Want to keep your brain — or the brain of someone you love — as healthy as possible?
Then it’s essential to know which commonly used medications affect brain function.
In this article, I’ll go into details regarding a type of medication that I wish all older adults knew about: anticholinergic drugs.
How Anticholinergics Affect the Aging Brain and Body
Anticholinergics are drugs that block acetylcholine, a key neurotransmitter in the body. This leads to lower brain function, which people often experience as drowsiness.
Sometimes that sedation is why people take the drugs, and a little sleepiness might sound benign. But when the brain is older, or otherwise vulnerable, these drugs can be problematic.
In fact, these literally have the opposite effect of the drugs often used to treat Alzheimer’s and other dementias. Donepezil, rivastigmine, and galantamine (brand names Aricept, Exelon, and Razadyne), for example, are designed to increase acetylcholine by blocking the brain enzyme that breaks it down.
Research has linked anticholinergic drugs to increased risk of Alzheimer’s disease, and also to hospitalizations in older adults. And the American Geriatrics Society has warned about them for years; anticholinergics are definitely on the Beer’s List of medications older adults should avoid or use with caution.
Acetylcholine is a neurotransmitter used in many other parts of the body, including the eyes, mouth, bowels, and bladder. So anticholinergic drugs commonly cause side-effects such as dry eyes, dry mouth, and constipation.
These drugs are in everything from allergy medicines to muscle relaxants to painkillers. They are in many over-the-counter (OTC) medications, and they are often prescribed for a variety of common health complaints.
7 Common Types of Medication that are Anticholinergic
Here are seven common types of anticholinergic medication that older adults should avoid, or use with caution:
1. Sedating antihistamines. The prime example is diphenhydramine (brand name Benadryl), which is available over-the-counter and has strong anticholinergic activity. Non-sedating antihistamines, such as loratadine (brand name Claritin) are less anticholinergic and are safer for the brain.
2. PM versions of over-the-counter (OTC) painkillers. Most OTC painkillers, such as acetaminophen and ibuprofen (brand names Tylenol and Motrin, respectively) come in a “PM” or night-time formulation, which means a mild sedative — usually an antihistamine — has been mixed in. Ditto for night-time cold and cough medications such as Nyquil.
3. Medications for overactive bladder. These include bladder relaxants such as oxybutynin and tolterodine (brand names Ditropan and Detrol, respectively).
4. Medications for vertigo or motion sickness. Meclizine (brand name Antivert) is often prescribed to treat benign positional vertigo. It’s also used to treat motion sickness.
5. Medications for itching. These include the strong antihistamines hydroxyzine (brand name Vistaril) and diphendyramine (brand name Benadryl), which are often prescribed for itching or hives.
6. Medications for nerve pain. An older class of antidepressant known as “tricyclics” isn’t used for depression that much any longer, but these drugs are occasionally still used to treat pain from neuropathy. Commonly-used tricyclics include amitriptyline and nortriptyline.
7. Muscle relaxants. These include drugs such as cyclobenzaprine (brand name Flexeril) and they are often prescribed for back or neck pain.
Also anticholinergic is the SSRI-type anti-depression/anxiety drug paroxetine (brand name Paxil), which is why geriatricians almost never prescribe this particular SSRI. However, other SSRIs, including escitalopram, citalopram, and sertraline (brand names Lexapro, Celexa, and Zoloft, respectively) are not anticholinergic, which is why SSRIs aren’t on the list above.
Many more medications have strong anticholinergic effects, but they tend to be prescribed less often. Ask your doctor or pharmacist if you want help spotting all anticholinergics you might be taking.
Who Should Avoid Anticholinergics?
You should especially avoid or minimize anticholinergics if you:
- Are worried about your memory,
- Have been diagnosed with mild cognitive impairment or dementia such as Alzheimer’s disease, or
- Want to reduce your risk of developing Alzheimer’s.
How to Reduce Brain Risk Due to Anticholinergics
For a longer list of anticholinergics that your older relative might be taking, I recommend this list, which specifies whether the drugs have “definite” anticholinergic activity versus “possible.” You’ll want to focus on identifying and minimizing drugs in the “definite” category.
To date, several research studies have reported a concerning association between cumulative lifetime dosing of anticholinergics and dementia risk. (See Anticholinergic Drug Exposure and the Risk of Dementia and here’s one specific for bladder drugs.) Other recent scholarly papers reviewing how anticholinergic medications affect older adults can be found here, here, and here.
For more help identifying and reducing anticholinergic drugs, you can also ask your doctor or pharmacist.
If you find that you or your older relative is taking an anticholinergic drug, don’t panic. But do plan on reviewing the benefits and risks with the doctor soon. You may be able to reduce the dosage of these risky drugs, switch to a safer medication, or try a non-drug treatment instead.
For more on medications that affect brain function, see 4 Types of Medication to Avoid if You’re Worried About Memory.
I also provide more on reducing risky medications here: Deprescribing: How to Be on Less Medication for Healthier Aging.
This article was first published in 2015, and was last updated by Dr. K in April 2022.
Hi Leslie thank you for your wonderful articles. Can any memory/neurological damage from cholinergics be reversed? I am a 52 year old and have been taking benadryl regularly for 20 years for idiopathic anaphylaxis and have recently noticed a marked decline in my memory, can i reverse some of the damage done?
Thank you
Congrats on being proactive in addressing your brain health. I’m not aware of any proven ways to reverse the “damage” from taking anticholinergics during one’s 30s and 40s, I don’t even know that we have a lot of research on the long-term effects of anticholinergics on the brain at that age.
What we do know is that the hormonal changes associated with perimenopause and menopause do affect women’s memory, and may have implications for later cognitive aging or other more significant forms of cognitive decline. There has also been a lot of research done on the effect of estrogen on cognition, but for now, it’s not clear to me how one might determine whether to give a woman estrogen (what kind of estrogen is given gets tricky) to protect and improve cognition:
Estradiol and cognitive function: Past, present and future
I don’t personally provide medical care to women who are as young as you are, but if you are concerned about your memory, you may want to consult with someone who does specialize in menopause and women’s health, they might be able to give you more specific advice, or perhaps even enroll you in a trial. I would also recommend getting evaluated for other common contributors to subjective and objective memory problems in people your age, as there are other medical problems that can affect memory and brain function.
If you can manage without taking benadryl, or with less of it, that’s probably safer for your brain. Good luck!
Am having issues forgetting a bad memory it’s keeps on replaying and replaying am almost going insane. I need to forget. Doctors for such problems are not available at my location. So I went online seeking help and found this site. Please what drugs can you advice me to take to stop this re occurrence of image in my head. I hope you see this message and reply back. I need help.
I’m sorry to hear that you’re suffering, and it sounds like you’re describing thoughts or images that you want to get out of your head, rather than a loss of memory?
That makes me think of something more like Post-traumatic stress disorder (PTSD) or an obsessive compulsive issue.
Those are very serious mental health conditions, and the treatment is very different to that of dementia, such as Alzheimer’s disease, which is the type of memory issue we Geriatricians deal with most often. Managing this kind of symptom usually takes a doctor or nurse led approach, and I’m afraid that a quick online solution is unlikely. I would advise someone with your issue to see whatever type of medical professional they can to get the proper diagnosis and treatment plan.
Stop taking Benadryl. Eat a cup of blueberries a day for brain health. Also avocado and nuts.
I definitely agree that cutting out Benadryl or other anticholinergic medications can improve brain performance!
Blueberries have been touted as a “superfruit” and does contain phytochemicals called anthocyanins that show promise in improving cognitive testing and possibly delaying onset of decline.
I hope you are still getting notifications on this comment. I’m 57 now and took Benadryl intermittently in my 20s and 30, but began taking it daily when I started taking care of an elderly relative who was a smoker. That made my allergies go wild. I’ve been having problems with recall and short term memory. I’ve cut out 3/4ths of my Benadryl but just replaced it with Claritin. I’d also been taking Trazadone at night, but I just cut that in 1/2. I also take Seroquel but stopped that 2 months ago now. My mood has brightened and I can think and remember things better already. My guess is that my brain functions better just from having more choline active. I started researching this subject in December which was the first time I learned about the dangers of anticholinergics such as Benadryl. I have chronic pain and major depressive disorder and when I’m depressed I can’t sleep. That’s why I take Trazadone, Seroquel, and Benadryl nightly. My Dr is aware I’ve been taking these meds long term but hasn’t warned me. I hope you’re doing well and can give an update.
Hi Brandon, I’m glad you found the article informative. It’s great that you are taking an interest in your medications and your brain health, which is important at any age.
I see many patients in my practice that are living with pain and major depression, and the medications used to treat these conditions can have anticholinergic side effects. Despite that, many people need to be on some anticholingeric medications long term, in order to be able to manage their symptoms.
The approach that I use in working with my patients is:
1. Try to find an alternative to an anticholinergic medication that has more favourable properties
2. Try to use the lowest dose possible of an anticholinergic medication
3. When symptoms have been well controlled for a while, try to reduce the dose or discontinue the medication
4. Optimize other treatment modalities, such as exercise, counselling, developing a strong support network, and eating healthy foods
Thanks again for reading the article, and best of luck to you.
Hello, my father of 74yrs old was walking perfect and holding a cup perfectly three months ago. He had a shoulder replacement 4 months ago. Now he has no sensation in his hands, and not hold a cup, or be able to eat properly. He can not even stand up by himself or walk he has fallen 15 times. He suffers from mild Dementia and is on Donepezil. He also suffers from arthritis and recently had an Mri of his back and fold some sciatic on his lower back. Our main concern is why did all of a sudden in a short period of time he lose his ability to walk and use his hands. We are worried and sadden that he is going through this. We have little sources 🙁
Sorry to hear about your father’s condition. It does sound worrisome. It is quite common for older adults to experience some delirium and confusion related to surgery, and this can take weeks or months to fully clear up. Being bedbound for a few weeks can also leave older adults with very diminished strength, which can lead to falls.
However, all of this isn’t usually associated with losing sensation in the hands or becoming unable to hold a cup. Those are true neurological changes, and so I would recommend asking your usual health provider for help evaluating them. It might also make sense to see a neurologist. Good luck!
Thank you so much. We are planning to talk to his MD and suggest and refer my dad to see a neurologist. Thank you again. Have a beautiful day.
R. Santos
I am a 73 year-old physically active male. My only prescription medicationI is 100mg/25 mg of Lozartan HCTZ in the morning, After discovering the risks of dementia from anticholinergics four months ago I weaned myself off of 50 mg of Doxepin after taking it for 25 years for insomnia. I’ve tried several “natural sleep aids” and followed the gamut of environmental and behavioral strategies, but still can’t remain asleep more than 4-5 hours. No problem getting to sleep, but pain from chronic sciatica and the need to urinate contribute to awakening me. The only thing that seems to help me get back to sleep is 25 mg of acetaminaphen PM. Yes, another anticholinergic, the very thing I’m trying to avoid (although I worry that the the damage is already baked in). I feel like I’m caught between a rock and a hard place, because I need my sleep. Any suggestions?
Hi Dale. Dr Kernisan has a great article about sleep which you can read here. It is natural for older adults to need less sleep, in general, than younger adults.
Another helpful site about sleep is mysleepwell.ca, which has a lot of information about Cognitive Behavioural Therapy for Insomnia, which can be very effective, without medication.
If a person is being woken up by pain, then it’s probably more of a pain problem than a sleep problem, and talking to your MD about pain management might be more effective than trying to find the ideal sleeping pill. Good luck.
I am wondering about the impact meclizine can have on dementia. I have dementia in my family and am a caregiver to my mother who has dementia. I take meclizine (non-drowsy Dramamine over the counter) when I travel or have positional vertigo. So I take it maybe 3-4 times a year. Should I look for an alternative such as regular Dramamine which is dimenhydrinate or will that be problematic as well?
Non-drowsy Dramamine is also known as meclizine which is an antihistamine. It is on the Beers list of potentially inappropriate medications for older adults. Very occasional use as you describe is certainly less risky that regular use, and a younger person may not have the same risk as well.
Please advocate 30 minutes a day of aerobic exercise such as walking to increase memory and cognitive function!
Thanks for the reminder of the importance of exercise. I usually recommend 150 minutes per week of fairly vigorous exercise per week, so 30 minutes a day would be on target or better! Here are the guidelines I use form the Canadian Society for Exercise Physiology: https://csepguidelines.ca/guidelines/adults-65/?msclkid=a10173c6c67511ecbc64dee92738f578
HI Leslie,
My mom’s doctor prescribed her with medication for an overactive bladder.
Now after reading our article, I’m concerned, as her dementia is getting worse.
Based on what you are saying, I think I will tell her doctor that I think it’s not worth the side effects.
I just wish there was a way to help her get through the night. Even with the bladder medication, she’s up 3 times. She has caregivers, but it’s tough for everyone.
Hi MJ and good job advocating for your mom. I did post an article on the website about urinary incontinence and you may find some tips there. You can read it here: https://betterhealthwhileaging.net/urinary-incontinence-in-aging/. I also interviewed Dr. Adrian Wagg which Dr. K and I discussed in a podcast, and you can listen to that here: https://betterhealthwhileaging.net/podcast/bhwa/urinary-incontinence-in-aging/
Another podcast you might want to check out is this one about nocturia (nighttime peeing): https://betterhealthwhileaging.net/podcast/bhwa/night-time-urination-and-insomnia-in-aging/
I suffer from chronic and debilitating vestibular migraines. I have tried so many different medications, many of them not recommended for older adults. But the daily pain is debilitating. I receive Botox treatments every 90 days, but it often falls short by a few weeks. Vestibular migraine patients are only 1 percent of all migraine patients. But those over 65 are excluded from all studies. And they caution reduced doses in the elderly. But at 77, I cannot tolerate the daily pain. Why are older adults not included in the studies?
I’m sorry to hear about your migraines and it sounds like you’re exploring a lot of solutions. I hope you get some relief.
You’re correct that age is often a factor in excluding people from clinical studies. I found this article that explored the topic and proposes some ideas about what the barriers are: https://onlinelibrary.wiley.com/doi/10.1111/bcpt.13536. They do raise a point about the higher chance of older adults being excluded because they may have co-morbidities that would affect study results, or may have cognitive impairment that cause ethical considerations when it comes to getting consent.
This was especially relevant during the COVID vaccine trials, as Dr. K has discussed in her COVID updates: https://betterhealthwhileaging.net/coronavirus-updates-for-older-adults-2022/
Wondering about husbands and my own muscle loss? I am 77 hubby is 81. He is on Synthroid o.5 and perendipril 4mg. I am on 2mg. We do 30 min. Treadmill daily and manage our own ADL.But we do notice especially with covid not much more than that. We feel a decline in muscle even to open jars, getting out of chairs etc. If we carry heavy items our arms and shoulders hurt. Should we take something to help or just keep moving?
It sounds like you have a strong commitment to exercise and I want to give you a gold star for that!
There is a phenomenon called “sarcopenia” in older adults that is basically loss of muscle mass and strength. Exercise is the key to reversing sarcopenia, and you may want to add resistance training to your cardio regimen. This would include things like lifting weights, or doing exercises that use your own body weight. Here’s an article about sarcopenia that you might find intersting:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5127276/
There has been a lot of research about supplements but so far nothing that is approved by the FDA or that we can strongly recommend.
Great article. Thank you.
Made me think about the medications I am on for years: clonazepan, sertraline; Telfast180.
Doctors “believe” I have depression, when in reality I have a diagnosis of ADHD since 6 years old. But it seems it is easier to have a forever label than work towards improve the quality of life.
What can I do ?
Thank you
I had to look up “Telfast” which is fexofenadine, a non-drowsy antihistamine (aka Allegra).
I looked up ADHD and depression, and it does appear that these 2 conditions may be genetically linked. ADHD may be a risk factor for developing depression later in life. Here’s an article I found: https://pubmed.ncbi.nlm.nih.gov/32249726/
I can’t make medication recommendations over the internet, but there are things that don’t involve meds that a person with depression can do, such as exercise, mindfulness meditation and getting out to socialize.
You can’t possibly say that when someone is stable on these medications!
It may be that a person considers themselves “stable” on a longstanding dose of an anticholinergic medication.
But most of the time, when a patient comes to see me, it’s because they’re experiencing a challenge, such as balance problems, falls, trouble sleeping, or worsening cognition. A reduction in the medications can often be helpful.
Of course, that’s a recommendation I would discuss with the patient and family, to decide on the best course of action for them.
Some sources say St. John’s wort is an MAO inhibitor. Should it therefore be treated as though it were on the Beers list?
From what I read, St John’s wort is not considered an MAO inhibitor: https://pubmed.ncbi.nlm.nih.gov/21463543/, although it may have a very little bit of activity on MAO (monoamine oxidase). St John’s wort, like all herbal supplements can interact with other medications, so asking your pharmacist to check for interactions with what you’re already taking is a good idea.
I am wondering about low dose gabapentin for sleep disturbance in menopause and post-menopause. I mentioned some disrupted sleep incidences to my MD who said that gabapentin in low doses is now being prescribed for this reason. I had taken the drug for several months a few years back for hip tendonitis nerve pain and it was effective for that and sleep, but as a long-term sleep aid, would it affect mental processes negatively? I don’t know that it’s an anticholinergic drug but could it be?
Thanks!
Post-menopausal sleep disturbance isn’t my main area of expertise, but it does seem to have some efficacy in those with hot flashes and sleep issues.
Gabapentin is an anti-seizure medication that is often prescribed for nerve pain, and can make a person drowsy, but it isn’t highly anticholinergic. I like to use the Anticholinergic Burden Scale, which you can find here: https://gwep.med.ucla.edu/files/view/docs/initiative2/conferences/Anticholinergic-Burden-Scale.pdf
Based on your research is there a class or specific anti anxiety drug that won’t impact the brain in a way that contributes to dementia?
My father has dementia and his 2 sisters and both his parents died from dementia/Alzheimer’s. I’m 52 and I feel like I’m destined to have it.
I am going through many life changes (not all bad but still add stress): moving, started a new job, empty nesting, dealing with sciatic pain, and walking both my father and father in law through their journeys with dementia/Lewy Body.
I know I would benefit from an anti anxiety medication but am nervous to take anything that might negatively impact my brain. I would love your insights.
Many thanks!
It sounds like you have a lot on your plate, and all of that can contribute to anxiety.
Remember that the biggest risk factor for Alzheimer’s is older age, and although family history plays some role, it’s not the most important thing.
Anti-anxiety medication, like benzodiazepines, can have sedating and anticholinergic side effects that affect brain performance, and so can antidepressants with anti-anxiety properties (like SSRIs). I usually prefer to use the antidepressants, because they have fewer short term side effects on cognition in general, and can have more long lasting effects (whereas benzodiazepines tend to act quickly to relieve anxiety, but the anxiety can come back when the medication wears off).
Short answer: there isn’t a perfect anti-anxiety medication. If a person needs medication to help with anxiety, it’s also good to work on non-medication strategies as well, like mindfulness, exercise, and cognitive behavioural therapy (CBT).
I hope that helps and best of luck!
My mom is 83 and has chronic lymphocytic leukemia. Since October, she has had recurring pneumonia that could be aspiration pneumonia. We are waiting for a swallowing test to be done. She was prescribed Codeine and Tessalon Perles for her cough. She is also taking Trazedone when she goes to bed. In the last 2-3 weeks she has become much more unsteady, confused and has some memory issues. It is a pretty drastic change. Her urinary incontinence has also gotten much worse. I am very concerned about her. What are your thoughts on possible anticholinergic toxity or hypoactive delirum. I have been doing alot of research and have just found out about some of these things. None of her drs have brought up any of these possibilities. I would greatly appreciate your advice.
Thank you so much!
I’m sorry to hear about your mom’s pneumonia.
Codeine is commonly prescribed for cough, but it can have numerous unwanted side effects in older adults including: sedation, constipation, urinary retention, and confusion. I have less experience with Tessalon, aka benzonatate, which is more of a topical anesthetic. And of course trazodone is a sleeping pill, an SSRI that can increase confusion and imbalance.
Urinary incontinence can be as a result of being less mobile, or due to urinary retention (the overfilled bladder overflows and incontinence is the result).
If your mom is able to reduce or stop those medications, I would hope to see her symptoms resolve, but, frustratingly, delirium can take a while to get better, even when the offending drugs are out of the picture.