Anticholinergic Medications in Older Adults: Prescribing Considerations

Risks of Anticholinergic Burden in Older Adults

Older adults experience a decline in acetylcholine physiology with aging, making them more susceptible to anticholinergic side effects 1
The Drug Burden Index shows that drugs with strong anticholinergic properties are associated with decline in cognition, functional status, and activities of daily living scores in older patients 1
Anticholinergic burden increases the risk of serious adverse events including injurious falls, episodes of confusion or delirium, emergency department visits, and hospitalizations 1

Tertiary-amine tricyclic antidepressants (TCAs) like amitriptyline have significant anticholinergic effects and are considered potentially inappropriate medications for older adults according to the American Geriatrics Society Beers Criteria 2
First-generation antihistamines such as diphenhydramine have strong anticholinergic effects and should be avoided in older adults 4
Muscle relaxants like cyclobenzaprine have anticholinergic properties and are poorly tolerated in older adults 1, 5
Paroxetine is associated with more anticholinergic effects than other SSRIs and should not be used in older adults 6

Assess the cumulative anticholinergic burden, considering the number, dose, and degree of anticholinergic activity of all medications 1
Consider alternatives with lower anticholinergic activity, such as SSRIs like citalopram, escitalopram, and sertraline for depression 6
For allergies, second-generation antihistamines have fewer anticholinergic effects 4

Be aware of the increased risk of anticholinergic side effects when these medications are combined with alcohol or other CNS depressants 4