By Hannah Grice, PharmD
The Beers Criteria®1 is a leading source of expert information about potentially inappropriate medications (PIM) in older adults. While these medications are generally harmless in young patients, they can have detrimental effects in older adults. Physicians and pharmacists can easily overlook misuse of these drugs, as many are readily available to patients who purchase over the counter (OTC). As an example, Beers criteria identifies first-generation antihistamines’ ability to block receptors and increase the risks of dementia in older adults. Having Benadryl® in a household is relatively common—yet, its long-term effects are not usually a consideration.
Adverse drug events (side effects) such as dry mouth, constipation, dizziness, confusion, depression, and falls have been linked to PIM2. Older adults are more susceptible to adverse reactions with anticholinergic medications. This class of medicines acts on muscarinic receptors in the central nervous system and blocks acetylcholine neurotransmission. Acetylcholine is involved in many daily functions, including cognition (thinking and awareness). Attention, learning and memory mechanisms are all affected by acetylcholine. In addition, it is involved in the peripheral nervous system (PNS) actions which are related to urination, intestinal movement and heart rhythm regulation. These drugs may bind exclusively to muscarinic receptors or may also bind with additional receptors causing various adverse effects. Anticholinergic medications may be used in many different disease states, ranging from seasonal allergies, motion sickness, and urinary incontinence to Parkinson’s disease and irritable bowel syndrome. With ®acetylcholine so heavily involved in major functions of the body, it is not surprising that they can lead to adverse effects in older adults.
Despite the known adverse effects of these medicines in older adults, they are still commonly prescribed or the patient purchases OTC and takes them unmonitored. One study showed that in a group of patients with mild cognitive impairment or dementia, 44.7% of the patients were taking anticholinergic drugs. Similarly, 11.7% of these patients were receiving a high anticholinergic load or burden. Although these medications may not cause adverse effects in every older adult, they still carry risk and should be avoided if possible. The table below lists PIM from the Beers Criteria and provides therapeutic alternatives.
Tips for avoiding anticholinergic adverse effects
Always encourage patients to try non-pharmacological therapy before starting an anticholinergic medication. Secondly, speak with a pharmacist before starting any new medications. Lastly, if starting a new anticholinergic medication, take the smallest effective dose for the shortest time needed.
PharmD Live combines a clinical pharmacist-led approach to monitoring patients using AI-driven telehealth technology and predictive analytics to deliver true value-based care and keep patients safe from medication misuse. Having a pharmacist review your patient’s medicines regularly can avoid these kinds of adverse drug events. Contact PharmD Live to learn about how you can take advantage of this care solution, and set up your patients and practice for success.
| Class of Medications | Beers Drugs with Strong Anticholinergic Properties (Names noted in bold are commonly used) | Alternatives |
| Antiarrhythmic | Disopyramide | Beta-blockers Diltiazem |
| Antidepressants | Amitriptyline Amoxapine Clomipramine Desipramine Doxepin (> 6 mg) Imipramine Nortriptyline Paroxetine Protriptyline Trimipramine | Sertraline Citalopram |
| Antiemetics | Prochlorperazine Promethazine | Evaluate risk vs. benefit |
| Antihistamines (first generation) | Brompheniramine Carbinoxamine Chlorpheniramine Clemastine Cyproheptadine Dexbrompheniramine Dimenhydrinate Diphenhydramine Doxylamine Hydroxyzine Meclizine Clidinium-chlordiazepoxide Dicyclomine Homatropine (excludes ophthalmic) Hyoscyamine Methscopolamine Propantheline Promethazine Pyrilamine Triprolidine | Cetirizine and loratadine still have anticholinergic effects but to a lesser extent |
| Antimuscarinics | Darifenacin Fesoterodine Flavoxate Oxybutynin Solifenacin Tolterodine Trospium | For urinary incontinence, try: weight loss, scheduled voiding, kegel exercises |
| Antiparkinsonian agents | Benztropine Trihexyphenidyl | Evaluate risk vs. benefit |
| Antipsychotics | Chlorpromazine Clozapine Loxapine Olanzapine Perphenazine Thioridazine Trifluoperazine | *Try non-pharmacological first: music therapy, pet therapy, assist with activities of daily living, relieve discomfort, etc. Atypical antipsychotics are better choice |
| Antispasmodics | Atropine (excludes ophthalmic) Belladonna alkaloids Scopolamine (excludes ophthalmic) | Evaluate risk vs. benefit |
| Skeletal muscle relaxants | Cyclobenzaprine Orphenadrine | Try multi-modal approach with non-pharmacological therapy and pharmacological therapy Start at lowest effective doses for pain medications Yoga, tai-chi |
Additional reading regarding Beers Criteria:
References:
- American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. https://pubmed.ncbi.nlm.nih.gov/30693946/.
- López-Álvarez J, Sevilla-Llewellyn-Jones J, Agüera-Ortiz L. Anticholinergic Drugs in Geriatric Psychopharmacology. Front Neurosci. 2019;13:1309. Published 2019 Dec 6. doi:10.3389/fnins.2019.01309
