Anticholinergic Burden
This week we’ll jump into a Medication related topic - the Anticholinergic Burden. Before we get too deep into antiCHOLINErgic, let’s cover AcetylCHOLINE.
Acetylcholine is a neurotransmitter; to break it down, it is the voice between nerves in our bodies. The role of acetylcholine is variable depending on what part of the nervous system it is in. If it is in the Central Nervous System (CNS), of which our brain is a major component, it supports our cognition. In fact, one of the main FDA approved treatments for Alzheimer’s Dementia is aimed at increasing the amount of acetylcholine in our brain. If the acetylcholine is in the Peripheral Nervous System (PNS), which is basically everything except our brain and spinal cord, it functions in a variety of ways but specializes in supporting our parasympathetic nervous system. Another way to say that, in keeping with the voice metaphor, is that it is the voice of telling our body to rest and digest. That is a thirty-thousand foot overview that will make the understanding of the Anticholinergic Burden easier to understand.
Many medications have anticholinergic properties. Some are intended to do this, like oxybutynin (Oxytrol or Ditropan), to try to treat certain disease processes directly. However many are not made to have a direct effect, and so there are anticholinergic side effects such as dry mouth, constipation, increased heart rate, dizziness, hallucinations, and falls. A commonly seen offender is the ubiquitous sleep-aid diphenhydramine (Benadryl), and the common story is that of an older adult who has used this medication off and on for sleep their whole life takes it one night and falls. Or an older adult with some cognitive impairment moves in with family and has trouble sleeping due to the adjustment; the family then tries a nonprescription medication, diphenhydramine, to help their loved one sleep and suddenly that person is hallucinating, yelling, and swinging fists at family members.
The sudden and immediate effects of anticholinergic medications aren’t the only problem. There is a study that was published in the Journal of the American Medical Association in 2015 that showed a cumulative effect of anticholinergic medications leading to a higher than average risk of dementia. The most common offending medications were tricyclic antidepressants, first-generation antihistamines, and bladder antimuscarinics. Simply put, older antidepressants that are more commonly used as pain modulators now, allergy medications like diphenhydramine, and medications for urinary incontinence like oxybutynin that we take when we don’t have dementia have an increasing effect of being diagnosed with dementia later in life.
Fortunately there is a tool to help us know just how high our anticholinergic burden is - the Anticholinergic Burden Calculator. If we score a three or higher on this scale, which is fairly easy, then we are at an increased risk of cognitive impairment and death. It is a simple tool to use, but do not discontinue use of medication without first consulting your physician. Always be sure to discuss your medication use, over-the-counter and prescription, with your physician.
Key Points:
Acetylcholine is a neurotransmitter that is vitally important to our cognition and daily lives
Medications that are anti-acetylcholine increase our chance of dementia and other side effects as we age
Have open discussions with your healthcare providers about your medications
