How to manage your patient’s dementia by discontinuing medications
‘Pharmacologic debridement’ refers to tapering and discontinuing medications that are no longer necessary or appropriate. Prescribers often are hesitant to discontinue medications prescribed by other clinicians and may assume that a medication used long term has been tolerated and helpful. However, as patients age—particularly if they develop dementia—their ability to tolerate a medication can change. Patients with dementia also may have difficulty attributing adverse experiences to medications and communicating these effects to providers. Some medical providers may not recognize adverse psychiatric and cognitive effects of the nonpsychiatric medications they prescribe because they do not have sufficient dementia expertise. Consulting with these providers may help determine the risk-benefit considerations of these medications.
Generally, anticholinergics should be discontinued if they are not essential to a patient’s health or if safer non-anticholinergic alternatives are available.5 Tapering may be necessary to prevent adverse effects from cholinergic rebound if a potent anticholinergic has been used chronically.5 The first step in addressing Mrs. J’s agitation is to discontinue the anticholinergic medications and monitor her symptoms. This pharmacologic debridement may avert the use of antipsychotics, which carry serious risks for dementia patients.1
Table
Drugs with clinically significant anticholinergic effects*
| Drug class | Medication(s) |
|---|---|
| Anticonvulsants | Carbamazepine |
| Antidepressants | Amitriptyline, clomipramine, desipramine, doxepin, imipramine, nortriptyline, paroxetine, protriptyline, trimipramine |
| Antihistamines | Azelastine nasal spray, brompheniramine, carbinoxamine, chlorpheniramine, clemastine, cyproheptadine, dexbrompheniramine, dexchlorpheniramine, diphenhydramine, hydroxyzine, mepyramine olopatadine nasal spray, phenyltoloxamine, promethazine, triprolidine |
| Antiparkinsonian agents | Benztropine, procyclidine, trihexyphenidyl |
| Antipsychotics | Chlorpromazine, clozapine, loxapine, molindone, olanzapine, pimozide, promethazine, quetiapine, thioridazine |
| Asthma and chronic obstructive pulmonary disease medication | Glycopyrrolate, ipratropium,† tiotropium† |
| Bladder antispasmodics | Darifenacin, flavoxate, oxybutynin, solifenacin, tolterodine, trospium |
| Gastrointestinal antispasmodics | Atropine, belladonna alkaloids, clidinium, dicyclomine, hyoscyamine, methscopolamine, propantheline |
| Insomnia medications | Diphenhydramine, doxylamine |
| Motion sickness/dizziness/nausea medications | Dimenhydrinate, meclizine, prochlorperazine, promethazine, scopolamine, trimethobenzamide |
| Muscle relaxants and pain medications | Cyclobenzaprine, meperidine, orphenadrine, phenyltoloxamine |
| Ulcer and acid reflux agents | Cimetidine, glycopyrrolate, ranitidine |
| *Not a comprehensive list †Unknown whether CNS effects are important Source: Reference 5 | |
- Cancelli I, Beltrame M, D’Anna L, et al. Drugs with anticholinergic properties: a potential risk factor for psychosis onset in Alzheimer’s disease? Expert Opin Drug Saf. 2009;8(5):549-557.
- Meeks TW, Jeste DV. Beyond the black box: what is the role for antipsychotics in dementia? Current Psychiatry. 2008;7(6): 50-65.
- Centers for Education and Research on Therapeutics. Anticholinergic pocket reference card. www.chainonline.org/home/content_images/Anticholinergic%20Pocket%20Card%20CLR%203_12_10.pdf.
Drug Brand Names
- Amitriptyline • Elavil
- Atropine • Sal-Tropine
- Azelastine nasal spray • Astelin
- Belladonna alkaloids • Donnatal
- Benztropine • Cogentin
- Brompheniramine • Dimetane
- Carbamazepine • Carbatrol, Tegretol, others
- Carbinoxamine • Palgic
- Chlorpheniramine • Chlor-Trimeton
- Chlorpromazine • Thorazine
- Cimetidine • Tagamet
- Clemastine • Tavist
- Clidinium • Quarzan
- Clomipramine • Anafranil
- Clozapine • Clozaril
- Cyclobenzaprine • Flexeril
- Cyproheptadine • Periactin
- Darifenacin • Enablex
- Desipramine • Norpramin
- Dexbrompheniramine • Drixoral
- Dexchlorpheniramine • Polaramine
- Dicyclomine • Bentyl
- Dimenhydrinate • Dramamine
- Diphenhydramine • Benadryl, Sominex, others
- Docusate Sodium • Colace
- Donepezil • Aricept
- Doxepin • Adapin
- Doxylamine • Aldex, Unisom, others
- Flavoxate • Urispas
- Glycopyrrolate • Robinul
- Hydroxyzine • Atarax
- Hyoscyamine • Cystospaz, Levbid
- Imipramine • Tofranil
- Ipratropium • Atrovent
- Loxapine • Loxitane
- Meclizine • Antivert
- Meperidine • Demerol
- Mepyramine • Anthisan
- Methscopolamine • Pamine
- Molindone • Moban
- Nortriptyline • Aventyl
- Olanzapine • Zyprexa
- Olopatadine nasal spray • Patanase
- Orphenadrine • Norflex
- Oxybutynin extended-release • Ditropan XL
- Paroxetine • Paxil
- Phenyltoloxamine • Dologesic, Durayin, others
- Pimozide • Orap
- Prochlorperazine • Compazine
- Procyclidine • Kemadrin
- Promethazine • Phenergan
- Propanthelin • Pro-Banthine
- Protriptyline • Vivactil
- Quetiapine • Seroquel
- Ranitidine • Zantac
- Scopolamine • Scopace
- Sertraline • Zoloft
- Solifenacin • VESIcare
- Thioridazine • Mellaril
- Tiotropium • Spiriva
- Tolterodine • Detrol
- Trihexyphenidyl • Artane
- Trimethobenzamide • Tigan
- Trimipramine • Surmontil
- Triprolidine • Actifed
- Trospium • Sanctura
Acknowledgements
This work was supported by an Agency for Healthcare Research and Quality (AHRQ) Centers for Education and Research on Therapeutics cooperative agreement #5 U18 HSO16094.
Disclosure
Dr. Carnahan receives grant/research support from the Agency for Healthcare Research and Quality.
