Popular Drugs May Cloud Brain

Many Over the Counter Medications can Averseley Affect the Brain Function

Many people are unaware that dozens of painkillers and psychiatric medications ranging from over-the-counter nostrums to popular anti-depressants can adversely affect brain function, especially in the elderly. Regular use of multiple medications that have this effect have been linked to cognitive impairment and memory loss.

Acetylcholine is a neurotransmitter (chemical messenger) with a range of functions in the body including memory production and cognitive functioning. Anticholinergic drugs block the action of the neurotransmitter acetylcholine and can occur occasionally as a direct action of the drug but often it occurs as an undesired side effect.

The danger for patients who knowingly or unknowingly take these drugs is that the effect of anticholinergic drugs is cumulative. Doctors are not always aware of all of the medications their patients take and do not always remember to review the anticholinergic properties of the various drugs they prescribe. This becomes particularly problematic for older patients who are more vulnerable to the effects of these drugs while tending to consume more medications than other age groups.

Recent Studies Focus on Anticholingergic Medicines

Recently a spate of new research studies has focused on anticholinergic medicines. In one such study they followed more than 13,000 British men and women age 65 or older for two years with researchers finding that the people taking more than one anticholinergic drug scored lower on tests of cognitive function than those who were not using such drugs. Additionally, the death rate for heavy anticholinergic medication users was 68 percent higher during the course of the study.

These findings were reported in The Journal of the American Geriatrics Society and stunned the investigators. “So far we can’t tell why they are dying, but it wasn’t because they were sicker or older,” said Dr. Malaz A. Boustani, director of the Wishard Healthy Aging Brain Center and a scientist at the Regenstrief Institute, both in Indianapolis, who was one of the paper’s authors. We adjusted for age, gender, race, other medications they were taking, other diseases and social status. We adjusted for everything we could, and that signal did not go away.” He added: “These are very, very common drugs. That’s the scary piece.”

Dr. Chris Fox, a senior lecturer at Norwich Medical School at the University of East Anglia in England and the paper’s lead author said he and his colleagues suspected that anticholinergics take a toll on bodily organs and systems like the cardiovascular system but there are no studies confirming this. Anticholinergics have also been implicated in the delirium that intensive-care patients frequently develop in the hospital.

“Clinicians don’t think of them nearly as often as they should as a potential cause of cognitive problems,” said Dr. Wesley Ely, a professor of medicine at Vanderbilt University who studies neuropsychological deficits that occur after intensive care hospitalization.

A stunning statistic is that at least 20 percent of the 36 million Americans 65 and older take at least one anticholinergic medication.

A study by Dr. Boustani included nearly 4,000 older adults in Indianapolis and found that those who had been using three or more anticholinergic drugs consistently for 90 days or longer were nearly three times as likely to receive a diagnosis of mild cognitive impairment as those who had not taken anticholinergics. “If you were taking one of the drugs we know is definitely an anticholinergic for 60 days you double the odds of developing mild cognitive impairment compared with a patient taking no anticholinergic medicines,” Dr. Boustani said.

No association was found between chronic use of anticholinergics and dementia, however, even though mild cognitive impairment often precedes dementia. Dr. Boustani said the reasons for this were not clear.



Studies Aim to Show the Magnitude Affect of Various Drugs

The aim of studies like these is to evaluate the magnitude of the effects of different drugs, to determine whether there are safe thresholds for their use, and to learn whether the effect is transient and reversible or not. Still, there is already a consensus in the scientific community that anticholinergic compounds should be prescribed with caution, especially for the elderly.

“There’s not much doubt about this,” said Dr. William Thies, chief medical and scientific officer for the Alzheimer’s Association, adding that studies from large clinics that treat people with memory disorders have shown that up to 25 percent of the patients who seek help have reversible disorders, including those caused by polypharmacy — taking a combination of medications, some of which may have anticholinergic activity.

“Still,” Dr. Thies said, “it would be unfair to suggest that this is the cause of a great deal of cognitive impairment in our society.”

Even so, why do physicians prescribe any medications with anticholinergic activity to elderly people, who may be using them regularly for many years? Not only are doctors often unaware of all the medicines their patients are taking but the list of drugs with anticholinergic properties is a long one.

The heart drug digoxin, the blood thinner warfarin, as well as the painkillers codeine and prednisone are considered mild anticholinergics. Those with the most severe effects include Paxil, Benadryl, a drug for overactive bladder called oxybutynin, and the schizophrenia drug clozapine. “People are worried but we’ve gotten pushback from some physicians who say, “‘Great, but what do we do? We’ve got to use these pills,’ ” Dr. Fox said.

Solutions and Advice for Patients

So what’s a patient to do?

If you or an elderly relative take one or more drugs on a regular basis ask your primary care physician to evaluate the cumulative anticholinergic burden of all them (as well as other potential interactions and side effects). “The patient is critical in triggering that kind of discussion,” Dr. Thies said. “It may not be automatic, but if in fact the patient asks for it, it’s much more likely to be done.”

Remember to tell your physician about drugs prescribed by other specialists as well as nonprescription or alternative medicines you take. He or she should be able to prescribe substitutes without anticholinergic effects. This review should be done once a year. However, you should never stop medications on your own without medical supervision.

Even before going to the doctor, do your own research. Use the Anticholinergic Burden Scale as developed by scientists from the Regenstrief Institute to assess your risk. The scale ranks drugs based on the strength of their anticholinergic activity from zero if there is no effect to 3 for severe effect.

Keep in mind that many over-the-counter drugs, including allergy medications, antihistamines, and Tylenol PM have anticholinergic effects. “Don’t overreact to your cold,” Dr. Boustani advised. “Try Grandma’s remedy for a couple of days before you ramp up to Advil PM or Aleve PM.”

For some conditions there may not be any adequate substitutes for essential anticholinergic drugs.

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