THERAPEUTIC TARGETS
Anticholinergics Medications with anticholinergic effects, whether as an intended therapeutic target or an unintended extension of pharmacologic actions, have been well associated with negative outcomes in elderly patients. Common anticholinergic side effects include tachycardia, dry mouth, constipation, urinary retention, blurred vision, and altered mental status. The latter two may combine to increase fall risk. At the same time, tachycardia can complicate cardiovascular problems, and other side effects may reduce the quality of life and/or contribute to a prescribing cascade.
Kiesel and colleagues identified 12 published scoring tools to quantify the anticholinergic burden from medications, and they sought to harmonize these tools into a single scoring system (Kiesel et al., 2018). After applying their revised scoring rubric to 504 medications and including only systemic medications, 18 were identified as having moderate and 29 as having strong anticholinergic effects. These 47 medications reflected therapeutic categories such as antihistamines, antidepressants, antipsychotics, and antispasmodics (Table 1).
Table 1: Medications with Moderate to Strong Anticholinergic Effects Moderate
Strong
Amantadine
Oxcarbazepine
Amitriptyline
Doxepin
Propiverine
Carbamazepine
Paroxetine
Atropine
Fesoterodine
Scopolamine
Cimetidine
Pethidine
Chlorpheniramine
Flavoxate
Solifenacin
Haloperidol
Pimozide
Clemastine
Hydroxyzine
Thioridazine
Loperamide
Quetiapine
Clomipramine
Imipramine
Tizanidine
Loxapine
Ranitidine
Clozapine
Levomepromazine
Tolteridone
Maprotiline
Theophylline
Cyproheptadine
Nortriptyline
Trihexyphenidyl
Methadone
Tramadol
Darifenacin
Orphenadrine
Trimipramine
Olanzapine
Dimenhydrinate
Oxybutinin
Trospium
Opipramol
Diphenhydramine
Procyclidine
As with PIMs, medications with a moderate to strong degree of anticholinergic effect may not consistently result in adverse medication outcomes. However, they are reliable predictors of increased risk, especially when combined with comorbidities, concomitant medication use, and other determinants of health. Central nervous system depressants Various medical conditions ranging from pain to seizures to mental health disorders have a pathologic basis or a treatment focusing on the central nervous system (CNS). Medications used to treat such conditions commonly act on neurotransmitters and/or receptors in the CNS. Such medication types include benzodiazepines, opioids, tricyclic antidepressants, selective serotonin (± norepinephrine) reuptake inhibitors, and antipsychotics. Any of these medications may predispose older, Laxatives Constipation is a common complaint in elderly patients. A diagnosis of functional constipation, according to Rome IV, includes having two or more of six characteristics, such as straining during 25% of defecations and fewer than three spontaneous bowel movements per week; loose stools rarely present without the use of laxatives; and insufficient criteria to meet irritable bowel syndrome (Rome Foundation, 2021). Additionally, a variety of medications and medical conditions have been associated with primary and/or secondary constipation (Box 1). While still commonly recommended, hydration and nonstrenuous exercise have not been proven beneficial in preventing or managing constipation in elderly patients. However, patients who consume fewer meals and fewer calories are more prone to constipation. In addition to supporting fluid intake and exercise, nonpharmacologic interventions to prevent or treat constipation may include timed toileting (e.g., each morning or postprandially) and increased
Providers and healthcare team members would be well served to conduct a risk–benefit assessment before and during ongoing treatment of patients who are taking any of these anticholinergic medications. Therapeutic alternatives with lower risk are often available. medically complex patients to side effects, including sedation, imbalance, and altered motor skills, which collectively increase fall risks. However, many diagnoses that can and should be treated require selecting a CNS-active medication. Therefore, a risk–benefit evaluation is critical in deciding which agent to select. In most cases, the adage “start low, go slow” is appropriate when prescribing CNS-active medications to older adults. fiber intake. From a pharmacologic perspective, when clinically appropriate, initial consideration should be given to removing constipating medications. After that, the addition of bulk- forming laxatives (e.g., psyllium, polycarbophil), stool softeners (e.g., docusate), osmotic laxatives (polyethylene glycol), or stimulants (e.g., senna, bisacodyl) has been a mainstay of treatment. Milk of magnesia deserves cautious use in elderly patients, especially those with cardiac or renal dysfunction, due to the risk of electrolyte imbalance. Phosphate-based enemas also pose electrolyte imbalance risks in addition to their aesthetic limitations. Docusate, while still commonly used, has limited evidence of efficacy. As long as they are tolerated, polyethylene glycol-based laxatives may offer an optimal balance of efficacy and tolerability (Jani & Marsicano, 2018).
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Book Code: RPTTX2024
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