Anticholinergic Drugs in Geriatric Psychopharmacology.

Jorge López-Álvarez,Luis Agüera-Ortiz,Julia Sevilla-Llewellyn-Jones

doi:10.3389/fnins.2019.01309

Abstract

Drugs with anticholinergic action are widely prescribed in the elderly population due to their potential clinical benefits. However, these benefits are limited by adverse effects which may be serious in particular circumstances. This review presents different aspects of the use of anticholinergics in old age with a focus in psychogeriatric patients. We critically review published data on benefits and disadvantages of anticholinergics, which are often controversial. Prevalence, pathophysiology and measurement methods of the anticholinergic action of drugs are discussed. We also present the most important drawbacks resulting from its use, including effects on cognition in healthy and cognitively impaired people, in aged schizophrenia patients, emergence of delirium and psychiatric symptoms, influence in functionality, hospitalization, institutionalization and mortality, and the potential benefits and limitations of their discontinuation. Finally, we suggest practical recommendations for the safe use of anticholinergics in clinical conditions affecting elderly patients, such as dementia, schizophrenia and acute hallucinatory episodes, depression, anxiety, Parkinson’s disease, cardiovascular conditions and urinary incontinence.

Highlights

Anticholinergic drugs bind to the muscarinic receptors and block acetylcholine neurotransmission, which is involved in many major body functions including central nervous system (CNS) functions such as attention, learning and memory mechanisms and peripheral nervous system (PNS) actions which are related to basal functioning of the organism such as urination, intestinal transit or heart rhythm regulation
Since cholinergic transmission is involved in many physiological functions, anticholinergic drugs can have adverse effects and affect the central and peripheral nervous systems
At 26 weeks, co-administration of solifenacin significantly improved the score of the ADAS-Cog, a widely used cognitive scale, versus baseline and versus the standard treatment with donepezil 10 mg/day. These results suggest that concomitant administration of acetylcholinesterase inhibitors (AchI) and a peripherally acting anticholinergic drug increases efficacy and tolerability of Alzheimer’s disease treatments (Chase et al, 2017)

Summary

INTRODUCTION

Anticholinergic drugs bind to the muscarinic receptors and block acetylcholine neurotransmission, which is involved in many major body functions including central nervous system (CNS) functions such as attention, learning and memory mechanisms and peripheral nervous system (PNS) actions which are related to basal functioning of the organism such as urination, intestinal transit or heart rhythm regulation. Considering the finite number of muscarinic receptors, a plateau effect can be reached at some point, which implies that the sum of the anticholinergic effects of the individual drugs may overestimate the total anticholinergic load Despite all these limitations, scales seem more useful than in vitro determinations to facilitate clinical decisions (Wawruch et al, 2012). In a study in Alzheimer’s disease, the intake of anticholinergic drugs (except antipsychotics, to avoid reverse causation) increased the risk of psychosis, showing more risk for an increased anticholinergic load (Cancelli et al, 2008) This is in line with another study where the presence of SAA was associated with delusional ideation and diurnal rhythm disturbances (Hori et al, 2011). This objective should be flexible because the cognitive effects may no longer be reversible or there is an evident risk of serious worsening of an underlying disease

Findings

DISCUSSION AND RECOMMENDATIONS

CONCLUSION