As people age, their bodies change in many ways. Metabolism slows down, organ function declines, and the prevalence of chronic diseases increases. These changes also affect how older adults respond to medications, making them more susceptible to adverse drug reactions and side effects.
There are many medications that can cause problems in elderly patients. However, two classes of drugs stand out as being particularly problematic: benzodiazepines and anticholinergics.
Benzodiazepines
Benzodiazepines are a class of psychoactive drugs used to treat anxiety, insomnia, seizures, and muscle spasms. Some common examples include diazepam (Valium), alprazolam (Xanax), and lorazepam (Ativan). While benzodiazepines can be beneficial for short-term use, they pose significant risks when taken regularly by older adults.
Some of the most common side effects of benzodiazepines in the elderly include:
- Excessive sedation
- Impaired balance and coordination
- Increased confusion
- Memory loss
- Depressed respiration
Benzodiazepines act on the central nervous system by enhancing the effects of the neurotransmitter GABA. This produces a calming, sedating effect. However, in elderly patients, benzodiazepines can overly suppress brain activity, leading to confusion and cognitive decline.
The risks of benzodiazepines are heightened by age-related changes in pharmacokinetics. As the body ages, it takes longer to metabolize and excrete medications. Benzodiazepines and their metabolites can accumulate in the body, causing enhanced effects.
Older adults are also more likely to have multiple health issues and take other medications. Benzodiazepines can interact with other drugs and exacerbate cognitive impairment, balance problems, and respiratory depression.
For these reasons, benzodiazepines are considered high-risk in seniors, especially with long-term use. The Beers Criteria, a set of guidelines on potentially inappropriate medications for older adults, recommends avoiding benzodiazepines in geriatric patients.
Key Facts on Benzodiazepine Risks in the Elderly
- Benzodiazepines act on GABA receptors, causing sedation and cognitive effects
- Elderly metabolize benzodiazepines more slowly, leading to drug accumulation
- Can exacerbate balance issues, confusion, respiratory depression in seniors
- Considered potentially inappropriate medications for long-term use in the elderly
Anticholinergics
Anticholinergic drugs are another class of medications that can cause significant side effects in older adults. Anticholinergics block the action of acetylcholine, a neurotransmitter involved in many important functions such as muscle contractions, gland secretion, and memory.
Some examples of anticholinergic drugs include:
- Antihistamines like diphenhydramine (Benadryl)
- Tricyclic antidepressants like amitriptyline
- Muscle relaxants like cyclobenzaprine
- Medications for overactive bladder like oxybutynin
- Antipsychotics like olanzapine
Blocking acetylcholine activity can lead to various adverse effects in seniors such as:
- Constipation
- Dry mouth
- Blurred vision
- Confusion
- Delirium
- Memory loss
- Urinary retention
The anticholinergic effects on cognition are especially concerning. Many studies have found links between anticholinergic drug use and cognitive decline, even dementia, in older adults. One study found seniors taking at least one anticholinergic medication scored lower on memory and reasoning tests.
The mechanisms by which anticholinergics may cause cognitive impairment are not fully understood. Some theories include:
- Reduced acetylcholine signaling interferes with memory formation
- Anticholinergics cause changes in brain metabolism
- Blood flow and glucose uptake in the brain are decreased
Older adults already have declining acetylcholine activity in the brain. Additional anticholinergic burden from medications can push their cognition over the edge.
Key Facts on Anticholinergic Risks in the Elderly
- Many common medications have anticholinergic activity
- Blocking acetylcholine can impair memory, reasoning in seniors
- Linked to cognitive decline and possibly dementia
- Older adults have less acetylcholine activity already
Comparing the Adverse Effects of Benzodiazepines and Anticholinergics
The following table summarizes and compares the major risks and side effects of benzodiazepines versus anticholinergics in older adults:
| Side Effect | Benzodiazepines | Anticholinergics |
|---|---|---|
| Sedation/drowsiness | Yes | No |
| Confusion | Yes | Yes |
| Memory impairment | Yes | Yes |
| Balance/coordination issues | Yes | No |
| Constipation | No | Yes |
| Dry mouth | No | Yes |
| Urinary retention | No | Yes |
| Respiratory depression | Yes | No |
As shown, both classes of medication can cause significant cognitive effects like confusion and memory problems. However, benzodiazepines are more likely to cause sedation and balance/coordination issues, while anticholinergics commonly lead to side effects like constipation and urinary retention.
Strategies to Reduce Risks of These Medications
Given the dangers of benzodiazepines and anticholinergics, strategies should be used to reduce risks in elderly patients who take these medications:
- Use lowest effective dose for shortest duration needed
- Avoid long-term use if possible
- Frequently re-evaluate need for continued use
- Prescribe alternative agents when available
- Monitor closely for side effects
- Educate patients and caregivers about risks
For anticholinergics, using a single agent rather than multiple medications with these effects can help lower anticholinergic burden. Discontinuing or reducing anticholinergics may improve cognition in seniors.
For benzodiazepines, gradual tapering of the dose is recommended rather than abruptly stopping use to avoid withdrawal effects. Cognitive behavioral therapy can also help seniors discontinue benzodiazepines.
Key Steps to Reduce Benzodiazepine and Anticholinergic Risks
Here are some key steps healthcare providers can take to minimize harms from these drugs in older patients:
- Prescribe lowest effective dose and duration needed
- Re-evaluate ongoing need frequently
- Choose safer alternatives when possible
- Taper benzodiazepines gradually
- Limit total anticholinergic burden
- Monitor closely for adverse effects
The Impact of Medication Side Effects on Seniors
Adverse drug reactions take a tremendous toll on older adults. According to the Centers for Disease Control and Prevention, over 100,000 elderly patients require emergency hospital care each year due to medication side effects.
Problems caused by drugs like benzodiazepines and anticholinergics can have catastrophic effects on seniors:
- Falls leading to injury or disability
- Car accidents from impaired driving
- Permanent cognitive impairment
- Loss of independence
- Nursing home placement
- Death
Beyond physical harm, side effects like confusion and sedation can significantly reduce quality of life for seniors. Drug-induced cognitive changes may lead to seniors losing the ability to participate in hobbies, social activities, and time with family.
Healthcare providers must carefully consider these impacts when prescribing medications with high risk of side effects. The benefits of treatment must be balanced with the potential for medication to adversely affect functional status, mental acuity, and overall well-being.
Consequences of Medication Side Effects in the Elderly
- Falls and injuries
- Car crashes
- Permanent cognitive impairment
- Loss of independence
- Nursing home admission
- Lowered quality of life
- Death
The Role of Pharmacists in Reducing Drug Risks
Because of their specialized training in pharmacotherapy, pharmacists play a vital role in helping minimize drug risks for older adults. Some of the ways pharmacists can help reduce side effects include:
- Identifying potentially inappropriate medications
- Recommending safer alternative therapies
- Educating patients about proper medication use
- Monitoring for drug interactions
- Advising dose adjustments for kidney/liver function
- Reporting adverse drug reactions
- Collaborating with healthcare providers
Pharmacists have extensive knowledge about medications that can help optimize prescribing and catch potential problems. Many also have expertise in geriatric pharmacology issues specifically. Tapping into pharmacists’ skills can improve medication safety for elderly patients.
Key Ways Pharmacists Promote Medication Safety in the Elderly
- Identify high-risk medications
- Recommend safer alternatives
- Educate about proper medication use
- Monitor for drug interactions
- Adjust dosing as needed
- Report adverse reactions
- Collaborate with healthcare providers
The Importance of Patient Education
Education is fundamental to reducing medication risks in seniors. Patients and caregivers should be informed about the potential hazards of medications they are prescribed.
For drugs like benzodiazepines and anticholinergics, patients should be counseled on risks like sedation, confusion, and dizziness that may increase fall risk. They should be told to use caution when getting up from sitting or lying down.
Providing written handouts can help reinforce education points. Having patients repeat back important information ensures understanding.
Seniors should also know the signs of adverse drug effects to report. For example, symptoms like constipation, vision changes, and urinary retention should prompt a call to the healthcare provider.
Explaining the plan to regularly re-evaluate the need for risky medications is also important. This sets the expectation that the doctor will periodically assess if the benefits still outweigh the risks.
Empowering older adults with knowledge about their medications allows them to be actively involved in their care. This helps minimize preventable harm from high-risk drugs.
Key Points for Patient Education
- Risks like confusion, sedation, dizziness, falls
- Use caution when changing positions
- Written handouts to reinforce education
- Have patient repeat back information
- Signs of adverse effects to report
- Plan to re-evaluate need for medication
Alternative Treatment Options
Using drug alternatives can reduce exposure to medications linked to side effects in seniors. Some options to consider include:
Benzodiazepine Alternatives
- Buspirone – Anxiolytic without sedative effects
- Hydroxyzine – Antihistamine with anxiolytic properties
- Antidepressants like SSRIs/SNRIs for anxiety
- Cognitive behavioral therapy for insomnia
- Melatonin for sleep
Anticholinergic Alternatives
- Selective norepinephrine reuptake inhibitors for depression
- Calcium channel blockers for hypertension
- Silibinin for stabilizing cognition
- Catheter instead of drugs for urinary retention
- Senna/fiber for constipation
Non-pharmacologic alternatives like cognitive behavioral therapy and catheter use can also reduce medication burden. Lifestyle changes like stress management, exercise, and limiting caffeine and alcohol use may alleviate conditions that drugs are prescribed for.
Healthcare providers should be knowledgeable about these options to determine the safest treatment plan for seniors. Using lower-risk alternatives when possible can help avoid side effects.
Conclusion
Benzodiazepines and anticholinergics are two major drug classes that can cause significant adverse effects in the elderly. Side effects like excessive sedation, confusion, and memory impairment put seniors at high risk of issues like falls, car accidents, and loss of independence.
Healthcare providers should prescribe these drugs cautiously and only when the benefits outweigh potential harms. Dose and duration should be minimized. Patients should be monitored closely and educated on risks.
By implementing safety strategies like safer prescribing, careful monitoring, education, and using alternative treatments, healthcare teams can reduce the likelihood of seniors experiencing medication side effects that negatively impact health and quality of life.