Who should not take anticholinergics?

Who Should Not Be On Anticholinergic Medications

Anticholinergic medications should be avoided in older adults, patients with cognitive impairment, dementia risk factors, and those with narrow-angle glaucoma due to their significant adverse effects on cognition, physical function, and overall health. 1

High-Risk Populations Who Should Avoid Anticholinergics

Older Adults

• Older adults experience age-related decline in acetylcholine physiology, making them more susceptible to anticholinergic side effects 2
• Approximately one-third of independent living older adults and half of those in long-term care facilities take potentially unnecessary medications with anticholinergic properties 3
• The Drug Burden Index shows that anticholinergic drugs are associated with decline in cognition, functional status, and activities of daily living scores in older patients 3

Patients with Cognitive Impairment or Dementia

• Anticholinergic medications can cause significant cognitive impairment, including memory problems, confusion, and delirium 1
• Exposure to medications with highly anticholinergic properties should be minimized in older persons with existing cognitive impairment 3
• Anticholinergic burden is a modifiable risk factor for dementia and cognitive decline in older adults 4
• There exists a dose-response relationship between anticholinergic use and increased risk for dementia 4

Patients with Specific Medical Conditions

• Patients with narrow-angle glaucoma should avoid anticholinergics due to risk of acute angle closure 1
• Men with benign prostatic hyperplasia should avoid anticholinergics as they can exacerbate urinary retention 1
• Patients with constipation or gastrointestinal disorders may experience worsening symptoms with anticholinergics 1
• Patients with cardiovascular conditions may experience complications as anticholinergics can worsen hypertension 1

Specific Anticholinergic Medications of Concern

High-Risk Anticholinergic Classes

• Older antihistamines such as diphenhydramine and hydroxyzine have strong anticholinergic effects 1, 2
• Muscle relaxants such as cyclobenzaprine have strong anticholinergic effects and are poorly tolerated in older adults 3, 2
• Overactive bladder medications like oxybutynin have significant anticholinergic burden 3
• Tertiary-amine tricyclic antidepressants (TCAs) like amitriptyline have significant anticholinergic effects 2
• Paroxetine has more anticholinergic effects than other SSRIs and should be avoided in older adults 2

Anticholinergic Burden and Polypharmacy

• The cumulative effect of multiple anticholinergic medications significantly increases risk of adverse outcomes 1, 5
• Anticholinergic burden increases the risk of serious adverse events including injurious falls, episodes of confusion or delirium, emergency department visits, and hospitalizations 2, 6
• Regular assessment and optimization of anticholinergic burden prior to prescribing can minimize anticholinergic-related morbidity 4, 7

Alternative Approaches

• For depression, SSRIs like citalopram, escitalopram, and sertraline have fewer anticholinergic effects than TCAs or paroxetine 2
• For allergies, second-generation antihistamines have fewer anticholinergic effects than first-generation options 1, 2
• For overactive bladder, consider topical anticholinergic agents rather than systemic ones to minimize cognitive side effects 1
• Alternative medications should be used for specific indications where medications with anticholinergic properties are indicated (e.g., depression, neuropathic pain, urge type urinary incontinence) 3

Clinical Recommendations

• Regularly review medication regimens to identify and reduce anticholinergic burden, particularly in older adults 1, 6
• When anticholinergic medications cannot be avoided, use the lowest effective dose for the shortest duration possible 1
• Consider deprescribing anticholinergic medications in older adults to potentially reverse adverse effects and prevent problems such as falls 6, 8
• Avoid combining anticholinergics with benzodiazepines, sedative-hypnotics, or other CNS depressants as this increases risk of adverse effects 2, 9
• Multidimensional health assessment for older adults, including medication review, is recommended to identify reversible conditions and rationalize medication use 3