Anticholinergic Medications in the Beers Criteria

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By Hannah Grice, PharmD

The Beers Criteria®1 is a leading source of expert information about potentially inappropriate medications (PIM) in older adults. While these medications are generally harmless in young patients, they can have detrimental effects in older adults. Physicians and pharmacists can easily overlook misuse of these drugs, as many are readily available to patients who purchase over the counter (OTC). As an example, Beers criteria identifies first-generation antihistamines’ ability to block receptors and increase the risks of dementia in older adults. Having Benadryl® in a household is relatively common—yet, its long-term effects are not usually a consideration. 

Adverse drug events (side effects) such as dry mouth, constipation, dizziness, confusion, depression, and falls have been linked to PIM2. Older adults are more susceptible to adverse reactions with anticholinergic medications. This class of medicines acts on muscarinic receptors in the central nervous system and blocks acetylcholine neurotransmission. Acetylcholine is involved in many daily functions, including cognition (thinking and awareness). Attention, learning and memory mechanisms are all affected by acetylcholine. In addition, it is involved in the peripheral nervous system (PNS) actions which are related to urination, intestinal movement and heart rhythm regulation. These drugs may bind exclusively to muscarinic receptors or may also bind with additional receptors causing various adverse effects. Anticholinergic medications may be used in many different disease states, ranging from seasonal allergies, motion sickness, and urinary incontinence to Parkinson’s disease and irritable bowel syndrome. With ®acetylcholine so heavily involved in major functions of the body, it is not surprising that they can lead to adverse effects in older adults.

Despite the known adverse effects of these medicines in older adults, they are still commonly prescribed or the patient purchases OTC and takes them unmonitored. One study showed that in a group of patients with mild cognitive impairment or dementia, 44.7% of the patients were taking anticholinergic drugs. Similarly, 11.7% of these patients were receiving a high anticholinergic load or burden. Although these medications may not cause adverse effects in every older adult, they still carry risk and should be avoided if possible. The table below lists PIM from the Beers Criteria and provides therapeutic alternatives. 

Tips for avoiding anticholinergic adverse effects

Always encourage patients to try non-pharmacological therapy before starting an anticholinergic medication. Secondly, speak with a pharmacist before starting any new medications. Lastly, if starting a new anticholinergic medication, take the smallest effective dose for the shortest time needed. 

PharmD Live combines a clinical pharmacist-led approach to monitoring patients using AI-driven telehealth technology and predictive analytics to deliver true value-based care and keep patients safe from medication misuse. Having a pharmacist review your patient’s medicines regularly can avoid these kinds of adverse drug events. Contact PharmD Live to learn about how you can take advantage of this care solution, and set up your patients and practice for success.

Class of MedicationsBeers Drugs with Strong Anticholinergic Properties (Names noted in bold are commonly used)Alternatives
Antiarrhythmic
Disopyramide
Beta-blockers
Diltiazem
Antidepressants
Amitriptyline
Amoxapine
Clomipramine
Desipramine
Doxepin (> 6 mg)
Imipramine
Nortriptyline
Paroxetine
Protriptyline
Trimipramine

Sertraline
Citalopram
Antiemetics
Prochlorperazine
Promethazine 
Evaluate risk vs. benefit
Antihistamines (first generation)
Brompheniramine
Carbinoxamine
Chlorpheniramine
Clemastine
Cyproheptadine
Dexbrompheniramine
Dimenhydrinate
Diphenhydramine
Doxylamine
Hydroxyzine
Meclizine
Clidinium-chlordiazepoxide
Dicyclomine
Homatropine (excludes ophthalmic)
Hyoscyamine
Methscopolamine
Propantheline
Promethazine
Pyrilamine
Triprolidine
Cetirizine and loratadine still have anticholinergic effects but to a lesser extent 
Antimuscarinics
Darifenacin
Fesoterodine
Flavoxate
Oxybutynin
Solifenacin
Tolterodine
Trospium
For urinary incontinence, try: weight loss, scheduled voiding, kegel exercises
Antiparkinsonian agents
Benztropine
Trihexyphenidyl
Evaluate risk vs. benefit
Antipsychotics
Chlorpromazine
Clozapine
Loxapine
Olanzapine
Perphenazine
Thioridazine
Trifluoperazine
*Try non-pharmacological first: music therapy, pet therapy, assist with activities of daily living, relieve discomfort, etc.
Atypical antipsychotics are better choice
Antispasmodics
Atropine (excludes ophthalmic)
Belladonna alkaloids
Scopolamine (excludes ophthalmic)
Evaluate risk vs. benefit
Skeletal muscle relaxantsCyclobenzaprine
Orphenadrine
Try multi-modal approach with non-pharmacological therapy and pharmacological therapy
Start at lowest effective doses for pain medications
Yoga, tai-chi

Additional reading regarding Beers Criteria:

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References:

  1. American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults. Journal of the American Geriatrics Society. https://pubmed.ncbi.nlm.nih.gov/30693946/. 
  2. López-Álvarez J, Sevilla-Llewellyn-Jones J, Agüera-Ortiz L. Anticholinergic Drugs in Geriatric Psychopharmacology. Front Neurosci. 2019;13:1309. Published 2019 Dec 6. doi:10.3389/fnins.2019.01309

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