Rethinking medicines part 5: anticholinergics and sedatives

Clinical scenario

Rose, 86, continues to take oxybutynin for urinary incontinence, alongside an opioid started for chronic pain, a laxative and an antidepressant. Rose has also developed a dry mouth and ongoing constipation and recently had another fall when getting up at night. During a medication review, the pharmacist identifies several medicines with anticholinergic or sedative effects and considers whether deprescribing some of these medicines may reduce her medicine burden and improve her function and quality of life.

What is anticholinergic and sedative burden?

Some medicines have anticholinergic or sedative effects that can affect cognition, alertness and physical function. Anticholinergic effects can include dry mouth, constipation, blurred vision, urinary retention and cognitive impairment. Sedating medicines can cause drowsiness. When several medicines with these effects are used together, their effects can quickly add up and increase medicine-related harm.

What does the guideline suggest?

Deprescribing guidelines (available at deprescribing.com) suggest considering deprescribing when the potential harms or treatment burden outweigh the benefits. This includes reviewing medicines with anticholinergic or sedative effects that may contribute to cognitive impairment, drowsiness, constipation and falls.

Relevant recommendations include:

• Genitourinary anticholinergics: consider deprescribing in older people with cognitive impairment or a high risk of falls, particularly when the overall anticholinergic burden is high.
• Opioids: consider deprescribing when there is no ongoing benefit, or when adverse effects or interactions outweigh the benefits, including cognitive impairment, sedation, falls and constipation.
• Macrogol laxatives: consider deprescribing where constipation is drug-induced and the medicine causing the constipation can be safely reduced, stopped or replaced.
• Antidepressants: consider the potential for adverse effects and medicine burden when reviewing ongoing treatment. Long-term antidepressant use is common, and deprescribing may be appropriate for older people taking antidepressants for major depressive disorder who have been clinically stable or in remission for 6–12 months.

For Rose, reviewing the combined anticholinergic and sedative effects of her medicines by using validated tools such as the Drug Burden Index may identify opportunities to reduce medicine-related harm.

Coming up

The next article in the Rethinking medicines series considers long-term preventive medicines.

Dr Xisco Reus and Professor Christopher Etherton-Beer are medical practitioners. Dr Amanda Quek and Associate Professor Amy Page are pharmacists. They are all researchers at The University of Western Australia.

Read other clinical stories here
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