Anticholinergic Medications in Older Adults and Strategies for Safe Deprescribing

In an interview with Pharmacy Times, Noll L. Campbell, PharmD, MS, Associate Professor Purdue University College of Pharmacy West Lafayette, IN discusses his presentation at the 2024 American Association of Psychiatric (AAPP) Conference. Campbell shares recent research that has found an association between the use of strong anticholinergic medications and an increased risk of dementia in older adults. He explains that while these studies do not prove causation, they provide evidence to support further research. Strategies for safely deprescribing these medications are explored, with Campbell finding that pharmacist-led interventions tend to be most effective. The roles pharmacists can play in educating patients and helping transition to safer alternative treatments are also covered.

Pharmacy Times

What are the main risks associated with anticholinergic medications in older adults, and why are they still used?

Noll L. Campbell, PharmD, MS

We know that anticholinergics have a lot of side effects, that's commonly educated. But the one that's most concerning, is a neurologic based side effect. It's something that's emerging and justified now some of the more recent science in the last few years. That's related to a potential link with the outcome of dementia. We know that they cause things around the rest of the body like constipation, dry mouth, and those are annoying, and those actually happen quite frequently. They're bothersome enough that sometimes people stop medicines because of that. But the one that we're most concerned about is the brain related dementia outcome.

Pharmacy Times

Can you briefly explain recent research suggesting a link between strong anticholinergics and Alzheimer’s Disease and Related Dementias (ADRD) in older adults?

Noll L. Campbell, PharmD, MS

There have been a fair number of studies, probably 5 or 6 large studies that have been conducted that draw a link or a what we call an association between the use of these people who use these medicines and a higher risk of dementia. These are really important studies to support the work that we're doing now. But they do is tell us that there may be a potential cause and effect relationship — they don't define or establish a cause-and-effect relationship. They just suggest a cause-and-effect relationship. They're really important studies to have, but they don't confirm for us that these anticholinergic medicines are a cause of dementia. So, now we have to go forward and take these in and conduct these studies that are more cause-and-effect types of studies. So, those are prospective randomized trials, which are going on now, but they're really important studies. Again, they've been conducted all around in patients all around the world. There have been some studies in the UK, but predominantly in the United States. They come from studies, including as many as 230,000 people in 1 study, but in some studies are smaller. But there are consistent studies showing a link between the use of these strong anticholinergics and dementia. It's enough support them to go ahead and do the next round of studies.

Pharmacy Times

Why is studying deprescribing anticholinergics important, and how might it help understand the risks related to ADRD?

Noll L. Campbell, PharmD, MS

It's important because now we we have enough support to raise the question that maybe these medicines are in fact, increasing the rate of dementia. They're not the only cause of dementia, right? So, dementia is irreversible, but there's a pathologic background and there's a pathologic mechanism to what's causing dementia. But we do think that potentially, these medicines are causing about 10% of dementias, at a rate of 500,000 new cases of Alzheimer's each year — maybe 700,000, or 800,000 types of all cause dementias. If we can reduce potentially 10% of those, that's really important work. That's something that we as pharmacists can help support.

Pharmacy Times

What are some basic strategies for stopping anticholinergic medications in older adults?

Noll L. Campbell, PharmD, MS

It's interesting because over about a decade, our research group has tried several ways to stop anticholinergics. We've tried interventions that are embedded within the electronic medical record system. We've tried human intensive interventions. What we found is that a low touch, highly scalable intervention is less likely to reduce to stop people from using anticholinergics. The more effective approach is a pharmacist based or a care coordination-based intervention. The important part of our research now is to understand what's the outcome or what changes if we stop medicines in older adults — or at least lower the dose. In order to do that, we need more of a human based front — I like pharmacist-based intervention to reduce anticholinergics. To do that, it takes a lot of coordination, a lot of communication with the patient themselves, as well as the providers and even sometimes caregivers as well. This is to understand what's the medicine doing, is there something else? Is the medicine working? Is there something else we can use that can treat the symptom but in a safer way — in a non-anticholinergic way. That requires a lot of decision making. It requires a lot of communication and the right type of communication for the person that you're communicating with.

Pharmacy Times

How can pharmacists help ensure safer use of anticholinergic drugs in older patients, based on recent findings and deprescribing approaches?

Noll L. Campbell, PharmD, MS

The best thing that pharmacists can do is educate and recommend alternatives. In our deprescribing approaches, we also help people walk through a change or help people walk through starting a new medicine so that they feel supported and feel if an anticholinergic is necessary, it's okay. But what we'll do is try to provide safer alternatives and help people understand what's the right strategy to using a safer medicine. It's less intimidating, right? I think knowing that you have somebody advocating for you, following you, and helping you because the health care field and the medical system is complex. It's hard to navigate and it is intimidating. I think having the pharmacist’s role there are deprescribing care coordinators — what we call it, that role is a really supportive role and help people navigate the healthcare system.