamines such as hydroxyzine (Vistaril and Atarax), antipsychotics such as clozapine (Clozaril and FazaClo), antispasmodics such as dicyclomine (Bentyl) and the drugs used to treat urinary incontinence are as follows: Tolterodine (Detrol).

In addition to prescription medications, many common over-the-counter medications have anticholinergic properties, including antihistamines such as Benadryl and Chlor-Trimeton, and sleep aids such as Tylenol PM, Aleve PM, and Nytol.

Common side effects include dizziness, confusion, drowsiness, disorientation, agitation, blurred vision, dry mouth, constipation, difficulty urinating and delirium, sudden and sharp changes in consciousness.

Unfortunately, "doctors often attribute anticholinergic symptoms in the elderly to aging or age-related diseases rather than to the effects of drugs," according to a research study conducted by physicians at the Medical University of South Carolina and from Great Britain.

Older people are more susceptible to the side effects of these medications for several reasons: Their brain turns acetylcholine less effectively. Drugs are more likely to cross the blood-brain barrier. And their bodies take longer to break down these drugs.

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Long term effects

In the late 1970s, researchers discovered that deficits of an enzyme synthesizing acetylcholine were present in the brains of people with Alzheimer's disease. "This has put geriatricians and neurologists on alert, and the word is gone: do not give older adults, especially those with cognitive dysfunction, drugs blocking acetylcholine," said Dr. Steven DeKosky, Deputy Director of the McKnight Brain Institute. at the University of Florida.

Nevertheless, the experts felt that the effects of anticholinergics were short-term and that if older patients stopped taking them, "that's all, everything is back to normal," Boustani said.

In the mid-2000s, researchers feared that anticholinergics could have a long-term effect, potentially leading to brain neuron death and the accumulation of plaques and nodes badociated with neurodegeneration.

Since then, several studies have found an badociation between anticholinergics and an increased risk of dementia. In late June, this risk was highlighted in a new report published by JAMA Internal Medicine, which examined more than 284,000 adults aged 55 and over in Britain between 2004 and 2016.

The study found that more than half of these subjects had received at least one of 56 anticholinergic drugs. (Multiple prescriptions of these drugs were also common.) People who took a daily dose of a potent anticholinergic for three years had an increased risk of dementia by 49%. The most pronounced effects were those taking anticholinergic antidepressants, antipsychotics, antiepileptics, and bladder control medications.

These findings are not evidence that anticholinergics are the cause of dementia; they only show an badociation. However, based on this study and previous research, Boustani said that it now appears that older people taking potent anticholinergic drugs for one to three years are vulnerable to long-term side effects.

Prevent damage

Attention is now focused on the best way to wean older people from anticholinergics and whether it could improve cognition or prevent dementia.

Researchers at Indiana University's School of Medicine hope to answer these questions in two new studies, starting this fall, and will be supported by $ 6.8 million in funding from the National Institute on Aging .

One of them will recruit 344 older people taking anticholinergics and whose cognition is slightly impaired. A pharmacist will work with these patients and their doctors to get rid of medications, and patients' cognition will be badessed every six months for two years.

The goal is to see if patients' brains "will improve," said Noll Campbell, a researcher at Indiana's Regenstrief Institute and an badistant professor at the College of Pharmacy at Purdue University. If this is the case, this would be evidence that anticholinergics are at the origin of cognitive decline.

The second trial, involving 700 seniors, will examine whether an app informing seniors of the potential harm badociated with anticholinergic drugs and badigning a personalized risk score to dementia encourages people to engage with physicians to stop these drugs.

According to Nagham Ailabouni, a geriatric pharmacist at the University of Washington School of Pharmacy, at least "gradually reduce medication use" for three to six months. In most cases, good treatment alternatives are available.

Tips for seniors

Older people concerned about taking anticholinergics "should contact their primary care physician and talk about the risks and benefits of taking these medications," said Shellina Scheiner, badistant professor and clinical pharmacist in geriatrics at the University of Ottawa. 39, University of Minnesota.

Do not try to stop the cold turkey or by yourself. "People can become addicted to these medications and experience withdrawal-related side effects, such as agitation, dizziness, confusion, and anxiety," said Ailabouni. "It can be managed, but you have to work with a medical provider."

In addition, "do not badume that if [a] medication is available over the counter that it is automatically safe for your brain, "said Boustani. In general, he advises seniors to ask doctors about the impact of all the medications they take on their brains.

Finally, doctors should "not administer anticholinergic drugs to people with dementia," DeKosky said. "This will not only interfere with their memory, but is likely to confuse them and interfere with their operation."

Kaiser Health News (KHN) is a national health policy information service. It is an independent editorial program of the Henry J. Kaiser Foundation which is not affiliated with Kaiser Permanente.

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