The Geriatrics For Caregivers Blog

A few years ago, while I was at a family celebration, several people mentioned memory concerns to me.

Some were older adults concerned about the memory of their spouses. Some were adult children concerned about the memory of their parents. And a few were older adults who have noticed some slowing down of their own memory.

“But you know, nothing much that can be done at my age,” remarked one man in his eighties.

Wrong. In fact, there is a lot that can and should be done, if you notice memory or thinking changes in yourself or in another older adult. And you should do it because it ends up making a difference for brain health and quality of life.

First among them: identify medications that make brain function worse.

This is not just my personal opinion. Identifying and reducing such medications is a mainstay of geriatrics practice. Among other reasons, we do find that in some people, certain medications are causing memory loss symptoms — or other cognitive symptoms — to be worse.

And the expert authors of the National Academy of Medicine report on Cognitive Aging agree: in their Action Guide for Individuals and Families, they list “Manage your medications” among their “Top 3 actions you can take to help protect your cognitive health as you age.”

Unfortunately, many older adults are unaware of this recommendation. And I can’t tell you how often I find that seniors are taking over-the-counter or prescription medications that dampen their brain function. Sometimes it’s truly necessary but often it’s not.

What especially troubles me is that most of these older adults — and their families — have no idea that many have been linked to developing dementia, or to worsening of dementia symptoms. So it’s worth spotting them whether you are concerned about mild cognitive impairment or caring for someone with full-blown Alzheimers.

Every older adult and family should know how to optimize brain function. Avoiding problem medications — or at least using them judiciously and in the lowest doses necessary — is key to this.

And don’t give anyone a pass when they say “Oh, I’ve always taken this drug.” Younger and healthier brains experience less dysfunction from these drugs. That’s because a younger brain has more processing power and is more resilient. So drugs that aren’t such problems earlier in life often have more impact later in life. Just because you took a drug in your youth or middle years doesn’t mean it’s harmless to continue once you are older.

You should also know that most of these drugs affect balance, and may increase fall risk. So there’s a double benefit in identifying them, and minimizing them.

Below, I share the most commonly used drugs that you should look out for if you are worried about memory problems.

The Four Most Commonly Used Types of Medications That Dampen Brain Function

1. Benzodiazepines. This class of medication is often prescribed to help people sleep, or to help with anxiety. They do work well for this purpose, but they are habit-forming and have been associated with developing dementia.

• Commonly prescribed benzodiazepines include lorazepam, diazepam, temazepam, alprazolam (brand names Ativan, Valium, Restoril, and Xanax, respectively)
• For more on the risks of benzodiazepines, plus a handout clinically proven to help older adults reduce their use of these drugs, see “How You Can Help Someone Stop Ativan.”
• Note that it can be dangerous to stop benzodiazepines suddenly. These drugs should always be tapered, under medical supervision.
• Alternatives to consider:
  • For insomnia, there is no easy and fast alternative. Just about all sedatives — many are listed in this post — dampen brain function. Many people can learn to sleep without drugs, but it usually takes a comprehensive effort over weeks or even months. This may involve cognitive-behavioral therapy, as well as increased exercise and other lifestyle changes. You can learn more about comprehensive insomnia treatment by getting the Insomnia Workbook (often available at the library!) or something similar.
  • For anxiety, there is also no easy replacement. However, there are some drug options that affect brain function less, such as SSRIs (e.g. sertraline and citalopram, brand names Zoloft and Celexa). Cognitive behavioral therapy and mindfulness therapy also helps, if sustained.
  • Even if it’s not possible to entirely stop a benzodiazepine, tapering to a lower dose will likely help brain function in the short-term.
• Other risks in aging adults:
  • Benzodiazepines increase fall risk.
  • These drugs sometimes are abused, especially in people with a history of substance abuse.
• Other things to keep in mind:
  • If a person does develop dementia, it becomes much harder to stop these drugs. That’s because everyone has to endure some increased anxiety, agitation, and/or insomnia while the senior adjusts to tapering these drugs, and the more cognitively impaired the senior is, the harder it is on everyone. So it’s much better to find non-benzo ways to deal with anxiety and insomnia sooner, rather than later. (Don’t kick that can down the road!)

 2. Non-benzodiazepine prescription sedatives. By far the most commonly used are the “z-drugs” which include zolpidem, zaleplon, and eszopiclone (brand names Ambien, Sonata, and Lunesta, respectively). These have been shown in clinical studies to impair thinking — and balance! — in the short-term.

• Some studies have linked these drugs to dementia. However we also know that developing dementia is associated with sleep problems, so the cause-effect relationship remains a little murky.
• For alternatives, see the section about insomnia above.
• Occasionally, geriatricians will try trazodone (25-50mg) as a sleep aid. It is thought to be less risky than the z-drugs or benzodiazepines. Of course, it seems to have less of a strong effect on insomnia as well.
• Other risks in aging adults:
  • These drugs worsen balance and increase fall risk.

3. Anticholinergics. This group covers most over-the-counter sleeping aids, antihistamines such as Benadryl, as well as a variety of other prescription drugs. These medications have the chemical property of blocking the neurotransmitter acetylcholine. This means they have the opposite effect of an Alzheimer’s drug like donepezil (brand name Aricept), which is a cholinesterase inhibitor, meaning it inhibits the enzyme that breaks down acetylcholine.

You may have heard that “Benadryl has long-term side effects on the brain.” That’s because diphenhydramine (brand name Benadryl) is strongly anticholinergic.

A 2015 study found that greater use of anticholinergic drugs was linked to a higher chance of developing Alzheimer’s, and a 2021 Cochrane review found that these drugs may increase the risk of cognitive decline or dementia.

Drugs vary in how strong their anticholinergic activity is. Focus your energies on spotting the ones that have “high” anticholinergic activity. For a good list that classifies drugs as high or low anticholinergic activity, see here. Or, you can look up any of your medications using this handy “anticholinergic burden scale” calculator.

I reviewed the most commonly used of these drugs in this video:

I also cover them in an article here: “7 Common Brain-Slowing Anticholinergic Drugs Older Adults Should Use With Caution.” Briefly, drugs of this type to look out for include:

• Sedating antihistamines, such as diphenhydramine (brand name Benadryl).
• The “PM” versions of over-the-counter analgesics (e.g. Nyquil, Tylenol PM); the “PM” ingredient is usually a sedating antihistamine.
• Medications for overactive bladder, such as the bladder relaxants oxybutynin and tolterodine (brand names Ditropan and Detrol, respectively).
  • Note that medications that relax the urethra, such as tamsulosin or terazosin (Flomax and Hytrin, respectively) are NOT anticholinergic. So they’re not risky in the same way, although they can cause orthostatic hypotension and other problems in older adults. Medications that shrink the prostate, such as finasteride (Proscar) aren’t anticholinergic either.
• Medications for vertigo, motion sickness, or nausea, such as meclizine, scopolamine, or promethazine (brand names Antivert, Scopace, and Phenergan).
• Medications for itching, such as hydroxyzine and diphenhydramine (brand names Vistaril and Benadryl).
• Muscle relaxants, such as cyclobenzaprine (brand name Flexeril).
• “Tricyclic” antidepressants, which are an older type of antidepressant which is now mainly prescribed for nerve pain, and includes amitryptiline and nortriptyline (brand names Elavil and Pamelor).

There is also one of the popular SSRI-type antidepressants that is known to be quite anticholinergic: paroxetine (brand name Paxil). For this reason, geriatricians almost never prescribe this particular anti-depressant.

For help spotting other anticholinergics, ask a pharmacist or the doctor, or check your medications with this handy “anticholinergic burden scale” calculator.

Alternatives to these drugs really depend on what they are being prescribed for. Often non-drug alternatives are available, but they may not be offered unless you ask. For example, an oral medication for itching can be replaced by a topical cream. Or the right kind of stretching can help with tight muscles.

Aside from affecting thinking, these drugs can potentially worsen balance. They also are known to cause dry mouth, dry eyes, and can worsen constipation. (Acetylcholine helps the gut keep things moving.)

4. Antipsychotics and mood-stabilizers. In older adults, these are usually prescribed to manage difficult behaviors related to Alzheimer’s and other dementias. (In a minority of aging adults, they are prescribed for serious mental illness such as schizophrenia. Mood-stabilizing drugs are also used to treat seizures.) For dementia behaviors, these drugs are often inappropriately prescribed. All antipsychotics and mood-stabilizers are sedating and dampen brain function. In older people with dementia, they’ve also been linked to a higher chance of dying.

• Commonly prescribed antipsychotics are mainly “second-generation” and include risperidone, quetiapine, olanzapine, and aripiprazole (Risperdal, Seroquel, Zyprexa, and Abilify, respectively).
• The first-generation antipsychotic haloperidol (Haldol) is still sometimes used.
• Valproate (brand name Depakote) is a commonly used mood-stabilizer.
• Alternatives to consider:
  • Alternatives to these drugs should always be explored. Generally, you need to start by properly assessing what’s causing the agitation, and trying to manage that. A number of behavioral approaches can also help with difficult behaviors. For more, see this nice NPR story from March 2015. I also have an article describing behavioral approaches here: 7 Steps to Managing Difficult Dementia Behaviors (Safely & Without Medications).
  • For medication alternatives, there is some scientific evidence suggesting that the SSRI citalopram may help, that cholinesterase inhibitors such as donepezil may help, and that the dementia drug memantine may help. These are usually well-tolerated so it’s often reasonable to give them a try.
• If an antipsychotics or mood-stabilizer is used, it should be as a last resort and at the lowest effective dose. This means starting with a teeny dose. However, many non-geriatrician clinicians start at much higher doses than I would.
• Other risks in older adults:
  • Antipsychotics have been associated with falls. There is also an increased risk of death, as above.
• Caveat regarding discontinuing antipsychotics in people with dementia: Research has found that there is a fair risk of “relapse” (meaning agitation or psychotic symptoms getting worse) after antipsychotics are discontinued. A 2015 study of nursing home residents with dementia concluded that antipsychotic discontinuation is most likely to succeed if it’s combined with adding more social interventions and also exercise.
• You can learn more about medications to treat dementia behaviors in this article: “5 Types of Medication Used to Treat Difficult Dementia Behaviors“

A Fifth Type of Medication That Affects Brain Function

Opioid pain medications. Unlike the other drugs mentioned above, opioids (other than tramadol and meperidine) are not on the Beer’s list of medications that older adults should avoid. That said, they do seem to dampen thinking abilities a bit, even in long-term users. (With time and regular use, people develop tolerance so they are less drowsy, but seems there can still be an effect on thinking.) As far as I know, opioids are not thought to accelerate long-term cognitive decline.

• Commonly prescribed opiates include hydrocodone, oxycodone, morphine, codeine, methadone, hydromorphone, and fentanyl. (Brand names depend on the formulation and on whether the drug is mixed with acetaminophen.)
• Tramadol (brand name Ultram) is a weaker opiate with weaker prescribing controls.
  • Many geriatricians consider it more problematic than the classic Schedule II opiates listed above, as it interacts with a lot of medications and still affects brain function. It’s a “dirty drug,” as one of my friends likes to say.
• Alternatives depend on what type of pain is present. Generally, if people are taking opiates then they have pain that needs to be treated. However, a thoughtful holistic approach to pain often enables a person to get by with less medication, which can improve thinking abilities.
• For people who have moderate or severe dementia, it’s important to know that untreated pain can worsen their thinking. So sometimes a low dose of opiate medication does end up improving their thinking.
• Other risks in older adults:
  • There is some risk of developing a problematic addiction, especially if there’s a prior history of substance abuse. But in my experience, having someone else — usually younger — steal or use the drugs is a more likely problem.

Where to Learn About Other Drugs That Affect Brain Function

Many other drugs that affect brain function, but they are either not used as often as the ones above, or seem to affect a minority of older adults.

Notably, there has been a lot of concern in the media about statins, but a meta-analysis published in 2015 could not confirm an association between statin use and increased cognitive impairment. In fact, a 2016 study found that statin use was associated with a lower risk of developing Alzheimer’s disease.

This is not to say that statins aren’t overprescribed or riskier than we used to think. And it’s also quite possible that some people do have their thinking affected by statins. But if you are trying to eliminate medications that dampen brain function, I would recommend you focus on the ones I listed above first.

For a comprehensive list of medications identified as risky by the experts at the American Geriatrics Society, be sure to review the 2019 Beers Criteria.

You can also learn more about medications that increase fall risk in this article: 10 Types of Medications to Review if You’re Concerned About Falling.

What to Do if You or Your Relative Is On These Medications

So what should you do if you discover that your older relative — or you yourself — are taking some of these medications?

If it’s an over-the-counter anticholinergic, you can just stop it. Allergies can be treated with non-sedating antihistamines like loratadine (brand name Claritin), or you can ask the doctor about a nasal steroid spray. “PM” painkillers can be replaced by the non-PM version, and remember that the safest OTC analgesic for older adults is acetaminophen (Tylenol).

If you are taking an over-the-counter sleep aid, it contains a sedating antihistamine and those are strongly anticholinergic. You can just stop an OTC sleep aid, but in the short term, insomnia often gets worse. So you’ll need to address the insomnia with non-drug techniques. (See here for more: 5 Top Causes of Sleep Problems in Aging, & Proven Ways to Treat Insomnia.)

You should also discuss any insomnia or sleep problems with your doctors — it’s important to rule out pain and serious medical problems as a cause of insomnia — but be careful: many of them will prescribe a sleeping pill, because they haven’t trained in geriatrics and they under-estimate the risks of these drugs.

If one or more of the medications above has been prescribed, don’t stop without first consulting with a health professional. You’ll want to make an appointment soon, to review the reasons that the medication was prescribed, alternative options for treating the problem, and then work out a plan to reduce or eliminate the drug.

I explain how to find a geriatric doctor near you here: How to find a geriatrician — or a medication review — near you.

To prepare for the appointment, try going through the five steps I describe in this article: “How to Review Medications for Safety & Appropriateness.”

I also recommend reviewing HealthinAging.org’s guide, “What to Ask Your Health Provider if a Medication You Take is Listed in the Beers Criteria.”

Remember, when it comes to maintaining independence and quality of life, nothing is more important than optimizing brain function.

We can’t turn back the clock and not all brain changes are reversible. But by spotting problem medications and reducing them whenever possible, we can help older adults think their best.

Now go check out those medication bottles, and let me know what you find!

 

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