Bad Drugs

Mrs. S is an 83 year old lady I met today for the first time at one of my nursing homes. I was consulted to evaluate her symptoms of confusion, worsening memory, and depression.

She was a recent admission from a local hospital, and was there for rehab. She presented at the hospital ER for a decline in functioning, problems with balance, dizziness, and falls. She was subsequently admitted. Her granddaughter, who is a nurse, had requested the evaluation.

Mrs. S appeared her stated age, and was not in the friendliest of moods. She had significant deficits in memory, naming, concentration, and was somewhat confused. Her granddaughter helped with most of the history.

She was taking an antidepressant called celexa, 2 blood pressure meds, an Exelon Patch (a medication for dementia), thyroid hormone, vesicare for incontinence, and xanax 3 times a day for anxiety. The Exelon patch had just been recently started at the hospital for her worsening memory.

According to studies, this is a typical scenario.

Mrs. S is an elderly person who starts having problems with incontinence. She goes to her primary care doctor or urologist who starts her on Vesicare. And initially all is good. Mrs. S is happy she is not having any more accidents and life goes on. But in couple of weeks things begin to change. And Mrs. S is not feeling so good. Mild symptoms initially, a little dizzy, somewhat unsteady on her feet, a bit more confused, memory getting worse. As the days pass she gets worse, and pretty soon she has a fall, and then another.

All medications for urinary incontinence belong to a class of drug called ANTICHOLINERGICS. These medications can cause significant side effects in the older population including confusion, hallucinations, constipation, falls, etc. Anticholinergics directly oppose the action of one of the most important neurotransmitters in the entire nervous system, Acetylcholine.

Medications like Aricept, Razadyne, and Exelon work by increasing the levels of Acetylcholine in the brain. So when you add an anticholinergic, you are basically making the medicines useless and many times making things altogether worse. On one end you are throwing water on the fire, and on the other end gasoline.

Unfortunately anticholinergics are not just prescription medications. There are several over the counter anticholinergics that anyone over 60 years old, or with cognitive problems should avoid. Common OTC anticholinergics are: benadryl (diphenhydramine)-found in Tylenol PM and many generic allergy and sleep aids. Stomach medications like Zantac, Pepcid, and Tagamet are also anticholinergic. Examples of anticholinergic prescription medications are: Detrol, Ditropan, Atarax, Flexeril, Soma, Vesicare, and Elavil. This is of course an incomplete list, but it’s a good start.

The Beers Criteria (or Beers List) provide a list of medications that are generally considered inappropriate when given to elderly people because these medications may pose more risk than benefit. Drugs are considered for the list when the side effect profile is unacceptable, when they are inferior to alternatives, or when medication dynamics (metabolism etc) are altered in elderly. It is certainly worth checking it out online at http://www.dcri.duke.edu/ccge/curtis/beers.html.

There are several studies linking use of anticholinergics in the elderly with poor outcomes. Delirium, confusion, hallucinations, worsening of cognition, falls and broken hips are all well documented. Even non-demented elderly persons who take anticholinergics can develop a syndrome indistinguishable from Mild Cognitive Disorder.

In the case of your wife, she was already taking 2 mildly anticholinergic drugs, Lasix and Digoxin. When the highly anticholinergic drug Detrol was added, her “anticholinergic load” increased significantly and she started experiencing anticholinergic side effects. Studies indicate that the higher the anticholinergic load, the higher the risk for side effects.

Avoiding anticholinergic drugs is one of the easiest, yet most important things we can do for our cognitive health.