Overview
In 2020, in terms of our aging population in the United States, there were approximately 47 million adults ages 65-84 and 7 million adults ages 85 and older. In 2040, the number of adults that are 85 and older is expected to double with about 15 million people falling into this category and ages 65-84 continuing to increase to approximately 65 million adults.
With this aging population, we can expect to see an increase in health conditions such as dementia, chronic obstructive pulmonary disease (COPD), urinary incontinence, depression, sleep disorders, and more. To treat these conditions, medications are commonly prescribed with the thought to improve the functions of daily living. Unfortunately, many of the medications that are prescribed have anticholinergic properties and may result in adverse effects in the elderly population. These side effects could potentially contribute to a patient’s physical and mental decline. Pharmacists play an important role in recognizing high-risk medications and recommending alternative pharmacological and non-pharmacological agents that could be safer in the elderly patient population.
Understanding Anticholinergic Medications
Acetylcholine is a neurotransmitter that allows communication between neurons in the body and contributes to muscle movement, memory, learning, glandular secretion, and more. Anticholinergic medications work by blocking acetylcholine from binding primarily to the muscarinic receptors and to a small degree, nicotinic receptors. Medications with anticholinergic effects result in relaxation of smooth muscles as well as reducing the production of bodily secretions. Below are some frequently prescribed anticholinergic medications.
While not explicitly stated in the Beers Criteria, we also frequently see medications that are used for overactive bladder and urinary incontinence being prescribed in older adults. These include medications such as oxybutynin, tolterodine, and solifenacin, just to name a few. As previously explained, these medications relax the smooth muscle of the bladder to cause urinary retention.
The Beers Criteria Explained
The Beers Criteria is a list created by the American Geriatrics Society (AGS) on potentially inappropriate medications in adults who are 65 and older. The aim is to help guide practitioners in choosing safe medications for older adults. It is important to keep in mind that this is just a general list – it is not patient specific. Practitioners must use their clinical judgement when recommending and prescribing medications on the Beers Criteria in a patient-centered approach. This list is updated every 3 years, with the most recent update being in 2023. As of today, the AGS has not yet released the 2026 version.
Recognizing the Anticholinergic Risk
Anticholinergic medications affect the central nervous system (CNS). These central effects can lead to confusion, delirium, cognitive dysfunction, memory issues, dizziness, and sedation. This is of big concern with our older population because it puts the patients at risk of falls and potential memory problems. In addition to affecting the CNS, anticholinergic medications also impact the peripheral nervous system. The peripheral effects can lead to “drying” effects as we commonly describe to patients. This includes urinary retention, constipation, blurry vision, and dry mouth. These effects are often bothersome to most patients.
Some patients may be on multiple high-risk medications. This can lead to something called an “anticholinergic burden”. If patients are on these kinds of medications long-term, it could also lead to an “anticholinergic burden”. A tool has been created to assess a patient’s risk of this effect, and it is called the “ACB Scale”. If a patient scores 3 or higher, then this puts them at higher risk of mortality and cognitive impairment.
What Makes Older Adults So Vulnerable?
As people age, the body starts to make less acetylcholine, and due to the mechanism of action described above, this results in a higher proportion of acetylcholine being blocked with anticholinergic medications. This leads to more potent effects in the elderly population. Additionally, a reduction in metabolism and excretion through the liver and kidney occurs as people age which can cause accumulation of anticholinergic medications and increasing effects. Lastly, the blood brain barrier becomes more permeable with age, resulting in the CNS effects described previously.
Potential Dementia Risks
While a direct link between anticholinergic medications and dementia has not been found, several studies have noted an association between patients who take anticholinergic medications and developing dementia. One study in Harvard Health Publishing found that a patient taking an anticholinergic medication long-term was associated with a 54% higher risk of developing dementia. It is important to note that the increased risk is associated with longer durations and higher doses, leading to an increased exposure – often referred to as the anticholinergic burden. However, other studies have not found a link between these kinds of medications and dementia. These other studies identified that the underlying conditions may actually put one at risk of developing dementia, not the medications themselves. Evidence suggests that the cognitive dysfunction that may occur with anticholinergic medication may be reversible after discontinuation of the offending agent, although this can’t be guaranteed, especially with an increased exposure. More data is needed to draw a conclusion about the long-term dementia risk that has been casually associated with anticholinergic medications.
Alternatives to Anticholinergics
At this point, one may be asking, “if not an anticholinergic, then what?” Well, there are other options that have been shown to be safer and still effective in older adults. Below is a chart similar to the one above that describes alternative pharmacologic options. These medications have been identified to have a lower anticholinergic risk than others in the same class.
Anticholinergic medications may still be deemed necessary in some patients. It is important to use clinical judgement and treat each patient individually in a patient-centered approach. As long as the benefits outweigh the risks, then these medications may still be used.
Additionally, non-pharmacological strategies may also play a role in reducing the reliance on anticholinergic medications. For example, patients with allergies may benefit from approaches such as allergen avoidance – keeping windows closed during pollen seasons or washing bedding regularly. In the management of depression, cognitive behavioral therapy (CBT) has demonstrated to be effective. For musculoskeletal discomfort, alternatives such as massage therapy or heat (e.g., heating pad) may reduce the need for muscle relaxants. Lastly, older adults experiencing overactive bladder or incontinence may find pelvic floor training a helpful tool to avoid anticholinergic medications and improve bladder control.
Pharmacist Considerations
Pharmacists play a vital role in identifying patients at risk for adverse effects associated with anticholinergic medications. Through careful medication review, pharmacists are well positioned to recognize individuals who may be susceptible to these effects. Deprescribing, as clinically indicated, is another key responsibility that pharmacists can engage in to reduce anticholinergic burden. In addition to educating patients, pharmacists can also guide providers by recommending safer, evidence-based alternatives. Services such as medication therapy management (MTM) further support this effort, especially for pharmacists who practice under collaborative practice agreements (CPAs) and have the ability to prescribe/deprescribe medications. By using this interprofessional collaboration, pharmacists can make meaningful impacts on patients’ health, ultimately improving safety, outcomes, and quality of life.
The Big Picture
As the U.S. population continues to age, the risks associated with anticholinergic medications become increasingly important to recognize and address. These agents are frequently used and are often effective, but their potential to contribute to cognitive dysfunction, falls, and decreased quality of life – specifically in older adults – is something to be talked about. Clinicians can make more informed prescribing decisions after understanding how these medications work and applying tools such as the Beers Criteria and ACB scale to help guide their decisions. Pharmacists are in a position to identify anticholinergic burden, recommend appropriate changes, and use interprofessional collaboration, along with patient input, to optimize therapy. Ultimately, careful medication management can minimize one’s anticholinergic exposure. Small changes may make big impacts on cognition and quality of life.
Olivia Johnson, PharmD
References:
- From The American Geriatrics Society. https://thecarepartnerproject.org/wp-content/uploads/The-Beers-List.pdf
- Ghossein N, Kang M, Lakhkar AD. Anticholinergic medications. PubMed. Published 2023. https://www.ncbi.nlm.nih.gov/books/NBK555893/
- Urban Institute. The US population Is aging. Urban Institute. Published December 12, 2019. https://www.urban.org/policy-centers/cross-center-initiatives/program-retirement-policy/projects/data-warehouse/what-future-holds/us-population-aging
- Mayo Clinic. Bladder control: Medications can relieve urinary problems. Mayo Clinic. Published 2017. https://www.mayoclinic.org/diseases-conditions/urinary-incontinence/in-depth/bladder-control-problems/art-20044220
- King R, Rabino S. ACB Calculator. www.acbcalc.com. Published December 17, 2023. https://www.acbcalc.com/
- Ruscin JM, Linnebur SA. Aging and Medications. Merck Manual Consumer Version. Published April 6, 2025. https://www.merckmanuals.com/home/older-people-s-health-issues/aging-and-medications/aging-and-medications#Benefits-and-Risks-of-Prescription-Medications_v838778
- Harvard. Common anticholinergic drugs like Benadryl linked to increased dementia risk – Harvard Health. Harvard Health. Published January 28, 2015. https://www.health.harvard.edu/blog/common-anticholinergic-drugs-like-benadryl-linked-increased-dementia-risk-20150128812
- Hanlon JT, Semla TP, Schmader KE. Alternative Medications for Medications in the Use of High-Risk Medications in the Elderly and Potentially Harmful Drug-Disease Interactions in the Elderly Quality Measures. Journal of the American Geriatrics Society. 2015;63(12):e8-e18. doi:https://doi.org/10.1111/jgs.13807
- Deglow B. Pharmacist-Driven Deprescribing to Reduce Anticholinergic Burden in Veterans With Dementia. Federal Practitioner. 2024;41(12). doi:https://doi.org/10.12788/fp.0539