Is Cogentin (Benztropine) safe to use in patients over 70 years old?

Use of Cogentin (Benztropine) in Patients Over 70 Years Old

Cogentin (benztropine) should generally be avoided in patients over 70 years old due to increased risk of anticholinergic side effects, cognitive impairment, and falls in this population. The risks typically outweigh the benefits in elderly patients.

Anticholinergic Risks in Elderly Patients

• Anticholinergic medications like benztropine have significant, often severe side effects in elderly patients involving the cholinergic, cardiovascular, and extrapyramidal systems 1
• Elderly patients (>70 years) are more susceptible to adverse drug effects due to altered pharmacokinetics and pharmacodynamics, including:
  • Reduced drug elimination
  • Decreased renal function
  • Increased sensitivity to medications 2
• Anticholinergic side effects are particularly problematic in older adults and can include:
  • Confusion and cognitive impairment
  • Dry mouth
  • Urinary retention
  • Constipation
  • Blurred vision
  • Increased risk of falls 1, 3

Alternative Approaches for Managing EPS in Elderly

• If an antipsychotic is needed and EPS management is a concern, consider using antipsychotics with lower EPS risk profiles:

  • Quetiapine has the lowest risk of EPS among commonly used antipsychotics and should be considered first-line when EPS is a concern 1
  • Aripiprazole is described as "less likely to cause EPS" but requires careful dosing (starting at 5mg) 1
  • Olanzapine has moderate EPS risk but generally good tolerability in elderly patients 1

• If an anticholinergic must be used for EPS management in elderly patients:

  • Use the lowest effective dose for the shortest possible duration 1
  • Monitor closely for anticholinergic side effects
  • Consider behavioral interventions before pharmacological treatment 1
  • Daily evaluation with in-person examination is recommended 1

Specific Concerns with Benztropine in Elderly

• Benztropine has been associated with increased risk of tardive dyskinesia compared to other anticholinergic agents 4
• Withdrawal of benztropine can potentially lead to withdrawal-emergent dyskinesia, which could be particularly problematic in elderly patients 5
• The combination of history of falls and dependency in activities of daily living (common in elderly patients) defines a condition of particular vulnerability to adverse drug reactions 3

Monitoring Recommendations if Use Cannot be Avoided

• If benztropine must be used in a patient over 70 years old:
  • Start with the lowest possible dose
  • Monitor for orthostatic hypotension, especially during initial dose titration 1
  • Avoid combining with benzodiazepines or other sedative medications 1
  • Evaluate renal function before initiating therapy 2
  • Monitor for cognitive changes, urinary retention, constipation, and vision changes 6
  • Regularly reassess the need for continued therapy 2

Conclusion

Given the high risk of adverse effects and the availability of safer alternatives, benztropine should generally be avoided in patients over 70 years old. If treatment for EPS is necessary, consider using an antipsychotic with a lower EPS risk profile rather than adding an anticholinergic medication.