Friend or Foe? Common Medications Can Heighten Risk of Cognitive Decline

Dr. Rhonna Shatz, medical director of the UC Memory Disorders Center and the Bob and Sandy Heimann Chair for Research and Education in Alzheimer’s Disease, spoke about common medications and dementia risks at the Sunflower Rev It Up for Parkinson's Symposium & Expo.

Dr. Rhonna Shatz, medical director of the UC Memory Disorders Center and the Bob and Sandy Heimann Chair for Research and Education in Alzheimer’s Disease, spoke about common medications and dementia risks at the Sunflower Rev It Up for Parkinson’s Symposium & Expo.

If you’ve been following the news about the latest discoveries in memory disorders research, you know that regular exercise, a healthy weight, a fiber-rich diet, coffee, and plenty of high-quality sleep will help you minimize your risk of cognitive decline.

Now comes something else to think about: the drugs in your medicine cabinet.

It turns out that a broad array of commonly used medications, including some over-the-counter drugs that millions of people depend on, may increase the risk of developing dementia. Rhonna Shatz, DO, medical director of the Memory Disorders Center at the University of Cincinnati Gardner Neuroscience Institute, says the connection is important for the public to understand.

The medications are called anticholinergics, a class of drugs that can impact brain function by interfering with acetylcholine, a chemical (neurotransmitter) that enables cells to send signals to other cells. Doctors describe the cumulative effect of these drugs as ACB: the anticholinergic cognitive burden.

Learn the ABCs of ACB

Researchers have divided the drugs into three groups. Those with a score of 1 have possible anticholinergic effects; those with a score of 2 or 3 have definite anticholinergic effects. Anticholinergic medications include:

•    Antihistamines, drugs that treat symptoms of seasonal allergies to mold, hay fever and pollen
•    Drugs that treat asthma, incontinence, gastrointestinal cramps, cystitis, chronic bronchitis and muscular spasms.
•    Tricyclic antidepressants, which are used to treat bipolar disorder, schizophrenia and depression
•    Benzodiazepines and psychotropics, which are used to treat seizures, epilepsy, anxiety, panic disorders and restless legs syndrome

“The use of anticholinergics – including antihistamines — over a long term creates a risk of dementia,” Shatz says.

Complete list of medications on the ACB scale >

Antihistamines include first-generation drugs, such as Benadryl and Chlor-Trimeton, which cross the blood brain barrier and cause drowsiness, as well as newer, second-generation drugs such as Claritin, which do not cause drowsiness. Benadryl is commonly found in over-the-counter sleep aids, such as Tylenol PM and Advil PM.

What does this mean for a populace whose medicine cabinets contain many of these drugs? Shatz offers answers to our most basic questions.

Q: What is your advice for the general population?
A: Ask your doctor to review your medications for anticholinergic activity and consider other treatments.  Some of the medications with anticholinergic burden are not commonly considered for this side effect.  It may be helpful to check your medication list against online lists for unexpected anticholinergic effects.

Q: What is your advice for older adults?
A: Older adults are more likely to have conditions that are treated with anticholinergic medications. This is especially true for the treatment of bladder control problems (oxybutynin, tolterodine, solifenacin), heart disease (digitalis, warfarin, furosemide, amiodarone), and mood and sleep problems (lorazepam, alprazolam, quetiapine, duloxetine, paroxetine). Confusion, memory impairment and gait problems are much more likely to occur in older adults who are taking these medications, and these symptoms can be misinterpreted as signs of Alzheimer’s disease or mild cognitive impairment. If symptoms arise, look at the medication list first before assuming that cognitive or gait problems are being caused by brain disease.

Q: What advice do you have for people who already have experienced cognitive decline?
A: Alzheimer’s disease, dementia with Lewy bodies, and Parkinson’s disease with dementia are brain disorders characterized by a deficiency in acetylcholine. (Nearly one-third of patients with Parkinson’s disease suffer from cognitive impairment and dementia.) These patients are treated with a group of medications called acetylcholinesterase inhibitors, which boost the levels of acetylcholine by preventing its metabolism. An anticholinergic burden beyond a 3 rating — or any single agent rated as a 3 — will interfere with the treatment effects of Aricept (donepezil), Exelon (rivastigmine), or Razadyne (galantamine) and worsen confusion and memory loss as well.

Q: What do these dementia risks mean for people who have mood disorders, allergies and/or asthma and need medications to function?
A: Some medications that have anticholinergic activity are necessary, and there are no appropriate or effective substitutes. Examples of these are digitalis for heart disease or inhalers like albuterol for asthma and COPD. However, in many instances, there are alternatives. Even for bladder control, local injections of botulinum toxin (Botox, Dysport, Xeomin, Myobloc) or topical gels are better than oral medications. Try to keep anticholinergic burden below a 5 rating overall and avoid the use of any pill with a rating of 3.

Q: Should normal, healthy adults consider cutting back on their use of anticholinergic medications?
A: Brain health can be achieved by focusing on two strategies:  1) avoiding undue stress on brain architecture and function, and 2) amplifying native brain stem cell regeneration.  Many of the drugs with anticholinergic activity are for conditions that can be modified by healthy living strategies. For example, no healthy adult should need a sleep medication. If you don’t sleep well, first check to see that you don’t have sleep apnea or another sleep disorder that is interrupting your sleep, and then follow good sleep hygiene guidelines.

Sleep HygieneQ: You mentioned brain stem cell regeneration. How can we help this process along?
A: The production of new brain cells in adulthood occurs in a part of the brain called the hippocampus, where native stem cells reside. But you need triggers for this process to occur. The brain is a survival tool, and it has learned over evolutionary time that certain stresses are needed to grow new cells. These stresses come in the form of vigorous, aerobic exercise – the kind of exercise you might have experienced eons ago if you were being chased by a wooly mammoth, or if you were hunting and in danger of not having food.

“Socializing is also vital. If we socialize, we are more likely to learn something we didn’t know before. The drive to socialize is so powerful that you can see it across all species, animals driven together in packs or swarms. One of the best ways to live an animated life is to imagine you’re on vacation every day of your life. Plan an itinerary. Choose things that are different from what you normally do.”

— Cindy Starr

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