Choosing Wisely:

Don’t recommend highly anticholinergic medications in older adults without first considering safer alternatives or non-drug measures.

Rationale and Comments: Many medications have strong anticholinergic activity including first generation antihistamines (e.g., diphenydramine, doxylamine), tricyclic antidepressants, gastrointestinal antispasmodics, antiemetics, muscle relaxants, medications for urinary incontinence, and medications to treat Parkinson disease. Older adults are more sensitive to adverse events associated with anticholinergics, including confusion, dry mouth, blurry vision, constipation, urinary retention, decreased perspiration, and excess sedation. Anticholinergics have also been associated with increased risk of dementia. These medications are especially problematic for people with existing cognitive impairment, and bladder anticholinergics should be used judiciously for these patients. It is important to inquire about over-the-counter antihistamine use and help patients select safer alternatives for sleep and seasonal allergies. For example, for seasonal allergies, second-generation antihistamines have minimal anticholinergic effects and allergies may be managed with inhaled steroids.
Sponsoring Organizations:
  • American Society of Consultant Pharmacists
  • Sources:
  • American Geriatrics Society guidelines
  • Disciplines:
  • Geriatric Medicine
  • References: • 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2019 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019;67(4):674-694.
    • Hanlon JT, Semla TP, et al. 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. J Am Geriatr Soc. 2015;63(12):e8-e18.
    • AUGS Consensus Statement: Association of Anticholinergic Medication Use and Cognition in Women with Overactive Bladder. Female Pelvic Med Reconstr Surg. 2017;23(3):177-178.
    • Gray SL, Anderson ML, et al. Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Intern Med. 2015;175:401-407.
    • Richardson K, Fox C, et al. Anticholinergic drugs and risk of dementia: case-control study. BMJ. 2018;361:k1315.

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